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Views And Reviews Primary Colour

Helen Salisbury: Measuring continuity of care

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6567 (Published 03 December 2019) Cite this as: BMJ 2019;367:l6567
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury@phc.ox.ac.uk
    Follow Helen on Twitter: @HelenRSalisbury

“My biggest problem is that thanks to NHS cuts it is impossible to see the same GP twice—unless I want to wait weeks—and it is so humiliating to explain my history to yet another relative stranger.” This sentiment was expressed by a patient on Twitter recently, and it’s likely that others share this feeling.

Continuity matters to patients, and it matters to doctors too. When discussing the appeal of a career in general practice with newly qualified doctors, continuity of care is a key factor. GPs see their patients for minor illnesses and major ones, for antenatal care, and with their children. We look after several generations of the same family, and our role covers new baby checks to end-of-life care. This doesn’t just provide the informational continuity that all GPs should have, where you have the right notes in front of you, but also relational continuity when you know the patient.

However, this traditional long term relationship is being eroded. In some areas, waiting times are so long for anything other than an emergency that patients have little choice but to take the next appointment with whoever is available.1 This is partly related to understaffing, but it’s undeniably also a result of prioritising access over continuity. Cash has been injected into general practice to provide appointments at evenings and weekends. These have mostly shuffled existing doctors around to work elsewhere on a Sunday afternoon rather than in their own practice during working hours.2

Access is politically important, and GP waiting times are a highly sensitive issue. They’re also easy to measure: at any given moment, when is the next available appointment? And when something is measured it can be incentivised. The Quality and Outcomes Framework, introduced in 2004, works by rewarding coded processes and activities. We learnt quickly that, if you financially incentivise an activity, it’s likely to happen, as we’re all looking endlessly for ways to keep our practices viable. The unfortunate flipside is that attention may be diverted from equally important domains or activities that aren’t financially rewarding.

So, if continuity is important—and lots of evidence shows that it improves patient satisfaction, reduces unnecessary referrals and admissions, and even increases longevity3—should we be making greater efforts to measure it? Tools do exist,4 and it shouldn’t be difficult to make them generally applicable. Once we have a measure, we can assess the impact on continuity from any proposed changes to our working practice.

If we do measure continuity, should we then reward it? Unfortunately, without careful planning, this could turn into yet another stick with which to beat the practices struggling most, which are currently scraping by with too few permanent doctors and a patchwork of locums.

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