Helen Salisbury: Measuring continuity of careBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6567 (Published 03 December 2019) Cite this as: BMJ 2019;367:l6567
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Data analysts have an important role and are particularly welcome in general practice which is short of data on day-to-day work in service practices.
It is therefore disappointing to read a letter from a data analyst which makes provocative and we believe inaccurate statements about continuity without any data at all.
Black, commenting on Salisbury’s article (1), writes that “the idea we should target increased continuity across all patients is an unrealistic pipedream (at least in the short term).” This is contradicted by our own experience of visiting several practices, all using personal list systems to great effect and achieving acceptable levels of continuity for the patient population as a whole.
It is also contradicted by our recently published data. Sidaway-Lee et al. (2019) (2) showed that over a two year period in a group general practice with 9,300 patients and with every GP working part time and having time out for holidays, study leave, and mandatory training, it was possible for 52% of face-to-face GP appointments for the whole registered list to be with their personal doctor. For patients aged 65 and over 65% of GP face-to-face appointments were with their personal doctor and even children and young adults had a third of these appointments with their personal GP.
This is no pipe dream but real world data. Black writes from “Ask My GP” a commercial company which has many general practice data. It would be helpful if they published them.
There are intrinsic problems with targeting continuity to specific groups. The first is the difficulty of identifying these patients. It may be more work for practices to try to identify patients with, for example, high attendance rates, than just trying to raise continuity across the board. Another potential issue is that in targeting one group, another group is disadvantaged.
Targeting continuity at a specific group is also contrary to Geoffrey Rose’s (3) principle that it is more effective to achieve a modest shift across a population than to target only an extreme group.
1. Salisbury H. Measuring continuity of care BMJ 2019;367:l6567
2. Sidaway-Lee K, Pereira Gray D, Evans P. A method for measuring continuity of care in day-to-day general practice: a quantitative analysis of appointment data. Br J Gen Pract. 2019 69 (682): e356-e362
3. Rose G. The Study of Preventive Medicine. Oxford :OUP. 1992
Competing interests: No competing interests
Continuity in GPs matters, but it matters more for some patients and conditions than to others. Not recognising this leads to ineffective policy.
Yes, there is evidence that continuity is important to GPs and their patients. But that evidence also shows that continuity is far more important to some patients and some conditions than it is to others. It seems to be, for example, much more important for patients with mental health conditions than to patients with short term minor illnesses and injuries.
And some patients are quite happy to trade continuity for speed of access. For them, continuity is a nice-to-have and speed is essential. For others, continuity is all that matters (both because they care about it and because the success of any treatment depends on it).
Despite these observations, rather too much of the debate on continuity seems to focus on improving it in general and fails to recognise that GPs could focus their limited resources of selectively improving it where it really matters. The trade-off of continuity versus speed of access isn't uniform across patients or conditions. If GPs recognise this and triage all the incoming requests before responding, then they can easily target higher continuity for the groups where it has a big benefit and offer speedier access where that is what patients need or want.
The idea that we should target increased continuity across all patients is an unrealistic pipe-dream (at least in the short term). But it is entirely possible to do much better right now–even without the extra resources primary care needs–by adopting intelligent approaches to triage in current GP practices. Rather too much academic research has ignored the possibility that a selective approach to continuity could lead to immediate, targeted improvements and has simply bemoaned the lack of resources that limits universal continuity.
Continuity matters a lot more to some than to others and GPs should focus their efforts to improve it where it matters most. That can lead to immediate improvement. This is surely better than waiting for the extra resources (that might take a decade or more to materialise) required to improve it for all patients.
Competing interests: I provide analytics to askmyGP, a company offering online requests to patients and workflow management to GPs.