Can general practice still provide meaningful continuity of care?
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj-2022-074584 (Published 14 November 2023) Cite this as: BMJ 2023;383:e074584
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Dear Editor
I disagree with Maarsingh et al's statement in their response that personal lists are 'unable to cope with all the current changes in society and healthcare' [1].
We have stuck with personal lists through many NHS reorganisations, societal change, and increased GP part-time working because of the benefits to both patients and doctors. In 2018 we started measuring continuity of care. Initially we used in-house searches and more recently adopted the SLICC (from November 2021-date). As a practice the SLICC data provides prompt feedback allowing us to tweak the appointment system in-order to balance continuity and timely access. Continuity of care has been maintained at 81.9-85% [2-6] over this period and rebuts Maarsingh et al's [1] claim that continuity of care will tend to decrease over time.
Practices with more than 5,000 patients (medium to large) have the most to gain from personal lists because access and continuity is near impossible to achieve without a plan [6]. As a similar sized practice to Dr Kemple's [7] we find personal lists work for us and our patients and agree that 'personal lists are a low-cost and high-quality intervention' [7].
I would agree with others that continuity requires a bottom-up approach, so practices can tailor continuity for their specific population but also a top-down incentives (funding and recognition) to allow practices space to enact change. I would urge the RCGP, BMA and NHS England to act.
1 Continuity from a Dutch perspective: multifactorial, tailored & bottom-up Maarsingh et al https://www.bmj.com/content/383/bmj-2022-074584/rr-0
2 Bucking the trend, don’t blame part time GPs 04 June 2018 https://bjgp.org/content/68/671/e420/tab-e-letters Sayers
3 Evaluating the relational continuity of care of four GP practices, one of which uses personalised lists, Riaan Swanepoel British Journal of General Practice 2020; 70 (suppl 1): bjgp20X711713. DOI: https://doi.org/10.3399/bjgp20X711713
4 Evidence to the parliamentary select committee on the future of general practice. 2022. https://committees.parliament.uk/work/1624/the-future-of-general-practic... FGP0093
5 Realistic not romantic – real world continuity in action Sayers et al https://bjgp.org/content/73/734/388/tab-e-letters#realistic-not-romantic... Published on: 17 November 2023
6 Access and continuity of care – the holy grail of General practice. Sayers LD BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o441 (Published 22 February 2022) Cite this as: BMJ 2022;376:o441
7 Re: Can general practice still provide meaningful continuity of care? Terence J Kemple November 2023 https://www.bmj.com/content/383/bmj-2022-074584/rr-2
Competing interests: LS and the practice has collaborated with St Leonards Exeter to utilise the SLICC tool and share periodic SLICC data from November 2021-present. We are the Tyneside practice cited in the article
Dear Editor,
The article by Denis Pereira Gray and colleagues extolling the virtues of continuity of care in General Practice is timely and crucial to the very survival of General Practice. Arguably the three attributes of General Practice which have contributed to its inherent value are continuity of care, ease of access and gate keeping. All three have suffered in recent years because of the workforce crisis, part-time working and the emergence of numerous alternative routes for patients into the broader health system. Once continuity of care disappears, as it has done in many Practices, the future of General Practice itself will be called into question. Long term conditions are increasingly managed by well trained nurses who could be employed by an Acute Trust; cohorts such as care of the elderly and palliative patients can be managed by MDTs with no need for a traditional GP at their centre and ’same day access’ is fast being devolved to Urgent Care Centres, 111 or private firms.
Dr Pereira Gray’s article goes some way to suggesting a solution. The problem is known and the value of continuity clearly demonstrable. Some General Practices are coping well despite suffering from the same workforce issues as others. The RCGP has support mechanisms in place should they be called upon. If the government is not prepared to take the issue seriously by including continuity of care in the GP contract [and removing some of the less worthwhile issues at the same time] perhaps it is time for the RCGP to grasp the nettle and set attainable standards for the profession before it is too late!
Competing interests: No competing interests
Dear Editor
I fear that continuity is in danger of being irrevocably lost. No doubt it will be difficult to retreat from current models which are heavily focused on first contact triage and remote consultations even though these models are being increasingly questioned. As Greenhalgh and colleagues have recently shown these do harm patients. They also inherently harm continuity of care.
It is bad for patients who have to negotiate complex multi-layered systems before they can see a GP much less "their GP".
It is bad for the system. Increasingly care is distributed and fragmented amongst multiple clinical and non-clinical staff which is often inefficient generating unwarranted investigations, treatments and referrals.
Lastly, it is bad for the doctors. Like all social beings they benefit from relationships with their peers. Relationships that are increasingly difficult to form and maintain in these fragmented models of care.. Futhermore, the lack of relational continuity between docotrs and patients does little to facilitate the experiential learning that leads to the experienced doctor's "wisdom".
Continuity is a precious gift that we must urgently work to preserve.
Competing interests: No competing interests
Dear Editor
Good GP continuity of care doesn’t need management intervention. It just needs slack in the system.
At long last there has recently been recognition of the huge benefits of continuity of care in General Practice. Those of us on the front line have known this for years but it is good that academics and managers have finally caught up.
But the proposed solution is more top-down initiatives with a named GP for each patient and incentives / targets to coerce staff into booking patients with the same GP. This is a typical management driven approach which fails to realise that much of the problem is the past 20 years of target driven culture.
If there are appointments available with the GP who has been seeing them about a problem, then patients will automatically book to see them. Patients do not want to have to explain the problem all over again to a new doctor who doesn’t know what was planned.
The key requirement is that there must usually be some free slots with most GPs. And this means that the GPs must not be working flat out with every appointment booked. But this runs counter to the management efficiency mantra of squeezing every last bit of work out of every clinician every day.
Improving access does not harm continuity because it naturally follows from having free slots with the GP the patient wants to see. But practices are being forced to offer unlimited same day appointments without providing the funding to buy the GP time required. Their only choice is to cannibalise routine appointments to meet the on-the-day target.
Having some free capacity in the system is actually more effective and cheaper for industries like health where demand can vary unpredictably. Being overwhelmed by demand leads to inefficient and expensive use of resources firefighting. This isn’t a surprise to GPs as practices have been planning capacity successfully for over 70 years.
The solution to improving continuity is to give GP practices the primary care funding for their patients and let them work out how best to spend it. Continuity of care is a powerful and inexpensive tool to help them look after patients and they will automatically use it.
Competing interests: No competing interests
Dear Editor
GPs can manage their own workload better and more fairly if they have continuity of care in a personal list system. As an appraiser I visited many GPs in shared list practices who felt stressed because they had little control of their workload. My practice switched from a shared list to a personal list system many years ago. Before the switch any of the practices 14,000 patients who happened to consult me could became my ongoing personal responsibility. After the switch to personal lists, I had about 1400 personal patients. All the rest had their own GP who was responsible for their ongoing problems. Of my 1400 patients only about 100 needed significant extra care at any one time. Their timely access to care improved because of the trusted relationships in a personal list and a reduction of avoidable appointments with other staff in the practice.
In these times of low morale and increasing demand we need better ways to manage workload for the benefit of doctors. Personal lists with continuity of care are a low-cost, high-quality way to provide better access for patients to their trusted GPs, and bring forward a new and sustainable generation of family doctors who can enjoy the privilege of these caring relationships.
Competing interests: No competing interests
Dear Editor
it is useful to see reviews of the importance of GP continuity. But it is unhelpful that two major issues were missed or misrepresented by the review.
The first mistake is the focus on continuity for all. Some patients need continuity far more than others. Many studies simply ignore this issue by analysing the results across all patients. But this does not demonstrate that focussing continuity on the subsets who need it most would not be a useful step especially in a resource-constrained environment like the UK. Demanding universal continuity based on those studies leads to a policy sledgehammer when a nutcracker would be better.
The second problem is the casual unreferenced claim that "Targets for speed of access and encouragement of on- the-day teams and remote triage have reduced continuity and undervalued GPs". But there is no solid evidence that either speed of access or remote triage hurt continuity if implemented well.
The typical traditional model of making a GP request–phone reception and hope they find any slot with someone as soon as possible–has no room for decisions that improve continuity even for those who need it most. But well implemented remote triage can easily do better. In good systems, the patient is asked what mode of consultation they want (phone, online, face to face) and whether they want to see a specific staff member. This facilitates the practice to allocate them as appropriate (including assessment of their clinical issues and history). This makes it far easier to enhance continuity on the basis of both need and preference (patients might sometimes choose speed over continuity). Hence why evidence shows the increase in remote consultation has not hurt continuity (https://bmjopen.bmj.com/content/13/11/e075152.full). Not all triage systems work this way, but the best do.
Ignoring the two points leads the article to make weak suggestions. yes, measuring continuity can help. But the best approaches to that are found in total triage systems taking patient preferences into account and providing real-time feedback on the demand for and deliver of continuity.
Changing the detailed local processes for handling and responding to patient demand is the best and fastest way to enhance continuity. Far better than the blunt sledgehammers of national policy . By denying the benefit of remote triage systems and pushing for blunt policies, the analysis misses the best way to fix the problem.
Competing interests: No competing interests
Dear Editor,
We would like to thank Sir Denis Pereira Gray and colleagues for their relevant and inspiring plea for a renewed focus on continuity of care. However, the authors propose limited solutions with personal lists (every patient has a named GP) as the key solution. Although we recognize the importance of personal lists, we believe that this approach is unable to cope with all the current changes in society and healthcare (e.g., GPs increasingly work part-time in larger practices, both patients and doctors are increasingly mobile, the prevalence of complex chronic diseases is increasing, other healthcare workers such as the practice nurse have entered general practice, patients increasingly expect fast access to any doctor): even with a named GP, continuity will tend to decrease.
These multifactorial changes require a multifactorial solution. Given the large differences between practices regarding list size, number of GPs, population, rurality, et cetera, this multifactorial approach should be tailored instead of one-size-fits-all.[1] During a survey among 249 GPs and 582 patients in the Netherlands, GPs and patients provided a wide range of suggestions for improving continuity of care.[2]
Furthermore, as the analysis of Pereira Gray et al clearly demonstrates, possible solutions require a bottom-up rather than top-down approach.
Finally, even with extensive support among all relevant stakeholders, interventions to improve continuity can easily fail during implementation.[3] Therefore, more research into implementing complex interventions is crucial.
To put it shortly, we emphasize the need for a renewed focus on continuity of care; a multifactorial, tailored, bottom-up approach of solutions to improve continuity – as well as also its implementation – is crucial.
References
1. Groot LJJ, Schers HJ, Burgers JS, Schellevis FG, Smalbrugge M, Uijen AA, van de Ven PM, van der Horst HE, Maarsingh OR. Optimising personal continuity for older patients in general practice: a study protocol for a cluster randomised stepped wedge pragmatic trial. BMC Fam Pract 2021;22(1):207.
2. Groot L, Te Winkel M, Schers H, Burgers J, Smalbrugge M, Uijen A, van der Horst H, Maarsingh O. Optimising personal continuity: a survey of GPs' and older patients' views. BJGP Open. 2023;7(2):BJGPO.2022.0099.
3. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies--a synthesis of systematic review findings. J Eval Clin Pract 2008;14:888-97.
Competing interests: No competing interests
Dear Editor
Denis Pereira Gray and colleagues argue that GPs should provide continuity of care despite the serious shortage of GPs.
Inspired by the UK general practice list system Norway introduced personal lists in 2001. According to the latest capitation report (November 2023) a typical general practice in Norway has four GPs working together. Median list size is 993 (1). According to a 2018 GP survey only a third of the doctors have clinical sessions every working day (2).
I used to work in an office with six GPs who each had clinical sessions 3 – 4 days a week. We recorded continuity for patients who had at least three visits during a four years’ period. Average SLICC (St. Leonard’s index of continuity of care) was slightly above 85 %. In another office a colleague with clinical sessions only two days a week achieved SLICC 75 %.
Patients who need follow up appointments usually get their next appointment at the end of the consultation with their personal GP. Patients who need a non-planned consultation when their own GP is absent, may be offered to see a colleague. But often they prefer to wait until their personal doctor is back. Most GPs have room in their schedule for such non-planned consultations. Thus, it is quite possible to provide excellent continuity, even when the patient’s personal GP isn’t present every working day.
Obviously, shortage of GPs is the major problem in the UK. It is hard to provide continuity when you must care for nearly twice as many patients as Norwegian GPs do. According to the latest capitation report only 3 % of Norwegian GPs have lists equal to or more than the average list size in the UK. These selected GPs are very experienced, having served in the same municipality for a median of 18 years (1).
Thus, it is possible to provide continuity even with large lists, but this probably requires experienced GPs who have cared for the same patients for many years. The challenge is how less experienced GPs, riddled by the demand for rapid access, may get their head above water to transform to stable, continuing care.
References
1. Patient adapted capitation [Pasienttilpasset basistilskudd]. https://www.helfo.no/fastlegeordninga/pasienttilpasset-basistilskudd
2. The GP survey 2018. [Fastlegeundersøkelsen 2018]. https://www.flo20.no/undersokelsen/
Competing interests: No competing interests
Re: Can general practice still provide meaningful continuity of care?
Dear Editor
Continuity of care within primary care in the UK is a long overdue initiative desired by both clinicians and patients alike (Can general practice still provide meaningful continuity of care, Nov 2023). However it also belongs in secondary care.
Admitting a patient to a hospital in the UK often involves multiple transfers between different wards and teams. Even when on the same ward they may see different clinicians each day of their stay. Whilst a fresh pair of eyes can bring a new perspective, or specialist knowledge from a referral, the overarching parent team should stay the same as much as possible.
Alternating doctors with no element of continuity is an inefficient way to practise medicine. It is time consuming for teams to digest the large quantity of clinical documentation up to the point when meeting a patient for the first time. Information can be easily missed, previous results can go unnoticed, and repeat investigations can be re-ordered at an unnecessary cost. Day to day clinical progress is more difficult to assess when seeing a patient for only a brief snapshot of their stay.
It also exasperates patients, who have to retell their story to multiple clinicians, and can confuse patients and their relatives when they receive different updates from different doctors, ultimately losing trust in the medical team.
The medical rotas are now designed in such a way that service provision is valued more highly than continuity of care within teams. In Australia, things are done differently. Patients are directly referred from the emergency department to specialist teams, and juniors work a standard week with the same team for their entire term, whilst being rostered a few extra hours some evenings to cover the out of hours service.
The NHS’ mentality that “any doctor will do” needs redressing, both for patient satisfaction and retaining the workforce that serves them. A simple relook at the way rotas are designed can go a long way.
Dr Sam Sussmes, Resident Medical Officer, Sydney Australia.
Competing interests: No competing interests