Does continuity of care need a reality check?

Continuity of care, defined by care given continuously by one doctor, is one of the most frequently talked about modalities of care provided by GPs; it’s the one we collectively feel that’s under threat, the one we’re trying to defend, and the one the government has picked up on to protect and promote. It enables us to build therapeutic relationships, and many patients and GPs value it. Indeed, 50% of our consultations are for chronic conditions, where relationship continuity clearly plays a significant role.

Is continuity of care always a good thing?

Is continuity even possible these days, given the changing shape of the GP workforce, organisational change in the health service, the increasing complexity of the work carried out in primary care and wider social changes amongst our patients? Relationship continuity isn’t necessarily all good. Patients can be taken up diagnostic and management cul-de-sacs, only to be rescued by a different clinician who was able to bring along a fresh perspective. And continuity can bring complacency, and assumptions - mistaken or stereotypical - that are adopted earlier on in the relationship, can snowball.

General practice is nowadays practiced differently to the traditional model that we and our patients were brought up with; the model powered by a continuous relationship with a family doctor available 24 hours a day. Your average GP is no longer a full-time partner with ample time to get to know their patients intimately.

Patients can be taken up diagnostic and management cul-de-sacs, only to be rescued by a different clinician who was able to bring along a fresh perspective

Indeed, with up to 25% of all GPs working as freelance GPs, and increasing numbers of practice-based GPs working part-time, the reality of the situation is that the pursuit of a continuous therapeutic relationship with one GP seems quixotic. We’re continually espousing the benefits of this continuity as the panacea to care delivery, yet as often as not are unable to deliver on that promise.

In its report “Continuity of care and the patient experience” in 2010, the King’s Fund distinguishes between two types of continuity of care: relationship continuity – a continuous therapeutic relationship with a clinician, and management and information continuity - continuity and consistency of clinical management.

It concludes that the balance of evidence is that relationship continuity leads to increased satisfaction among patients and staff, reduced costs and better health outcomes, although there are some risks and disadvantages that need more understanding and mitigation. Management continuity is almost always desirable but, within the context of the increasing complexity of services, achieving it is challenging.

Among the authors recommendations is to better understand the importance of continuity and the need to prioritise or incentivise it, and to study the effects – including costs and benefits – of discontinuities of the clinician. In other words, by placing relationship continuity at the vanguard of our arguments to support general practice, our profession is putting its arguments in one evidence-lite basket.

Let's celebrate diversity

Diversity of care is a current fact of life in our health service and there is every sign, with changes in the GP workforce and with the proposed expansion of community care, that this diversity is set to stay and even increase.

So what does this all mean for the care that can be offered by freelance GPs working in the NHS, who are less likely to enter the hallowed long-term therapeutic relationship? Let’s not rush to apologise or make amends, but explore all the potential benefits of this patient seeing you today. A fresh pair of eyes, an unjaundiced and objective opinion, an alternative perspective. You probably have different personal experiences relating to their illness, and a new way to look at managing their care. Continuity can breed complacency, and many of us will have stories of grateful patients with chronic problems, the group most likely to appreciate “continuity”, who felt disregarded or in a stalemate with their usual GP. Not to mention those patients with an alarming acute problem who are glad for a timely appointment.

There are also the ways in which you support relationship continuity with their usual GP, by reinforcing your colleagues' management wherever appropriate, perhaps explaining it differently, or emphasising important points.

There is even now research to suggest that seeing different GPs increases the rate of cancer diagnosis.

Management and information continuity - the patient narrative

Undoubtedly there is a substantial and important group of patients for whom long term relationship continuity is important; those with terminal diagnoses, frail elderly, mental health problems. But how much of the relationship continuity that patients generally seem to appreciate is because they perceive that seeing one individual will ensure that there is a receptacle who “knows my problems”?

How much of the benefit of relationship continuity comes from the fact that there is one individual GP informally storing lots of significant information about that patient, their management plan and important care contacts, in their head? Only for that care plan to collapse if that individual GP goes on leave or is unexpectedly absent. Freelance GPs trying to cover an absent practice-based GP in these circumstances have ample experience of trying to find traces of elusive management information.

In the absence of the impossible guarantee that patients will only ever see the same clinician each time, surely continuity of management and information is the key. We need to explicitly recognise the absolute reality of discontinuous care and actually empower individual clinicians to record the delivery of care as an ongoing comprehensive management narrative that any other clinician or caregiver can recognise and continue. As a wider health and social care service, we also need to develop records that can be shared between all caregivers.

Evidence needed

So rather than blindly pursue the mantra of relationship-continuity-is-the-only-way, we also need to research its potential weaknesses; at the same time as exploring the complementary modalities of both care diversity and management continuity, that enable us to deliver care in a sustainable way, compatible with the reality of our primary care workforce and our patients’ needs, in all their diversity.

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