Improving continuity of care in general practice: four lessons from the frontline

When we need to access health care in the UK, the first place most of us go is to our GP. Alongside delivering primary care, GPs are the first point of call for non-emergency care. And we know that the quality and consistency of a patient’s relationship with their GP can have a significant impact on their health outcomes. But there are now indications from patient survey data that continuity of care is in decline in the UK.

Continuity of care broadly means seeing the same health professional more of the time and that those interactions are supported by easy access to information about the patient. This allows patients and clinicians to develop a long-term relationship resulting in higher quality and more consistent care. This might also mean, for example, that each time you see your doctor you don’t have to start sharing your medical history over again – you can pick up where you left off. For those fortunate enough to have minimal health needs, this continuity is a nice benefit. But for those with multiple complex conditions, this relational continuity can mean the difference between appropriate, timely care and a missed diagnosis. Our five project teams are pursuing increased continuity in the context of the ongoing debate about balancing prompt GP access and preserving continuity. This all while adapting to frequent changes in primary care policy. 

In 2017, the Health Foundation published research showing that patients with ambulatory care sensitive conditions, who see the same GP more of the time, have fewer unplanned hospital admissions related to these conditions. This January we launched a funding programme to support teams to increase the continuity of care in general practice, while generating learning about how they did so. We are currently working with five teams of GP practices and federations, each receiving funding to trial interventions to increase continuity of care in practice.

What have we learned so far?

Halfway through the programme, we have already learned a lot from teams about their experience of improving continuity in their practices. We want to share four key lessons.

1. The role of data

The use of data is key across all sites, both in measuring existing continuity and identifying opportunities for improvement. St Leonard’s, an Exeter-based practice, are spreading the use of their own easy-to-use tool for measuring continuity across local GP practices – beginning with GP seminars and training to support use of the tool. South Cumbria Primary Care Collaborative have developed a real-time dashboard to enable individual GP practices to monitor their levels of continuity. The dashboard also supports modelling the impact that changing the named GP has on the GP’s workload, helping to promote informed decisions about reallocating patients.

Valentine Healthcare Partnership have partnered with data analysts at Datasyrup to identify patients with multiple attendances but no diagnosis. Using previous attendance data to spot changing patterns of use, alongside case note reviews and interviews, they have developed a system to identify this patient group. They are now exploring how increased continuity will benefit this cohort and what interventions to use.

2. The road to implementation isn’t smooth

A common lesson is that the external context and changes in national policy can affect local implementation projects. In Weston-Super-Mare, local inequality and deprivation have increased the burden on primary care, making it harder for practices to retain GPs. In June, the introduction of Primary Care Networks (PCNs) made it difficult for some GP practices to keep continuity of care as a top priority. While PCNs were set up to deliver long-term benefits, their implementation has been time and resource intensive.

3. The impact of continuity on GPs needs to be managed

Some of the teams have found that increasing continuity between GPs and high-attending patients can increase workload and the risk of clinician burnout. This arises because while extra interactions with high-attending patients would have been spread across colleagues in the past, that relationship now rests solely with the individual named GP. Teams are exploring solutions to this challenge, including peer support for GPs. One team is trialling a tool to match the GP’s capacity and the average attendance of the patient to even out the distribution of high attending patients.

4. Continuity needs to be a priority for all staff in a practice

Every team has found it important to reach beyond GPs and engage with all staff. A receptionist who understands and believes in the importance of continuity can make a real difference, as they are often in control of appointment booking systems. The impact of the engagement work undertaken by teams is already becoming clear. Our qualitative evaluators, Mott MacDonald and the University of Manchester, have found that continuity is seen as the most important strategic priority across all staff groups surveyed in the programme (203 respondents within the baseline staff Continuity of care in general practice survey. GP base includes 43 participants, 39 in the wider clinical teams and 121 administration staff). While knowing about the importance of continuity doesn’t always result in change, awareness is a good start as teams continue their work.

What’s next for the programme?

Throughout the first half of the programme, we have placed a lot of emphasis on drawing out and sharing learning from the projects between project teams, as well as with the wider community of people interested in continuity of care.

On 26 November 2019, we will be co-hosting an insight webinar with the Royal College of General Practitioners (RCGP) – Continuity of care in general practice – why is it important and how can we improve it? This is a great opportunity to learn more about the continuity of care programme and hear directly from the project sites. Register for the webinar

We also have a community of practice, hosted by RCGP, an online community where you can interact with the programme learning and outputs and join the debate around the importance of continuity and how to increase it. To join the community, please email continuityofcare@rcgp.org.uk.

Angus Wiltshire (@wiltshire_angus) is a Programme Officer in the improvement team at the Health Foundation.