Continuity of Care 'Achievable, Improves Services, Admissions, Mortality'

Becky McCall

October 15, 2021

"Continuity needs to become the way we do things," says a Morecombe GP, pioneering a programme to encourage greater continuity of care between GPs and their patients. 

"If continuity was a drug made by a pharma company and was advertised to the degree of DOACs [direct oral anticoagulants] for example, then it would be top of what we write on our prescriptions every single day," said Dr Hugh Reeve, GP and board member of Morecambe Bay Primary Care Collaborative on the Health Foundation's Improving Continuity of Care in General Practice programme. 

The programme, which is supported by the Royal College of General Practitioners (RCGP), was discussed alongside practical tips on how to change a practice's approach to care continuity at this week's Annual Conference of the RCGP. 

"It [continuity of care] doesn't receive the attention it should," added Dr Reeve, speaking at the session. "We incentivise access, but there is no incentivisation to provide better continuity of care." 

Patient-GP relationships lie at the heart of the intense public scrutiny behind current issues around face-to-face versus remote GP consultations. But whether visits are in-person or remote, or a hybrid of the two, most people accept that continuity of care should be central to a productive and caring doctor-patient relationship.

Studies confirm that continuity of care leads to better patient outcomes. Professor Mark Rickenbach from the University of Winchester, and a GP in Chandler's Ford, who also spoke during the session, shared data from a new Norwegian study looking at continuity of care in general practice. "It found that the duration of the regular GP-patient relationship is significantly associated with lower use of out-of-hours services, fewer acute hospital admissions, and lower mortality. This dose-response relationship found indicates causality."

Improving Continuity of Care in General Practice - What Does It Mean?

The Health Foundation programme awarded five large-scale GP practices and federations grants of up to £250,000 over 12 to 24 months to carry out targeted quality improvement work to increase continuity in their practices.

The initiative stemmed from a finding that elderly patients who see their usual GP more often have fewer emergency admissions, said Candida Perera, head of improvement programmes at the Health Foundation, addressing the annual meeting.

The five group practices included Morecombe Bay Primary Care Collaborative (10 practices), St Leonard's Practice, Exeter (5 practices); One Care Ltd, Bristol (24 practices); Pier Health, Weston-Super-Mare (7 practices); and Valentine Health Partnership, London.

Ms Perera pointed out that the real question was, "how do we achieve continuity of care?"

She highlighted that it was more than access alone and in fact related to, "quality-adjusted access and asking what good quality care looks like".

Exploring what the concept of continuity of care meant to delegates attending, GPs shared their thoughts.

“Continuity allows you to be aware of the wider context without needing to ask and may give you a red flag without it being verbalised," said audience member, Patrick Byrne.

GP Dr Emma Tonner, noted: "I think it [continuity of care] is really satisfying and rewarding as a clinician. It's also better for my learning to follow through cases and learn from your patient's journey."

Alice Norman said she felt continuity of care made her, "feel more part of the community than if only providing one-off transactional consults".

The RCGP Continuity of Care Toolkit

The continuity of care toolkit for GP practices contains a range of items to help a practice improve its approach to continuity of care. A tracker helps a practice determine how well it is doing on continuity of care, while there is an evidence base of continuity data. Other items include templates for staff and patient surveys, interactive activities for staff on the benefits of continuity, and a guide on setting up a 'microteam' (a small group of GPs one of whom a patient always sees).  

"There are questions to work out where your practice is now and what you can do next. A small difference can make a big change," explained Prof Rickenbach.

"We already know there is increased GP satisfaction, but also increased patient and staff satisfaction, less duplication of work, tests, and reduced investigations, and earlier diagnosis for all things," he added.

"Continuity also underpins access and workload. Reduced workload and improved access have been seen at Pier Health in Somerset."

Case Study - Morecombe Bay Primary Care

Dr Reeve, who is also a GP from Nutwood Medical Practice, Morecombe, South Cumbria, discussed how his practice and others in and around Morecombe, improved their continuity of care after a patient and staff survey highlighted they “weren't doing very well".

"We got medical students to talk to patients in the waiting room and ran focus groups too," he said, describing the process of assessing their practice's continuity of care status.

Getting the whole practice team together and on board with the need for change in continuity was the first challenge, he said, adding that data from business executives show that 70% of barriers to change are related to employer resistance.

He described how one practice group had difficulties implementing change. "We went on an away-day and it soon become really obvious where problems were," said Dr Reeve.

He added that for practices that were resistant to change, COVID was the trigger that stimulated change.

"Setting realistic goals is also important - we know Rome wasn't built in a day," he pointed out. A lot of practices thought the challenge was too big for them, so they broke it down into manageable chunks. "Some broke the patient lists into target groups, so Valentine in London targeted frequent users, but elderly, or those with learning difficulties are other examples."

They also looked at whether continuity of care was achieved with the usual GP or whether it was with a microteam or buddying system. "Microteams are best in groups of two or three GPs, which also addresses issues around GPs being in for five or six sessions per week."

Other tips shared by Dr Reeve were to make it easy for a patient to see their usual GP, to regularly review and update continuity as GPs move around, and to support admin teams to promote continuity. The Toolkit has means to help practices do these things and others to encourage continuity. 

Presented at the Royal College of General Practitioners Annual Meeting 2021. October 14-15, 2021. Liverpool.

Dr Reeve and Professor Rickenbach have declared no conflicts of interest.

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