GP Provider Support Unit, Birmingham and Solihull

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Connecting patients with the right person is often the most important aspect of access. 

To improve access, manage workload and improve clinicians’ job satisfaction, it’s time to take a deliberate approach to continuity.

 

Introduction

Video about continuity: why prioritise continuity; why is this an issue right now; 4 steps for improving continuity; options for measuring continuity.  

Continuity matters greatly to patients and clinicians. More than half of a typical practice’s workload is devoted to ongoing care, so problems with continuity have widespread consequences.

Higher continuity…

  • Improves satisfaction for patients
  • Improves satisfaction for clinicians
  • Reduces avoidable appointments
  • Improves LTC outcomes
  • Reduces mortality
  • Reduces A&E attendances and admissions
  • Reduces DNAs

[References below]

Continuity in general practice has been falling for years

This is not because GPs do not value continuity, but because practices have not deliberately designed for it as teams have become larger and more complex.

Percentage of patients reporting they get continuity when requested (GP Patient Survey, national data)

Continuity of care trends 1

In the 1960s and 70s when the founding principles of primary care were being described, it was generally very easy for patients to obtain continuity of care. If a practice had one doctor, continuity was 100% – except when the doctor took a holiday. However, as practices grew (partly to avoid GPs having to be on call 24/7) there was a risk that continuity could be eroded by accident. Today most practices have more than one doctor and several other clinicians available for patients. Without asking ‘who is the best person’ at the start of each patient contact, continuity is almost guaranteed to fall – and the national Patient Survey shows that it has, year on year, especially in larger practices. 

Some of the access improvement initiatives over recent years have further compounded the reduction in continuity by emphasising only one aspect of good access, such as speed. This has resulted in ‘when can we see you’ being prioritised over other questions in reception. 

Right Access First Time encourages practices to consider ‘who’, ‘when’, ‘how’ for every patient contact. This allows continuity to be included as a deliberate principle. 

Steps for improving continuity

Identifying the patients to prioritise for continuity is an important first step. 

Many practices will want to take a staged approach here, beginning with a relatively small cohort of patients to test and tweak their approach, and later expanding it to more patients. 

There are two main situations in which continuity is particularly important:

a) Patients who will always need continuity. Continuity is always a priority for some patients because of their particular medical or personal needs. For these patients, a number of options exist for identification:

  • name them. Experienced GPs will usually be able to name a significant number of patients who would benefit greatly from continuity as a priority.
  • flag as you go. Where memory fails, clinicians can flag patients during the working day where they wish them to have continuity as a priority in future.
  • search. Key patient features can be searched for in the clinical system. Commonly used searches identify patients with:
    • 9+ GP consults in the past year
    • 5+ pharmacologically active repeat medications
    • Any psychoactive medications on repeat
    • Certain diagnoses such as dementia, longstanding mental health problems and others

 

b) Patients needing continuity for a particular episode. Continuity can be very important during a particular episode of ill health, investigation or treatment. Patients in the middle of such an episode may be best prioritised to receive continuity with one clinician regardless of whether they usually see another clinician or do not usually require continuity at all.

  • These patients will be identified at the time by their clinician. 

It will usually be necessary to note on a patient’s record that continuity is a priority, in order for staff to know to take appropriate steps when the patient contacts the practice. Some sort of flagging system will need to be used for this. 

There are two main methods used by practices to flag patients for ‘continuity prioritiy’: 

a) Record a problem heading. Adding a specific heading to the patient record can identify them as being a ‘continuity priority’ patient. SNOMED CT includes a the code 423779001 (‘Continuity of care management’) which is ideal for this.

b) Alerts or pop-ups. Adding a pop-up (in SystmOne) or an alert (in EMIS) can also be used. This avoids requiring receptionists to always check the patient’s problem headings when signposting them, but increases the risk of ‘alert fatigue’. This makes it more likely that an alert will be missed by a busy receptionist.

Whichever approach or combination of approaches is used, the practice will need to consinder:

  • How to ensure the appropriate flag is added reliably when a clinician judges it to be appropriate?
  • If alerts are used, how to trim out old and low-priority alerts to reduce the risk of ‘alert fatigue’. 
  • How to ensure the appointment book makes it as straightforward as possible for patients to be signposted to a specific clinician?

Once patients requiring continuity have been identified and flagged, the whole practice team needs to be involved in promoting continuity. 

The practice can work with the team to identify impactful actions that can be taken at each step of the patient pathway to protect and promote continuity for high priority patients. Patients and carers themselves can also play an important role in this, if they are informed that the clinician wishes them to be connected with them personally where possible. 

It is essential to measure continuity as changes are introduced, in order to know if the changes are the right ones to achieve an improvement. 

There are four methods for measuring continuity of care in everyday general practice. None is perfect, and practices may wish to use a combination.

MethodNotesProsCons
a) Patient surveyThe national GP Patient Survey includes a question about continuity. Practices can refer to their nationally collected data or run their own short surveys using similar questions. No clinician time involved. Results can be compared with historical data over several years.
The nationally administered survey includes only small numbers of patients. The metric relies on patient memory of when they have previously contacted the practice.
b) Clinician auditA rapid tick-box audit can be completed by a clinician for a specified clinic, in which they note whether continuity was important and whether it was provided. Based on clinical judgement of the relevance of continuity. Doesn't rely on recall. Very quick for the clinician to complete. The practice may need to remind clinicians to complete the data collection. It is likely to be used only on a periodic basis (eg quarterly / annually depending on whether changes are actively being made).
c) Search on clinical entriesA computerised search of consultations asks “Across all patients (or group) what proportion were with the most frequently consulted clinician?”. This is called the ‘usual provider of care’ (UPC) method.Automated process. Doesn't require consultation entries to be flagged in any particular way.All consultations need recording correctly in the records.
d) Search on appointmentsA computerised search beginning with the appointment book asks “Across all appts in given period, what proportion were with the usual GP?”. This is the St Leonards Indicator of Continuity of Care (SLICC) method.
Automated process. The 'usual GP' needs to be flagged in the records, and kept up-to-date for all patients.

The BSol rapid continuity audit

The BSol GP Provider Support Unit is developing a new rapid audit which practices can use to measure continuity of care. 

This will be available by December 2023 for BSol practices, and information will be shared as part of the RAFT programme’s locality meetings. 

The audit will use the ‘clinician audit’ method for measuring continuity (option b) above), because of its speed and the use of clinical judgement. Used on its own or alongside the audit of avoidable appointments, it will provide practices with new insights to inform improvement work as we seek to improve access and manage workload in the RAFT programme. The audit will be provided free by the PSU and each participating practice will have its own results dashboard. 

References

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