JRSM >
Volume 96, Number 4 >
Pp. 160-166
Institute of General Practice, University of Exeter, Barrack Road, Exeter EX2 5DW, UK
Correspondence to: Sir Denis Pereira Gray E-mail: SaNDNet{at}pms.ac.uk
 | INTRODUCTION |
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 TOP INTRODUCTION METHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Over many years a research group in Exeter, including all the authors of this paper, has been developing a theory of continuity, based partly on clinical experience and partly on published evidence. The essence of the Exeter theory is that, in primary care, a ‘personal doctor’ with accumulating knowledge of the patient's history, values, hopes and fears will provide better care than a similarly qualified doctor who lacks such knowledge; and that the benefits of such continuity will include not only greater satisfaction for the patient but also more efficient consultations, better preventive care and lower costs.
When we assess continuity in primary care, the duration of registration with the general practitioner (GP) is only one background factor. A more important consideration is the total time the patient and doctor have been in direct communication; and this will include contacts about third parties, such as a child, or an elderly relative during a home visit. We recognize that continuity can have disadvantages; for example, a fresh eye may see what the familiar eye has missed. In this paper we examine the published evidence for and against continuity in primary care.
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Further references were found from the citations of earlier publications and from the authors' files on the subject, dating back to 1973. Information about continuity of care was sometimes discovered in publications primarily on other subjects. In this review we examine the arguments for and against continuity of care under five headings. Each section begins with a brief note on the perceptions of the Exeter group (‘theory’); then follows a summary of the published evidence.
| PROPOSITION 1: ADVERSE EFFECTS, OR NO BENEFIT, FOR PATIENTS |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Evidence
Examining outcomes in terms of complications and patient satisfaction in 61
pregnant women,
Flynn3 concluded:
‘Provider continuity had no significant effect on either outcome’.
Similarly, Rodney et
al.4 found
satisfaction as good with residents (short-term contacts) as with faculty
(permanent staff); it must be said, however, that faculty were not offering as
much continuity as might have been expected.
Freeman and Richards5 found that continuity of care did not lead to patients talking more to their doctor about epilepsy. Moreover, two research groups have concluded that GPs who know their patients well can have special difficulty in strict application of evidence-based care.6,7
The main published data indicating that continuity is disadvantageous to patients is from Hanninen et al.8 In a study of 212 diabetic patients they compared those who had had at least two years' continuity of GP care with those who had had less than two years. The control of HbA1c was significantly worse in the group with continuity. Overland et al. likewise raised the possibility of harm in patients with diabetes.9 They found that patients attending one GP had significantly more diabetic complications than those attending several GPs; their HbA1c concentrations were also higher, though not significantly. Interpretation of these results is complicated by the greater age of those attending a single GP, since complications in diabetes are age related.
A key issue is paternalism/maternalism. This is hard to measure, but Coulter10 has underlined the importance of information, understanding and choice. In the words of another, ‘Doctors advise: patients decide’.11
| PROPOSITION 2: ADVERSE EFFECTS FOR DOCTORS |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Patients with insoluble problems can leave the doctor feeling frustrated, and this is made worse by long-term continuity. Eventually, the patient rather than the illness may come to be seen as the issue. When a succession of physical complaints seem incompatible with known diseases, the explanation may be somatization. Interpretation of the psychosocial aspects and the care of these patients demands interpersonal skills that not all doctors possess. Some doctors, indeed, are intrinsically unsuited to relationship-based primary care and might be happier moving to a specialty such as accident and emergency medicine. Finally, virtually all criminals, psychopaths and people with personality disorders use medical services, and continued contact with such individuals can be a negative experience for the doctor.
Evidence
Interviewing 207 Norwegian GPs,
Hjortdahl12
concluded that if standards are ‘too ambitious or unrealistic’,
they often become counterproductive. Not all GPs like or want substantial
continuity ‘Which GP does not feel a tingle of enthusiasm when they spot
an unknown name on their surgery
list?’13
One of the early reports on adverse effects for doctors came from Balint,14 who noted the stress generated by long-term efforts to help patients with complex difficulties. O'Dowd15 coined the term ‘heart-sink’ for the patient who, after many consultations (i.e. continuity of care), comes to be seen by a general practitioner as a problem.
| PROPOSITION 3: GOOD EFFECTS FOR PATIENTS |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Evidence
Certain categories of patient are consistently reported as seeking
continuity of care and other groups appear not to value it so much. In
general, the latter are the reciprocal of the former; thus, those valuing it
most are the elderly, the female, and those with chronic problems/diseases,
especially the
disabled.16
Breslau17
concluded: ‘A continuous doctor—patient relationship conducive to
the expression and resolution of psychological needs, is of special importance
when a patient's illness is severe’. The young rate it less than the
old.18 Those
valuing it least have been described in the UK as ‘usually young adults,
free from known long-term health
problems’.19
Pilotto et al. analysed which patients were most likely to change
doctor (i.e. break continuity) and found that they were of younger age,
functioning well physically, of normal body mass index and doing shift
work.20
McKinley et al. measured satisfaction scores and found them significantly lower in patients who had been seen by deputizing doctors than in those seen by practice doctors.21 According to Shers et al., having children and the previous experience of a serious life event were two factors that made patients keener to see their personal doctor.22
Interpersonal communication
Experience is clearly a factor. Looking at satisfaction scores, Bradley
noted that nearly half the patients who saw a general practice trainee
(registrar) reported the consultation ‘not relaxed’ compared with
only one-tenth of those who saw an established
GP.23 When Gabel
et al. asked patients what they understood by continuity, ease of
communication was one of the main factors in what they called
‘familiarity with the
physician’.24
An anecdotal statement from a patient was ‘This time I saw a different
doctor I explained all my symptoms again which took up to 10 minutes... I
regret the time it took to be diagnosed... The problem with lack of continuity
in general practice is that the patient's character is not taken into
account’.25
In a survey of 644 Dutch patients, seeing one's own doctor was thought to ease
communication.22
Preventive care
There is evidence that continuity favours preventive care. Analysing over
12 000 questionnaires from Australian patients in 133 Australian general
practices, Steven et al. noted that patients visiting only one
practice were significantly more likely to report blood pressure screening in
the past year, cholesterol screening in the past 5 years, smoking cessation
advice (if appropriate), cervical cytology and advice on the benefits of
exercise and
diet.26 Sturmberg
et al. examined the effect of personal-provider continuity and found
that it increased the comprehensiveness of
care.27
Diagnosis
Continuity of care is associated with better diagnosis. After random
allocation, a primary care team which saw the patients regularly was able to
diagnose more behavioural problems than a control
group.28 Steinwachs
and Yaffe29 showed
that doctors who knew their patients judged them to need care more often than
those who did not.
Education
Breslau et al. in the USA found that improvement of continuity
reduced later use of
healthcare.17
Perhaps this was achieved through health education. When Pereira Gray changed
from combined lists to ‘personal lists’ (with the aim of
strengthening doctor—patient
continuity)30 he
reported increased education for patients about self-management for minor
illness.
Adherence to advice
Prescribed drugs do not work unless taken. Medical advice is widely
ignored, even when the patient is a child. In the USA, Charney et al.
showed that mothers decided whether or not to give penicillin according to how
well they trusted the paediatrician who prescribed
it.31 In a British
general practice, Ettlinger and Freeman reached similar
conclusions.32
Likewise in chronic diseases there is evidence of better adherence to medical
advice with continuity of care. Two studies, for example, have shown benefits
in asthma
care.33,34
O'Connor et al. surveyed 1387 patients in an American health maintenance organization, comparing those who had a regular health provider with those who had not.35 After adjusting for age, sex, education level and ownership of organization they found that patients with a regular provider were more likely to follow a special diet for diabetes, to monitor blood sugar at home, to have foot examinations and cholesterol tests and to have had a recent preventive examination; they were also more likely to be on insulin, to have been immunized against influenza and to have had their retinas examined with pupil dilatation. Since these indices cover a large part of modern care for diabetes, the results of this big population study constitute important evidence in favour of continuity of care.
Patients' evaluations
Numerous surveys have indicated that patients value continuity. One of the
earliest was that of
Lawson36 in 1980,
and the latest that of Baker et
al.37 who, in
a two-country study, found that 79% of patients considered that seeing the
same doctor every time they had a health problem in primary care was
‘important’ or ‘very important’. A slightly lower
proportion, 64%, was found by two other groups, and this was closely matched
by the proportion of GPs who took the same view
(69%).38,39
Personal lists and patient satisfaction
Patient satisfaction is now properly regarded as an important outcome
measure of quality, especially in primary care. Continuity is a factor, and
Marsh and
Kaim-Caudle40
showed that, even in a big group practice, a National Health Service GP could
achieve over 80% continuity of care (percentage of all contacts by registered
patients with the same doctor). The term ‘personal lists’ was
coined in Exeter.30
Roland et al. compared patients of GPs using personal lists with
those of GPs using combined lists and found greater continuity of care with
the former.41 Other
workers reported 49-58% consultation with the registered doctor in group
practice compared with 83% in a practice with personal
lists.42 Baker and
Streatfield43 have
shown that, in practices with personal lists, patient satisfaction is
greater.
Ideally, the value of continuity would be resolved by randomized trials, but long-term studies of this sort are exceptionally difficult. Two short-term studies, in children44 and in elderly men,45 have indicated that continuity increases patient satisfaction. Breslau and Mortimer,46 in the USA, concluded from a questionnaire survey that continuity of care accounted for a large part of the association between source of care and satisfaction. Hjortdahl and Laerum,47 in Europe, looked specifically at general practice and concluded that the continuity/satisfaction relationship was strong.
Biological outcomes and health status
Whereas Flynn,3
as noted earlier, found no benefit from continuity in obstetric care,
different conclusions were reached by Shear et
al.48 A group
of women receiving high continuity of care through family physicians had
babies with birthweights 220 g greater than those of women cared for in
obstetric clinics. Huygen et al. showed that 5 years' continuity of
care plus an ‘integrated’ consulting style led to significant
improvements in health status, as judged by responses to a wellbeing
questionnaire.49
Another group found that GP continuity of just 2 years was associated with
better quality of life on scores for mental health, health perception, and
painlessness than those in patients who had less than 2
years.8 However,
their blood glucose control was worse.
Howie et al. coined the term ‘enablement’ and developed an instrument to measure it.50 Using this method, another group reported greater enablement when the doctor showed interest in the effect of the health problem on the patient's life.51 Patients were enabled more when they had a doctor who knows the patient's emotional needs.
Relationships and trust
Without continuity there is no
relationship.7 One
way to examine the value of continuity is to see what happens when it is lost.
Flocke et al. found that patients who had been forced to change
primary care physician, by health maintenance organization contract changes,
received poorer quality of
care.52 Patient's
willingness to accept advice, on medical or surgical treatment, depends
greatly on trust—an element strongly associated with
continuity.53,54
Trust is also associated with patient satisfaction; and Baker's group have
noted that lack of trust for one doctor affects attitudes to others in the
practice.37
Fugelli55 sees
continuity as a means to generate trust.
Empathy and friendship
Gabel et al. found that one of the factors maintaining continuity
for patients was ‘friendship with the
physician’.24
Mutual empathy breeds
compassion.56
Empathy was stated as a target for primary care by Dixon et
al.57 and in
the same year the president of the Patients' Association wrote that
‘Empathy is what we really
need’.58 Such
relationships are deepened by home visits. Nearly one-third of British
patients who had received five or more home visits said that they regarded the
doctor as ‘something of a personal
friend’.59
| PROPOSITION 4: GOOD EFFECTS FOR DOCTORS |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Evidence
Much has been written on the value to doctors of continuity of care,
especially in general
practice,60,61,62
and the Royal College of General Practitioners in the UK, the Leeuwenhorst
Group from Europe, and the Institute of Medicine in the USA all write of the
importance of sustained partnership with patients in primary
care.63,64,65
On the issue of efficiency, Forman66 was the first to quantify the time saved by conversing with a known patient on the telephone, rather than having a face-to-face consultation. Another matter highlighted by continuity is a cross-generational pattern of illness. Such relationships in grandparents and grandchildren were examined by Huygen,67 and Seamark et al.68 later showed how young women tend to follow the reproductive pattern of their mothers.
What of satisfaction, on the doctor's part? Blankfield et al. asked residents and faculty (staff doctors) to rate various features of practice, and their satisfaction scores correlated highly with the continuity of care provided.69
Hjortdahl70 surveyed a representative sample of Norwegian GPs and related the doctor's own subjectively evaluated knowledge of the patient to the outcome of the perceived influence of this knowledge on their diagnosis and management. In three out of four consultations where the doctor had previous knowledge this was judged clinically useful and conversely in more than a third of consultations with previously unknown patients this lack of information was perceived to be a hindrance. Accumulated knowledge about the patient was found more helpful in management than in diagnosis and particularly for psychosocial problems. Scandinavian work has established that GPs amass much psychosocial information about their patients and can make use of it clinically. In doing so they come to feel more committed to their patient.71,72,73 Most professionals enjoy being competent so this is likely, though not yet proven, to add to their job satisfaction.
| PROPOSITION 5: GOOD EFFECTS BEYOND PRIMARY CARE |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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Evidence
Accident and emergency departments
In the UK Sweeney et al. looked at patients who had not
received continuity of
care74 and found
that non-continuity was associated with greater use of accident and emergency
departments and other open-access health facilities. Similar observations have
been reported from the USA.
Orr75 showed that
the use of hospital emergency departments by children was reduced if they had
a regular source of care. Gill et
al.76 looked
at Medicaid patients and reported an inverse relation between continuity of
care by family physicians and the use of emergency departments.
Hospital admissions
For children, access to continuous comprehensive primary care has been
linked with lower rates of hospital admission and
surgery.44 For
adults, continuity has likewise been linked to lower admission rates and also
to shorter stays when admission was necessary. In Medicaid patients, Gill and
Mainous77 found a
reduction in admissions for all causes 2 years after high continuity of care
had been established with a family physician. The same team then went on to
explore whether the effect was associated with a person-to-person relationship
or with continuity of care with members of the primary care team. They found
that it applied only to the family physician in
person.78
Costs to the health system
The most costly elements of health services are hospitals, so a reduction
in admissions by greater continuity in primary care offers the possibility of
substantial savings. Butler et al. were able to analyse total costs
in the USA
system.79 Children
who had a regular source of care incurred costs as much as a quarter less than
those children who moved between multiple sources of care. This was
confirmed,80 but
with the added point that the finding was true for children on
Medicaid—i.e. the most socially deprived.
Lack of continuity increases health service costs, as patients are more likely to change doctors. Safran et al. commented, ‘Health plans cannot afford to ignore [the fact] that the essence of medical care involves the interaction of one human being with another’.81 Weiss et al. researched a group of elderly Americans who had had 10 or more years' continuous care and concluded that annual costs in this group were over $300 less than in comparable patients who had had one year or less with a usual provider of care.82
| CONCLUSIONS |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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From the data examined, we reach five conclusions:
From this review we conclude that primary care would be much impoverished by a move away from continuity: the reverse is desirable. The evidence has come from four widely separated geographical areas—Australia, the continent of Europe (mainly the Netherlands and Scandinavia), the UK, and the USA. The findings are generally consistent across health systems, languages, nations, and continents, despite different methodologies. The bulk of it comes from general practice/primary care, where continuity is most achieved. However, continuity of care has been shown to be beneficial in other settings. We can reasonably expect the findings to apply to healthcare professionals in general.
| Acknowledgments |
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Much analysis on the theory of continuity in primary care has been conducted in the St Leonard's Medical Practice, Exeter. Thanks are due to Ms Manjo Luthra and Mrs Christine Pike, who undertook repeated computer searches, and to Mrs Joy Choules, of SaNDNet, for editorial support and reference checking.
| REFERENCES |
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TOPINTRODUCTIONMETHODSPROPOSITION 1: ADVERSE EFFECTS,...PROPOSITION 2: ADVERSE EFFECTS...PROPOSITION 3: GOOD EFFECTS...PROPOSITION 4: GOOD EFFECTS...PROPOSITION 5: GOOD EFFECTS...CONCLUSIONSREFERENCES |
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