How does continuity of care work when patients are seen outside their regular general practice? A theory based on two case studies of extended access providers.

Problem

Longitudinal continuity of care (patients seeing the same GP) is associated with multiple benefits to patients, clinicians, and health care systems. This form of continuity is declining in British general practice. However, continuity in the modern healthcare system consists of more than just consulting the same clinician. Theoretical models of continuity recognise concepts such as information sharing and coherent, joined up, seamless management of care across care boundaries. There is some theoretical work on the potential mechanisms that underlie the benefits of longitudinal continuity. This previous work is based on little empirical data and does not consider the interplay of other aspects of continuity. This study seeks to understand how the different elements of continuity interact when patients are seen away from their regular general practice and how this may affect potential health outcomes. This is important as there often appears to be an unwritten assumption by some primary care policy makers that good informational and management continuity can make up for a lack of longitudinal continuity.

Approach

Qualitative comparative case studies of two contrasting large-scale providers of extended access hubs were carried out based on a methodological approach described by Stake. The focus of the work was on extended access appointments for patients with undifferentiated medical problems. Data collected included clinician-patient observations and semi-structured interviews with hub staff, managers, commissioners, and patients. Analysis ran concurrently with data gathering and facilitated the iterative adaptation of data collection. The model of continuity described by Haggerty et al was a sensitising concept underlying data collection and analysis.

Findings

Observations suggested that, whilst informational continuity is important, it alone cannot ensure that patients experience joined up coherent care (management continuity). There are multiple linked patient, system and clinician factors that contribute to the patient experience of continuity. These factors also influence health outcomes but often in ways that a patient may be unaware. The positive effects of longitudinal continuity, including its contribution to positive health outcomes, cannot be fully replaced by other methods.

Consequences

The theory developed in this work provides a framework for policy makers and those designing services to consider when trying to provide patients with the experience of continuity when they are being seen by more than one clinician. The factors described in this theory should be optimised to try and maximise the patient experience of continuity and improve health outcomes. However, even with maximal optimisation of these factors, the benefits of longitudinal continuity cannot be replaced. Primarily, we should be seeking to improve longitudinal continuity, especially for patients with complex health needs.