Are continuity and locum use for acute consultations associated with differing subsequent practice and hospital workload?

Problem

Workload is probably the biggest challenge facing general practice, but little is known about modifiable factors influencing it. Some practices believe that locums increase practice workload and repeat appointments. Locums provide around 3% of consultations but the outcomes of their care are relatively poorly documented. If patients see a GP they know well, they are likely to benefit from continuity of care including greater satisfaction, mutual trust, adherence to treatments and reduced mortality. Continuity helps doctors tailor advice/ treatments and feel more responsible. We aimed to determine whether practice and hospital workload differed following consultations with locums compared with practice GPs with or without continuity.

Approach

This was an observational/cross-sectional analysis of consultation-level data from English general practices from the Clinical Practice Research Datalink (CPRD) from 2015 to 2017. We used antibiotic prescription as a marker for acute consultations. The GP with continuity (regular GP) was defined as the GP with whom the patient had the greatest number of face-to-face consultations during the two years preceding the index consultation. Regression models were used to calculate adjusted relative risks for emergency department consultations and admissions, outpatient referrals and test-ordering as well as the patients’ GP re-consultation interval following consultations with the three types of GP. Within the analysis, we controlled for deprivation, gender, age, comorbidities, total practice demand, patient consultation frequency, practice factors, year, seasonality and day of the week.

Findings

After exclusions, the sample comprised 508,652 consultations from 222 practices, with 2,854 GPs. Of these, 198,102 (38.95%) consultations were with the patient’s regular (continuity) GP, 252,550 (49.65%) a non-regular practice GP, and 58,000 (11.4%) a locum. Regular GPs were more likely to see patients who were older (61 years versus 55 years for locums and 57 years for non-regular practice GPs, P<0.01) and had more co-morbidities.After adjustment, consultations with GPs with continuity were associated with fewer subsequent hospital admissions and lower A&E use but higher outpatient referrals relative to locums and non-regular GPs. Locums ordered tests less (Relative Risk (RR) -24.3%, 95% CI: -27.3% to -21.2%) than regular GPs while non-regular GPs ordered tests more often (RR 19.1%, 95% CI: 16.4% to 21.8%). Patients seeing their regular GP for acute consultations, had on average a 9% longer (95% CI: 8-10%) re-consultation interval than if they saw any other GP.

Consequences

The differences in outcomes were associated more with having continuity than GP locum status. Continuity of care was associated with reduced practice workload, fewer hospital admissions and less use of A&E. Our analysis, adjusted for a range of confounding factors, showed that if the populations seen by different GP types were the same, patients without continuity would have more appointments. These are key findings considering the current GP and hospital workload burden.