Is General Practitioner continuity of care achievable in large, multi-site practices?

Problem

Continuity of care is associated with multiple benefits, including increased patient satisfaction, decreased use of hospital services and lower mortality rates. However, continuity of care is declining across General Practice (Levene, 2018) and is particularly poor in larger practices (Barker, 2017). With a national trend to larger, multi-site practices, is maintaining continuity of care plausible? This work sought to address this issue through measurement of General Practitioner (GP) continuity of care in a very large, multi-site practice.

Approach

GP continuity of care was measured in the second largest practice in southwest England, with a list size of 39,144 over three sites (city centre practice, suburban practice and a university practice). The practice has 10 partners and 18 salaried GPs, totalling 16 full-time equivalent GPs. Of the 28 doctors, 27 work part-time. The practice uses personal lists (Pereira Gray, 1979), whereby each GP takes professional responsibility for a defined list of patients.Continuity of care was measured with the commonly used ‘Usual Provider of Care’ index (UPC). The UPC is the proportion of a patient’s consultations which were with the GP that the patient saw most often. The Continuity of Care Calculator from the University of Bristol was used within EMIS Web. Data were analysed from the last two years, with a sample size of 1 in 6 registered patients. All face-to-face consultations (surgery and home visits) and all telephone consultations with GPs (including registrars and locums) were included.

Findings

Data were analysed for 6,524 patients. The number of patients who had consulted was 4,352, with a mean number of GP consultations per patient per annum of 2.3. The UPC index was 63.8% +/-0.8% (95% CI).

Consequences

A ‘medium’ level continuity has been considered as UPC 0.4-0.7 (Barker, 2017). This work illustrates that it is possible for a very large, multi-site practice to achieve a reasonable or ‘medium’ level of continuity of care. These results are interesting in the context of previous work (Barker, 2017), which found that continuity was lower among practices with more doctors, with a UPC of average 0.59 for practices with >7 full-time equivalent GPs. In contrast, the average UPC for practices with 1-3 full-time equivalent GPs was 0.7.The practice had no specific focus on increasing continuity. The practice does however operate a personal list system and these results illustrate the benefit of personal lists in achieving continuity of care (Roland, 1986). In a time of unprecedented change in General Practice, with a focus on access and larger practices, it is easy to see how the trend for declining continuity of care may continue. However, we must remember the numerous benefits of continuity of care and that it is realistic for larger, multi-site practices to achieve continuity.