Is continuity of primary care declining in England? A longitudinal study at practice-level with repeated measures for the years 2012 to 2017

Problem

Continuity of care, usually defined as seeing the same GP, is central to primary care and is associated with improved patient outcomes. We aimed (i) to confirm reports of decline in continuity of care, ii) to identify patient characteristics and experiences associated with any decline, iii) to identify consequences of any decline for patients.

Approach

Longitudinal study applying multilevel modelling whereby time and practices were level-1 and level-2 units, respectively. Aggregated data at practice-level came from repeated questions in GP-Patient Surveys between 2012-2017. We analysed (i) trends in percentages of patients reporting A) having a preferred GP, and B) seeing their preferred GP always/often. We also estimated regression coefficients for relationships between percentages of patients (iiA) having and (iiB) seeing their preferred GP always/often and percentages of patients in a practice with long-term conditions (LTCs) and difficulties in appointment-making, and (iii) between the percentage of patients confident in health-management and percentage of patients seeing their preferred GP always/often. We focused on relationships within practices over time, since these reflect effects of changes in the indicators on changes in outcome. Models were adjusted for age, gender, ethnicity, religion, full-time work/study, and response rates. Practice-years were excluded if response rate was less than 20% or had missing information, resulting in over 42,000 observations (practice-years) in the three regression models.

Findings

Overall, 56.7% (95%CI 56.4, 57.0) of patients had a preferred GP in 2012, this declined gradually by 9.4%-points (95%CI -9.6, -9.2) by 2017. Of these patients, 66.4% (95%CI 66.0, 66.8) always/often saw their preferred GP when consulting in 2012. This gradually declined by 9.7%-points (95%CI -10.0, -9.4) by 2017.

When practices showed an increase over time of 10% of their patients having difficulties in appointment-making then the percentage having a preferred GP decreased by 0.7%-points (95%CI -0.8, -0.6) and the percentage always/often seeing their preferred GP decreased by 4.6%-points (95%CI -4.7, -4.4). An increase over time of 10% of patients having LTCs was associated with an increasing percentage having a preferred GP by 1.7%-points (95%CI 1.6, 1.8) and increasing percentage seeing always/often their preferred GP by 0.5%-points (95%CI 0.3, 0.6).

When practices showed a decrease over time of 10% of their patients seeing their preferred GP always/often then the percentage of patients confident in health-management decreased by 0.2% (95%CI -0.2, -0.1).

Consequences

Patients reported a steady decline over time in continuity of care. Access difficulties led to worse continuity of care while an increase in patients with LTCs resulted only in a slight increase in continuity of care. Declining continuity of care was associated with a slight decline in patient health-management. Continuation of declining continuity of care could result in poorer patients’ outcomes and should alarm clinicians and policymakers.