Written evidence submitted by Centre for Primary Care University of Manchester (FGP0187)
Dr Patrick Burch, University of Manchester
Dr Mhorag Goff, University of Manchester
December 2021
This evidence submission is to answer the following question posed by the committee
“What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?”
Patrick Burch is an Academic Fellow at the University of Manchester and has been a practicing GP since 2012. He is currently undertaking a PhD investigating how patients that are seen for healthcare outside of their surgery experience continuity of care. He has worked as a GP Partner in the northeast of England, Perth (Australia) and now practices in the Peak District. Mhorag Goff is a Research Associate at the University of Manchester and has been researching health services since 2015. She is currently researching continuity of care within primary care networks.
We would be delighted to provide more detailed evidence in an oral session should that be helpful to the Committee.
Source of evidence: Academic literature, personal experience as a GP
Just over half of patients in the England do not have a preferred GP.(Ipsos MORI, 2020) This figure has been steadily rising for the last decade. The reasons for this drop are complex and likely involve factors such as changing expectations from patients, decreased clinical working hours from GPs, increased demand on appointments and movement of chronic care to other members of the healthcare team.
In 2014 GP practices agreed to introduce a scheme that provided each patient aged over 75 with a named GP. This was done without consulting grassroots GPs, and the scheme was largely implemented in the absence of a wider strategy to improve continuity of care. Although some patients expressed approval of the scheme and sought care from their named GP, most practices did not change their appointment systems or other working practices. The scheme did not improve continuity or reduced unplanned admissions.(Tammes et al., 2019)
A system such as this in which a patient is assigned a named GP only works if the patient is able and willing to see that GP and can build up a trusting relationship with them over time. There are practices that successfully operate a system of all patients being assigned a named GP. These schemes can successfully increase continuity, but they require significant commitment from both clinicians and administration staff. There have also been trials of practices providing named GPs to only those patients that are believed to be most in need of continuity.(The Health Foundation, 2018).
Overall, this evidence suggests that having a named GP can improve continuity and outcomes, but it must have buy-in from doctors and be introduced alongside broader changes in working practices.
Source of evidence: Academic literature
There is a large body of research spanning several decades into the relationship between continuity of care in general practice and healthcare outcomes. There is a small amount of evidence to suggest that continuity can, on occasion, be associated with negative consequences such as delayed diagnosis for patients, or demotivated practitioners. However, this is far outweighed by the range of positive outcomes that it is linked to. It is one of the few aspects of primary care treatment that has been shown to be linked to a reduction in patient mortality.(Baker et al., 2020) Other outcomes linked to continuity include:
All patients have the potential to benefit from continuity. However, continuity is particularly important for older patients and those with multiple or complex health or social problems. Whilst continuity is not always necessary for effective diagnosis or treatment, if a GP knows a patient, they are more likely to be able to form a more complete picture of their health and better diagnose and effectively treat them. This may be framed in terms of clinicians having better knowledge of significant information about the patient they are treating, where the more complex the health problem, the more important this is. Continuity of formal information (i.e., complete health care records) cannot make up for a lack of personal knowledge. Patients are more likely to disclose information to GPs who they have formed a trusting relationship with and are more likely to comply with suggested treatment. GPs are also more likely to feel greater responsibility towards patients they have seen before.(Hjortdahl, 1992)
The relationship between continuity and timely access is not straightforward. Access at a basic level is a pre-requisite for continuity of care. Continuity in practices can be increased without negatively affecting access (The Health Foundation, 2018). Different patients place different value on continuity; however, this may reflect conditioning of their expectations of continuity, particularly for younger patients, rather than their needs. Conversely older patients who have experienced single-handed practices may have higher expectations of relational continuity. Many patients are willing to “trade-off” continuity for quicker access to care, depending on what problem they require help with.(Cheraghi-Sohi et al., 2008) Due to pressures on appointments, the design of primary care systems and working practices, it is not always possible to provide timely access to a patient’s preferred GP. There are occasionally instances of patients who have waited to speak to “their” GP but should have sought help more urgently from the first available doctor. GP appointments and better design of appointment systems can improve patient access to a preferred GP. However, there will always be instances when it will not be appropriate, or a patient will not be willing, to wait to see a particular GP.
Continuity of care in general practice is linked to multiple beneficial outcomes for patients, staff and the NHS. Levels of continuity have been steadily declining for several years. All patients have the potential to benefit from continuity but patients with more complex medical, social or psychological issues are likely to benefit more. Assigning patients to a named GP without other changes in general practice will be very unlikely to improve declining rates of continuity. To successfully increase levels of continuity, any scheme assigning patients to named GPs will require changes in working practice and will need significant commitment from the general practice workforce.
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December 2021