Written evidence submitted by Dr Kate Sidaway-Lee (FGP0213)

 

Dr Kate Sidaway-Lee PhD

St Leonard’s Research Practice, Exeter

I am a researcher working within a general practice. Our practice research team is unusual in that we produce our own research and have a large number of publications with a particular focus on continuity of care in general practice. We recently were funded, as part of a national programme, by the Health Foundation, to run a health improvement programme on continuity of care. This programme has broadened our experience of continuity of care to a variety of practices locally and nationally.

With my experience and expertise on continuity of care, the question I wish to focus on is the role of having a named GP, and being able to see that GP, in providing patients with the continuity of care they need. In particular I would like to highlight the importance of measurement of continuity and explain our method of measurement which I think is one of the most straightforward and appropriate for use in a practice setting. Having continuity with patients may also improve GP morale in the long term.

Named GP

Simply giving patients a named GP has been shown not to improve continuity.1 Unfortunately, many practices saw this as simply an administrative exercise and, having nominated a named GP for each patient, made no changes to their ways of working. Having looked at many GP websites, many do not have the required statement on their website that all patients now have a named GP. Many have this statement but go on to add “however you can continue to see any GP”.

The only practices who are really using the named GP are those who are running a form of personal lists. Some call this a usual doctor system.

Continuity in practice

Many GPs seem to believe that continuity is not possible and that it makes things more rather than less difficult. However, we have worked with a number of practices which use personal lists and we find that the GPs in these practices are more satisfied with their work and are less likely to feel overwhelmed.

Patients who have experienced continuity of care appreciate its value. Although continuity is considered to be most of benefit for older people and those with more health needs, for continuity to fully benefit patients, it ideally needs to be in place before a deterioration of health takes place. Offering continuity to everyone as standard, as much as possible, is likely to be most effective.

There is a large body research evidence that continuity is associated with improved health outcomes2 as well as patient satisfaction3. This extends to mortality4 and continuity has also been linked to reduced healthcare utilization and costs.5

Continuity measurement using the SLICC

For practices to implement continuity effectively, there needs to be measurement. There are a number of different measures used in research to measure continuity. The only one that is suitable for regular measurement of continuity for all patients with appointments is the SLICC (St Leonard’s Index of Continuity of Care).6 This measure requires a named GP with whom the patient should have continuity. If the named GP scheme was fully implemented, this would be in place for all patients.

The SLICC is our main measure as it reflects the patient experience of seeing their own GP. This is calculated by dividing the number of consultations patients have with their own GP, by the number of consultations with any GP. This is calculated by GP list and for the whole practice and is expressed as a percentage. It is a fairly simple measure and is easy for busy GPs to understand and interpret.

The second measure we use is the OPR (Own Patient Ratio) which reflects the GP experience more closely. This is the proportion of patients a GP sees who are their own patients; this is calculated by dividing the number of GP appointments with their own patients by the total number of consultations provided by that GP.

We have put together a toolkit which enables practices to measure the SLICC each month and to collect the monthly measurements to build up a picture of continuity levels and trajectories over the course of a year. Ideally, this measurement would become embedded in GP computing systems such as SystmOne, EMIS and Vision, making it available to the majority of practices.

Measuring continuity for each GP list using these two measures enables practices to understand how systems designed to improve continuity are working within the practice. They are sensitive enough to pick up months when a GP went on holiday and can also pinpoint whether a GP has an appropriate list size.

We now have a number of practices in various parts of the country using our toolkit, or an adaptation of it, to measure the SLICC and OPR. Practices have commented on how useful they find it and that it has helped them to track and improve continuity. Some practices, including larger practices, have high levels of continuity by these measures.

Other measures of continuity

There are a number of other measures used in continuity research. Some research1 uses the questions on preferred GP from the General Practice Patient Survey (GPPS) but the wording of these means they can be biased by patient expectation and preference.

The only quantitative measure that is as straightforward to understand as the SLICC is the UPC (Usual Provider of Care) index.7 This is calculated for each patient by dividing the number of appointments with the most seen GP by the total number of appointments. This causes bias as in a usual practice setting, the greater number of patients included will have only two appointments so can only have the values of 0.5 or 1 on the UPC (as in they saw two doctors for their two appointments or one doctor for both). Often a mean average of the UPC is used, disregarding the inherent skew. With the SLICC, because the doctor with whom the patient should have continuity is pre-specified (is the named GP), this skew does not occur, a SLICC of 0% is possible. The most seen “Usual” GP in the UPC can be any GP, which could include a trainee or locum who is unable to take long term responsibility for the patient.

More complex (and difficult to interpret) measures such as the Bice-Boxerman are also used.8  Some are designed to take into account team continuity. However, there is a problem with all these measures, including the UPC, in that only patients with at least two, and sometimes three consultations, can be included. This means it is not accurate over short timescales (less than one year unless in a very high-attending patient group) and also that it focuses on frequent attenders. As the SLICC is not used at a patient level, but at a group level, it does not have this problem, making it the best measure for regular monitoring of continuity within a practice. Further information on the SLICC and an example of its use in general practice can be found in our publication from 2019.6

References

1.               Tammes P, Payne RA, Salisbury C, Chalder M, Purdy S, Morris RW. The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012–2016. BMJ Open 2019;9(9):e029103.

2.               Pereira Gray D, Sidaway-Lee K, White E, Thorne A, Evans P. Improving continuity: THE clinical challenge. InnovAiT Educ Inspir Gen Pract 2016;9(10):635–45.

3.               Adler R, Vasiliadis A, Bickell N. The relationship between continuity and patient satisfaction: A systematic review. Fam Pract 2010;27(2):171–8.

4.               Pereira Gray D, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors - A matter of life and death? A systematic review of continuity of care and mortality. BMJ Open  2018;8(6):e021161.

5.               Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: Cross sectional study of routinely collected, person level data. BMJ 2017;356:10–1.

6.               Sidaway-Lee K, Pereira Gray D, Evans P. A method for measuring continuity of care in day-to-day general practice: a quantitative analysis of appointment data. Br J Gen Pract [Internet] 2019;69(682):e356–62.

7.               Breslau N, Haug MR. Service delivery structure and continuity of care: a case study of a pediatric  practice in process of reorganization. J Health Soc Behav 1976;17(4):339–52.

8.               Pollack CE, Hussey PS, Rudin RS, Fox DS, Lai J, Schneider EC. Measuring Care Continuity. Med Care 2016;54(5):e30–4.

December 2021