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Relational continuity of care (RCC) is the extent to which patients see the same clinicians over time. Considered a core feature of general practice, it is linked to patient satisfaction and better health outcomes, especially for older patients, those with long-term conditions and the vulnerable. Although current NHS policy is to maintain continuity for patients with long-term conditions, it has been declining for at least a decade. Contributing factors are thought to include growth in practice size, more part-time working, greater staff and patient turnover. It may also be because practice policies have focused on access, rather than continuity. Because they often neither measure nor monitor it, general practices may be unaware how their within-practice policies impact RCC. Furthermore, conceptions of RCC differ between clinicians and between patients, and there are different ways of measuring RCC which reflect these different conceptions. A shared understanding of continuity will help practices decide on the purpose of measurement, what they want to measure and which RCC index best meets their aims. We do not know the extent to which practice-level characteristics - practice size, part-time working, staff turnover and patient turnover - affect RCC. We therefore do not know the extent to which within-practice policies to maintain RCC can mitigate the effects of practice-level characteristics. The health of older patients and those with chronic diseases may benefit most from continuity. The optimum balance between access and continuity may therefore vary across different patient groups. For a realistic strategy to improve RCC it would help to know if there are groups in which there is a stronger case for RCC and in which it should therefore be prioritised. There are potentially many ways to optimise continuity. As no two general practices are the same, the most successful approach is likely to depend on the practice context. This project uses a variety of methodologies to address these questions, with the overall aim of helping practices optimise continuity of care. First, we develop an understanding of RCC to help practices determine how best to measure and monitor their own RCC. This will be achieved by hosting consensus workshops of patients, primary care clinicians and researchers. Second, in a large number of general practices, we will model the association between RCC and practice-level characteristics including staff turnover, part-time working, practice size and if linkage is possible, practice funding per patient. From this we will understand the drivers of RCC and identify practices showing higher-than-predicted RCC (positive deviants) for investigation as case studies. Third, we will undertake detailed case studies in a sample of general practices, focusing on positive deviants. We will explore staff and patient experience of continuity (including possible trade-offs between access and continuity) and investigate the interplay between measured RCC and informational or management continuity. We will identify practice policies contributing to RCC, along with barriers and facilitators to their implementation. Qualitative findings will be triangulated with the practice’s measured continuity and subjectively reported continuity in the General Practice Patient Survey (GPPS). Fourth, we will undertake economic analysis to estimate the projected effects of RCC on resource costs and health outcomes, using linked primary and secondary care data. This will help us understand the likely effects of changing RCC in a general practice and whether these effects vary in different patient groups (by age, sex, deprivation status and chronic disease status). Fifth, we will develop empirically-informed practical guidance to improve continuity of care, collating findings of our quantitative analysis of predictors of RCC, case studies, economic analysis, and existing work on continuity of care in the UK and internationally. |
