Relational (or longitudinal) continuity
Many patients with type 2 diabetes experienced relational continuity with a named GP or practice nurse with whom they consulted regularly. The availability of the named GP or practice nurse, even if only by telephone, was crucial for patients in allowing them to maintain relational continuity:
‘… you live and you breathe diabetes from the moment you are told you're diabetic. And Sister [A] is just … you only have to pick up a phone and she'll be there … that to me is continuity.’ (Patient 1, age 66 years, female, practice 3)
Patients commonly perceived continuity as relational where there was familiarity, trust and confidence in the relationship factors that acted to develop and maintain the continuity:
‘I would prefer to see just one doctor and I feel that I know him and he knows me …’ (Patient 5, age 62 years, female, practice 5)
‘I prefer to see one, because I still think there's more continuity…I think once you've got a doctor you can trust then hang on. I mean, why swap it for some unknown …’ (Patient 1, age 69 years, female, practice 4)
Relational continuity made patients more comfortable, and inspired confidence to address embarrassing problems:
‘… there's something better about seeing your own GP, because you go in and you're instantly at ease, because you know him, whereas you go in to a strange person, or somebody, and especially if it might be a little embarrassing problem, you think “Ooh, crikey,” you know. And you don't quite know where to start. But you feel better when it's your own doctor …’ (Patient 1, age 69 years, female, practice 4)
‘The thing is you see one GP; he gives you confidence …’ (Patient 4, age 58 years, male, practice 6)
However, some patients had bad experiences of relational continuity when the GP failed to diagnose their condition, perhaps because of overfamiliarity. As a result, some of these preferred to consult another GP, in order to get a new perspective. This only really happened, however, when there had been an opportunity to consult someone else:
‘I used to be under one doctor and he'd hardly give you anything. He [was] giving me paracetamols once and I [was] getting worse and they sent for this locum that came during the night. She was … a young woman and she says “oh he wants to be in hospital straight away, he's got pneumonia”. And he'd given me paracetamol. So I changed from him …’ (Patient 4, age 78 years, male, practice 3)
‘… I mean I had an [incident] here … I saw my doctor, and I'd been complaining about pains in me chest for about 2 year[s], anyway it wasn't until I went to hospital and had tests up there, and I came down, back down to see my doctor and he said, “Oh I'm glad they've found something wrong with you” I thought, “well 2 year[s] I've been complaining”.’ (Patient 4, age 58 years, male, practice 5)
Specific attitudes exhibited in consultations with a GP or practice nurse were crucial in influencing the perception and development of relational continuity:
‘I think we're all comfortable with Sister [B] and we respect Sister [B]. We can discuss with her what holidays she's been on, and we are comfortable with the lady and that continuity is personal attention and it is what we want.’ (Patient 6, age 70 years, male, practice 1)
Good adherence and better monitoring seemed to be enhanced as a result of relational continuity:
‘… and if he [the usual GP] offers any advice, take notice of what he says … he knows that next time that you come to see him whether you are doing what he's telling you to do.’ (Patient 1, age 68 years, male, practice 5)
‘… it's the continuity of care isn't it, you know, your doctor knows what problem you had last time you came and if you've still got it …’ (Patient 5, age 71 years, female, practice 4)
The structure of patients' practices influenced the way they perceived continuity. In single-handed practices, or those operating personal lists, patients were usually unable to consult anyone but their registered GP:
‘Well, he's … the only doctor in the practice … you've no other choice, put it that way.’ (Patient 4, age 75 years, male, practice 2)
‘… I mean here's really well organised at this practice [practice uses a personal list], they don't want you to be going to see anybody, any time. They like you to keep to your own, your GP.’ (Patient 5, age 71 years, female, practice 4)
Patients were also aware that being registered at a large group practice could sometimes cause difficulty in consulting a named GP, which could hinder the establishment of relational continuity:
‘… I mean until they started building this practice up, we'd about three doctors … but now you've got about at least six doctors here now, so they don't know you …’ (Patient 3, age 69 years, female, practice 5)
The presence of diabetes was the factor that made patients with type 2 diabetes consult a GP-diabetes specialist. Many of these patients perceived continuity as being relational continuity with the GP-diabetes specialist:
‘But listening to all these people about continuity of care, I think that we should have a specialist, a guy that knows about diabetes that you need to go to get this care, and I think Dr [Y] has to some extent put himself in that way.’ (Patient 3, age 67 years, male, practice 4)
Some patients with type 2 diabetes valued consulting the GP-diabetes specialist whom they perceived as an expert, likely to benefit them more than if they consulted another GP in the practice. Also, as a result of continuity with the GP-diabetes specialist, they felt that he/she could detect signs of diabetic complications and start appropriate interventions earlier:
‘It's good for the doctors if they become a specialist, like a diabetic specialist, because they see more of diabetic patients in the practice and so they get plenty of experience which, if you just went to a GP who saw everybody, they would only see one or two diabetics probably and they wouldn't know as much about it.’ (Patient 6, age 76 years, female, practice 4)
‘I think if you see him [GP-diabetes specialist] regular you've less chance of complications, because I think he will pick up on them so early that, you know, they could treat them before they got to any terrible state.’ (Patient 4, age 63 years, male, practice 4)
As part of diabetes care, some patients attended the hospital regularly; thus, they had more experience of hospital care and recognised longitudinal or relational continuity provided by hospital doctors. Their main reasons for attending the hospital were to monitor the progress of their diabetes and to be reassured about their health:
‘The continuity that we were talking about, all right, I now go down to the clinic once a year, and as long as everything's all right I'm quite happy.’ (Patient 3, age 72 years, male, practice 4)
Patients viewed their contact with hospital doctors as an important part of the management of their diabetes; newer treatments could be accessed and complications recognised earlier:
‘All I can say is that your ordinary GP can only have a limited experience on different things, and I would say that diabetes is one of them, you have to go to a specialist who knows the job.’ (Patient 3, age 91 years, male, practice 3)
‘There are occasions when you need a kick, and you need to have something different. Now, unless you are going to a consultant and who actually then says something different, then you're gonna get the same treatment from the doctor that you've got here, and you'll get the same pills and the same quantity of them and no changes …’ (Patient 6, age 70 years, male, practice 1)
On the other hand, the majority of patients agreed that they could not receive their diabetes care from the same doctor on each visit to the hospital, due to regular turnover and rotation of staff; therefore, longitudinal continuity was absent. This frustrated them because they could receive different treatment and advice, which is confusing:
‘… at the infirmary … definitely the continuity of care just was not there … I didn't see the same doctor in 3 years. I saw a different doctor every time … I got different types of advice …’ (Patient 5, age 65 years, male, practice 1)
However, a few patients had a chance to consult the same doctor at the hospital (consultant or registrar) frequently, which they considered to be evidence of continuity:
‘Well, when I went to the infirmary I did have continuity, because I was seeing a lady registrar, and I used to see her every time I went, every 3 month[s], and I did have continuity with her …’ (Patient 2, age 69 years, female, practice 1)
Cross-boundary or team continuity
Some patients preferred to receive care from a named GP; however, sometimes they consulted other GPs. Another group of patients preferred to receive care from any available GP at their practice and not necessarily always from the same GP. Also, some patients recognised that, when their condition was urgent or severe, immediate intervention became a priority, rather than waiting to consult a named GP:
‘As continuity I like to see the same doctor every time if possible, but obviously if an emergency arises I'll see anybody, as I did this last weekend. I got an allergic reaction and my tongue swelled up on Saturday and I came to see the emergency doctor.’ (Patient 4, age 67 years, male, practice 4)
‘…I don't have a problem with if I come in and see different GPs, you know, there's no problem with seeing different people, provided I get cured of whatever it is I've got.’ (Patient 4, age 60 years, male, practice 1)
The system in some large group practices did not encourage patients to consult the same GP each time. This in turn made patients unconcerned about whom to consult. These patients became familiar with the idea of consulting any GP, regarding all GPs who worked at the practice as equal:
‘I think it's just to get another doctor's name … I think what it is, they give you a doctor that goes on your prescriptions … but it doesn't, necessarily mean that you've, that is your doctor alone…They share them out, don't they? Share the patients out among them.’ (Patient 1, age 88 years, male, practice 5)
‘They're all our GPs, we belong to a group practice, we don't have one doctor, we have six doctors …’ (Patient 4, age 58 years, male, practice 5)
Some patients identified doctors, particularly younger GPs or locums, who did not show a personal interest, and were more concerned with providing physical rather than personal or psychosocial care:
‘…you're seeing a different face, they're doctoring you from notes you're not getting that personal contact.’ (Patient 4, age 75 years,male, practice 2)
Also, patients considered that consulting more than one doctor could disorganise the treatment plan initiated by their named GP, as they might receive different opinions from the various doctors, confusing them about whose advice to follow:
‘… if you're working under two or three they all have slightly different opinions of everything and somewhere along the line if you're seeing three or four GPs and they all have a little difference of opinion, somewhere along the line there will be a slip-up.’ (Patient 4, age 58 years, male, practice 6)
‘I think if you see too many people you get too many different variations on a theme, don't you…’ (Patient 5, age 65 years, male, practice 1)
Some patients seemed only willing to consult specific GPs, being selective about whom they saw. Their choice needed to fulfil their expectations:
‘… I'm not really bothered who I see as long as I know they're good at what they're doing and you get good doctors like you get good electricians and bad electricians”.’ (Patient 2, age 57 years, male, practice 4)
Continuity of information
Patients also identified continuity of information. Medical records offering continuity of information enabled patients to consult any available GP at their practice. They believed that all the details of their medical, social and personal history were available in the records, to provide a holistic picture, even to an unfamiliar GP:
‘I would have preferred to have continued with my GP. I suppose that also it is not strictly necessary because now everything is in the computer. So, the computer helps a lot for this sort of continuity. Everybody knows what this patient is like.’ (Patient 1, age 59 years, male, practice 4)
‘I'm not really bothered about seeing one doctor. I'm just quite, as long, if I feel ill and I want to see somebody and I can get in, that's fine, and if all my records are on the computer I'm quite happy to go that way.’ (Patient 7, age 49 years, female, practice 7)
Since patients could consult different healthcare professionals, they felt that their medical records should be available so that the GP-diabetes specialist, and indeed other team members, could be aware of their management:
‘… now continuity, as you said, is interaction between the doctor and the nurse…because now everything is in the computer.’ (Patient 1, age 59 years, male, practice 4)
Finally, patients recognised the importance of continuity of information as a form of communication that should take place between the hospital and their general practice, and the importance of two-way information sharing.
‘The one in charge of your health care in the system is your GP. So, even though you go to a specialist … he has to refer to your GP. So all the information must be fed to the GP”.’ (Patient 1, age 59 years, male, practice 4)
