In the qualitative analysis, two overarching themes were identified of patients’ perceptions of GP attitude and approach, and patients’ perceptions of GP knowledge and technical competence. Figure 1 shows the behaviours and attributes of GPs within these categories that patients perceived as the most important, and the attributes that patients perceived as particularly affected by relational continuity.
Attributes perceived as driven by continuity
Most patients perceived continuity as very important. Although, for some patients, continuity could be achieved with a healthcare team, relational continuity with a single GP was essential for many patients. The attributes and behaviours of GPs that patients perceived as driven by relationship continuity converged on four themes, highlighted below.
GPs knowing patient history
Knowledge of the patient’s history was the attribute most clearly perceived as driven by relational continuity. One patient explained:
‘You don’t have to go through the same stuff over again [with relational continuity] … and having an unusual disability … I think that does also make a difference because you don’t have to try and explain it to yet another person.’
(P10, female [F], 35–54 years, white)
This language of ‘going over the same stuff’ was used by other patients. More than simply an inconvenience, some patients perceived this as a safety issue. One patient with a rare long-term condition described the impact of seeing different doctors:
‘I find with GPs, they’re very good but when you go in there, they haven’t looked up your notes and sometimes they try and give me things that I know I shouldn’t, perhaps, be having.’
(P9, F, 55–64 years, white)
This patient attributed this to the rarity of her condition, and to her receiving secondary, as well as primary, care.
There were some exceptions, where patients believed that informational continuity was sufficient for good care. One patient, with postoperative cancer, explained why he did not prioritise relational continuity:
‘They’re very knowledgeable, they seem to … know my problems, they’ve got it all on computer … I don’t think I got a problem with any of the doctors down there … They seem to know what’s going on.’
(P1, male [M], ≥75 years, white)
However, most patients who raised GP knowledge of their history as important felt it was strongly affected by relational continuity.
GPs giving clear and consistent advice
Patients found inconsistent advice between different GPs disconcerting, and felt that this was often a consequence of discontinuity. One patient explained why she disliked seeing different GPs:
‘Very often, they [other GPs] will criticise a plan of action that you’ve already discussed with your own GP for relevant reasons … There’s an inconsistency.’
(P15, F, 35–54 years, black)
Although there were some exceptions, most patients agreed that clarity and consistency of advice were affected by relational continuity, particularly patients with ongoing problems that had not yet been fully diagnosed.
GPs taking responsibility and action
Patients valued their GPs taking, first, responsibility and, second, action, and many thought this was affected by relational continuity. The word ‘responsibility’ is not intended to imply paternalism, nor override the patient’s responsibility for their own health, but refers to the GP assuming an ongoing duty of care for their patient. The word ‘action’ means taking steps to progress the presenting problem. This could include new prescriptions, advice, referrals, or a ‘wait and see’ approach, set within an overall plan. Indeed, patients often saw the most appropriate action as seeking to understand the problem and developing an ongoing plan rather than a ‘quick fix’ prescription.
Patients experienced situations where a GP seemed unwilling to take responsibility or action, often related to discontinuity. One patient with multiple long-term conditions explained the effect of moving to a practice where continuity was prioritised:
‘Well, the previous [practice], if, like, I was ill, I’d see different doctors, and they, sort of, just wanted me in, straight out, giving me different pills and all that, and, sort of, nothing worked, but then when I changed [practices], I [saw] one doctor, GP, and he just tells me what’s wrong with me and gives me advice, sort of, and it’s quite good.’
(P2, M, 35–54 years, white)
From the patient’s perspective, the new doctor explained things clearly, whereas the patient experienced a lack of engagement and a dismissive attitude from his previous GPs. The patient went on to describe how he perceives his GP as treating him as ‘his’ patient, for whom he has ongoing responsibility. He also explained how the ‘advice’ included self-management, dietary advice, and switching from injecting to tablets, through a process of shared decision making.
Another patient felt that her GP’s knowledge of her history helped him to take responsibility and action:
‘I prefer to see […] my own GP [because otherwise] … the GP don’t understand the complications of my personal circumstances, very often GPs don’t want to listen to… the ongoing issues, they want to be able to … deal with something there and then, within a couple of minutes … GPs that don’t know you well and the situation well, are not willing to … act.’
(P15, F, 35–54 years, black)
The patient’s perception was that, when relational continuity was broken, the GP sought to deal with the presenting problem as quickly as possible, without addressing ongoing problems. The patient acknowledged that this is partly down to issues of time and patient safety; valuable consultation time is spent re-explaining the problem and the GP does not understand her clinical history sufficiently to safely take action.
Patients were also aware of the risks in relational continuity; some patients perceived that over-familiarisation prevented GPs from taking necessary action, for example, a change of medication or a referral. One patient, with multiple long-term conditions, prioritised relational continuity of care for years, but felt that more decisive action occurred when she changed GPs.
‘Like, I’m in pain … “Oh, I’ll give her tramadol, that’ll knock her out, that’ll shut her up.” [Laughs] … I don’t know. I just feel that I’ve had a better service by moving to see somebody else … Because, I think, he’s used to me coming through the door and thinking “Oh, it’s her again” … but, if I go to somebody new, they’re looking at me afresh.’
(P16, F, 35–54 years, white)
This patient felt that relational continuity of care had perpetuated the same management, despite it not working for her.
GP trust and respect in the patient
GP trust and respect in the patient was frequently raised as of key importance. The concept of trust and respect explored here (which is the patient’s perception of GP trust and respect, not necessarily the GPs’ intentions) involved three related aspects: first, the patient perceiving that they are believed; second, the patient perceiving that their problems have been taken seriously, rather than minimised; and, third, the patient perceiving that the GP has respect for their expertise in their own health and body.
The first aspect described was belief. Several patients felt that their GP simply disbelieved them.
‘Sometimes they [doctors] sort of listen to what is said and then they kind of, in a way, … halve it for seriousness or for accuracy.’
(P8, F, 65–74 years, white)
This patient described this as a characteristic of ‘some doctors’, but suggested it happens more when continuity is broken. Another patient similarly described feeling disbelieved after seeing different doctors for the same recurring problem:
‘I think it is true that if you go to the same doctor and you say to them, “Oh, the thing you gave me last week didn’t work.” They’d actually believe you … While sometimes they just don’t believe you in a way, you know.’
(P20, F, 18–34 years, white)
The second aspect of trust was patients perceiving their problems being taken seriously. One female patient who had a long-term condition with a physical and mental component said:
‘I don’t like being brushed aside as being … neurotic or something like that, erm. I think it occurs more with doctors that don’t really know you … I mean, there’s a trust issue, isn’t there? You have to have a trust, erm going on between you and the practitioner.’
(P10, F, 35–54 years, white)
This patient’s experience of being ‘brushed aside’ occurred more often with discontinuity. She explicitly described ‘trust’ as being built up through relational continuity. However, although she talked about mutual trust, her examples were about her perception of the GP’s trust in her. Other patients agreed that discontinuity resulted in their problems being minimised. One female patient explained the effects of seeing a different doctor thus:
‘I think they don’t have a feel for either me as a patient, they don’t know me, whether I’m … somebody who wimps about something little, or I’m seriously only come for really bad things.’
(P17, F, 55–64 years, white)
The third aspect of trust identified was GPs trusting patients as experts on their own health and body.
For example, one patient, who had seen different GPs for pain following his third back surgery, and was ultimately found to have an infection, felt the GPs did not respect his knowledge and experience of his own symptoms:
‘I think they were going on assumptions that because I’d had … a discectomy and a laminectomy … there is muscular pain, as it all heals and then tightens up … but I was trying to explain to them that that wasn’t the pain. And I know the difference, and they just weren’t really having it.’
(P3, M, 35–54 years, white)
This patient felt that his understanding of his own body was not respected or trusted by health professionals. He acknowledged that, because he had been in a lot of pain, he had prioritised access over continuity. When asked if he felt continuity made a difference, he said:
‘If I did see the person over time, they would … probably get some picture of my ability to understand what’s wrong with me … that’s probably really irritating to GPs, that people come in that self-diagnose, but if you’ve got a long-term condition, you kind of get an idea of … what’s normal and what’s not normal.’
(P3, M, 35–54 years, white)
Many patients perceived that trust and respect from their GP is particularly affected by relational continuity. However, there were some patients who felt that their GP trusted and respected them even without continuity. P3 described how, before his last surgery, he had seen various GPs before the protruding disc was diagnosed. The GPs explained that the symptoms were likely a weakness from his previous operation, until one GP took his problems seriously.
‘I got a sense that she … that when I said, “Look, it’s really painful and I know pain because I’ve had lots of back problems, I know what that pain’s like and … this is really … this is really bad” … I felt when I left, thank God, she … she realises this is something different.’
(P3, M, 35–54 years, white)
A young female similarly described repeatedly consulting GPs with anxiety and depression, but the extent of her illness was downplayed, until she connected with her current GP:
‘I was going to leave that surgery because I was so fed up and then I just walked in, in a real state and saw anyone … she didn’t make me feel stupid, or like I was being over the top or anything like that … which I’ve had before, people just, sort of, be like, “Oh you’ll get over it”, I’ve been dealing with … anxiety and this sort for over 10 years. So, you know, if it was just something that would pass, I’d know.’
(P18, F, 18–34 years, white)
Both of these patients felt an immediate connection with a GP, who they felt respected their understanding of their own conditions. The examples show that, although patients are more likely to perceive that their GP trusts and respects them when they have continuity, they can also perceive it at a first consultation. This differs slightly from the other three attributes that patients saw as driven by relational continuity, in that patients believed it was possible for GPs to trust and respect them even without continuity, whereas patients acknowledged practical problems and safety issues with GPs knowing their history, giving consistent advice, and taking responsibility and action without continuity.
Attributes perceived as less driven by continuity
Several attributes of a GP were important to patients, including listening, taking time, and caring (GP approach), and clinical competence and performing an examination (GP knowledge and expertise). However, patients perceived these as less directly affected by relational continuity. Instead they saw these as traits/practices inherent to a particular doctor. Although patients who had good relational continuity did often perceive their usual doctor to listen, take time, and care, the distinction was that these patients sought continuity of care with doctors who they perceived as possessing these important traits, rather than seeing them as attributes and behaviours that are driven by continuity.
GP attitude and approach
Of these attributes and behaviours, listening was the one most frequently raised as important. One patient explained:
‘Doctor P is like that … He will sit back and listen to you … he won’t be playing on his computer … and that’s, that’s, to me, is 90 per cent of it, is listening to what you’ve got to say.’
(P14, M, 65–74 years, white)
The patient describes a doctor who not only listens, but is also seen by the patient to be listening, for example, by not ‘playing’ on his computer. The patient described the doctor as ‘like that’, seeing his listening skills as an inherent quality rather than driven by the doctor–patient relationship.
‘Taking time’ was also consistently seen as an important GP behaviour and patients preferred to see GPs who were prepared to spend time:
‘I do like to see the same one if I can, even though it’ s quite hard to get, but he is good, and it’ s like he’ s got time for you, some of them … As you get in there, ’it s like you haven’ t even finished writing your prescription, and then you’ re finished, you know.’
(P22, F, 18–34 years, black)
As with listening, this patient preferred continuity because of the GP’s approach of having ‘time for you’, but saw this as a characteristic of this GP and the reason she sought continuity with him, rather than being facilitated through continuity.
The last attribute in this category that patients found important was that their GP cared for them. Patient opinion varied as to the extent to which continuity of care influenced this. Some patients felt that they had a strong relationship with their GP, which had built up over time and was strengthened by continuity of care. Patients used words such as ‘caring’, ‘empathy’, and ‘a good friend’ to describe such clinicians. However, although patients saw continuity as strengthening the doctor–patient relationship, most patients perceived ‘caring’ as a character trait. For example:
‘He’ s a great guy.’
(P14, M, 65–74 years, white)
‘In the past, ’I ve seen some not very nice doctors who have sort of implied that’I m being a drama queen and that I should just get on with it.’
(P18, F, 18–34 years, white)
Although both these patients valued the doctor–patient relationship, and perceived it as being built over time, their descriptions (‘a great guy’ and ‘not very nice’ doctors) are of character traits inherent within the doctor, rather than driven by continuity of care.
GP knowledge and technical competence
Performing an examination (where necessary) and clinical competence were important to patients, but not perceived as being driven by continuity. These attributes and behaviours were raised much less frequently than those related to GP attitude and approach.
