INTRODUCTION
Continuity of GP care, defined as a patient seeing a GP repeatedly over time, was a core principle in general practice, but has fallen in recent years.1 Recently, however, continuity has suddenly moved from the shadows of policymaking to centre stage through research showing a dozen beneficial outcomes associated with it.2–5 Although most of the evidence is observational, recent evidence has found a dose–response relationship in general practice.2 On the balance of probabilities, continuity of care is beneficial for patients. However, while the evidence for continuity has never been stronger, BJGP Editor, Euan Lawson, wrote ‘we are losing this battle’.6
National averages conceal large local variations, and attitudes to the continuity of GP care now vary greatly. On the one hand, there are the majority of general practices that usually use the pooled list system of practice organisation. These practices mostly devolve continuity to patients and accept that substantial continuity of GP care is now too difficult to provide for more than a minority of patients. On the other hand, there is a smaller group of general practices that believe continuity of GP care remains fundamental and which provide good continuity, usually through personal lists. We write from one of these in a practice that has used personal lists continuously for 48 years. The philosophy being that for GP continuity every patient counts.
TWO SYSTEMS
Differences between the two systems are that with personal lists a single GP accepts long-term responsibility for a list of patients and seeks to empower (inform and encourage self-care) them over time. Patients are systematically encouraged to see their own GP, either face-to-face or remotely. Whereas, in pooled list practices the practice collectively takes responsibility for every patient, and after a consultation doctor and patient may not expect to see each other again as continuity is provided on an ad hoc basis. This affects how much information patients disclose and reduces incentives for GPs to plan ahead.
Personal lists are little discussed in GP educational meetings. The MRCGP examination does not test understanding of them. It is often stated that personal lists can’t work nowadays despite them having been successfully used for 20 years throughout Norway.2 We estimate around one in ten practices in England currently use personal lists, with perhaps as many as a quarter in the South West (unpublished data, 2022).
Internal practice organisation affects patients through the very different levels of GP continuity produced. Although all practices are required to give all patients a named, accountable GP (defined in the NHS GP contract), many practices interpreted this as an administrative exercise and do not encourage patients to see their named GP. A key level of GP continuity in personal list practices is whether the average patient will encounter their named GP more than half the times they consult. As early as 1979 Pereira Gray described personal lists as: ‘the key to personal care’.7
There are several studies showing GP continuity is associated with better quality of GP care, both in acute situations, such as children with possible meningitis, and in the management of chronic disease8 and dementia.4 Patients have lower mortality with doctor continuity3 and primary care continuity specifically.9
A QUIET DIVISION
The Select Committee on Health and Social Care is reviewing general practice. It focused on continuity while interviewing the Secretary of State for Health and Social Care and drew his attention to the remarkable size of the benefits for patients in two new studies on continuity of GP care, both published in the BJGP.2,4,10 These both found significantly fewer admissions to hospital with GP continuity and other important benefits for patients, notably more than halving the incidence of incontinence in patients with dementia. The Secretary of State for Health and Social care agreed that having GPs who know their patients is likely to be beneficial.10
The Select Committee on Health and Social Care has created an opportunity for leading GPs, including Iona Heath, former President of the Royal College of General Practitioners, to support continuity (evidence number: FGP0381).11 Also, a small group of leading-edge personal list practices have reported providing good levels of GP continuity. All evidence can be viewed on the cited government website.11 Jacob Lee (FGP0254) and colleagues, with over 17 000 patients in a socially deprived area in Bristol, report measured GP continuity of over 50% of appointments with the personal GP. Luke Sayers (FGP0093) and colleagues in North Tyneside report 85% GP continuity across a practice with over 12 500 patients. In Devon we are joined by Sam Hilton (FGP0160) and William Sherlock (FGP0087). Also, Liz Grimshaw and partners, in Bristol, provide 75% GP continuity and have received accolades and awards from patients (Liz Grimshaw, personal communication).
The Select Committee on Health and Social Care’s evidence reveals that general practice has quietly divided into two groups. The majority, usually using pooled lists, perceive a sea of requests for appointments, many from people they do not know well. Some fear drowning under demand. Yet amid this sea there are islands of hope and confidence for the future, with reports from a small minority of practices all using personal lists and providing good, measured GP continuity. They seem more satisfied and more in control of their workload. How can this be?
Personal list practices probably find their workload more manageable for several reasons. First, it is quicker and more efficient to respond to a patient’s problem when the GP knows the patient and immediately sees the context; agreeing management plans is much easier too. Patients do not like having to repeat their story. Practices run more smoothly with clarity of clinical responsibility. Successive consultations with the same patient add ‘accumulated knowledge’12 of progressively increasing value. GPs provide higher quality care to patients whom they have seen repeatedly. GP continuity breeds trust by patients13 who then disclose more sensitive information, follow advice more often,14 take medication more efficiently,5 accept personal preventive advice more often, potentially preventing several diseases, and are more empowered over time.
CONCLUSION
The shortage of GPs is a national priority to remedy, but meanwhile the greater the shortage the greater the logic that existing GPs work as effectively as possible. The evidence is that GPs add most value when consulting with patients whom they have seen before.
Despite widespread part-time working, despite the influx of many other health professionals, including pharmacists and physiotherapists, who will provide valuable technical care, and despite lack of recognition by NHS England, GP continuity remains a key feature of efficient general practice. It is high time that NHS England required computer suppliers to provide practices with core management data, including measured continuity.
Continuity in the UK has been damaged by four myths: that GP continuity is not clinically important and that GPs are interchangeable; that part-time GPs preclude its provision; that personal lists are old-fashioned; and that measuring GP continuity is difficult. Recent evidence greatly undermines these myths. The continuity tide may be turning.
Continuity will enable GPs to be the professionals in general practices of the future with the widest generalist knowledge, applying it to patients they get to know, through a biographical perspective. GPs in future will become, through continuity, the patient’s most trusted adviser, supported by a wider team.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2022
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