Themes
Many themes highlighted in this review relating to the perceived importance (or not) of continuity, factors influencing its attainment, or downstream consequences are frequently inter-related and not specific to remote approaches per se. However, widespread remote approaches may add a level of nuance and complexity to continuity through interactions with wider factors influencing the quality of access and consultations, in particular the underpinning principles of clinical ethics and ethics of care.
Sparsity of studies specifically reporting and measuring continuity.
Of the initial 176 studies selected for full-text analysis, it was notable how few looked explicitly at continuity. Most were rejected because it was impossible to differentiate continuity from broader concepts such as ‘pre-existing relationships’ between patients and their primary care teams or a doctor’s ‘prior knowledge’ of their patients. Moreover, few studies differentiated between aspects of continuity. Johnsen et al43 looked specifically at relational and episodic continuity, while Trabjerg et al,44 Hansen et al,38and Tönnies et al41 reported improved managerial and informational continuity with integrated primary–specialist consultations without referring to it as such, for example, describing ‘more coherent patient trajectory[ies] ’ and ‘roles and tasks [becoming] more apparent to both patients and professionals and [sharing] knowledge between health sectors’.44
Patient factors influencing continuity of care.
Several studies reported the value some individuals placed on relational continuity with ‘their’ GP or primary care clinician.33–35 Sometimes this was because of uncertainty with less visible aspects of continuity (such as informational continuity) or because relational continuity itself was valued. For example, one participant with ongoing mental health problems reported their concern that ‘it’s quite complicated and my preferred GP knows me from day one and has worked with me and referred me and supported me … I just didn’t know how much this person knew’.33
In one study, patients who valued relational continuity actively chose a telehealth appointment with their GP over an in-person consultation with a different GP.36
Health professional factors influencing continuity of care.
Some GPs emphasised the importance of consultations (remote or face-to-face) with known patients,37,40,42 with some indicating such knowledge was a prerequisite for effective consultations.42 Some GPs reported how the flexibility of remote approaches could enhance this continuity with their patients by allowing them to keep their ‘finger on the pulse much more’.37 Johnsen et al43 used a nationwide survey of Norwegian GPs to quantify the value GPs placed on relational and episodic continuity in determining the suitability of using video consultations. Both measures of continuity resulted in statistically significant higher suitability ratings, suggesting that GPs viewed remote consultations as more suitable for follow-up presentations, particularly in the context of high relational continuity.
System factors influencing continuity of care.
Some studies reported improved access to patients’ usual or preferred GP with remote care approaches,33,35 with one patient using an Australian GP telehealth model reporting that ‘in fact, I’m probably seeing him [the GP] more now via the phone’.35 However, some also reported a trade-off for patients between continuity and ease or speed of access.33,40,45 Salisbury et al45 carried out an independent evaluation of Babylon GP at Hand (BGPaH), a private company offering NHS GP consultations, and found that individuals choosing BGPaH, who were generally young with few long-term health needs, did so because of speed and ease of access, deprioritising continuity. However, some patients with complex needs were concerned about its absence because, as one BGPaH user stated, ‘there’s nothing for long-term health management’.45
Several studies illustrated the strategic development of remote approaches to improve relational, informational, and managerial continuity both within and between the healthcare system. Integrated care consultations, for example, whereby the patient and GP were situated together in the GP practice and conducted a joint remote consultation with an oncologist, were shown to improve understanding of the roles of different specialists (such as cancer and mental health) in the patient’s journey, resulting in a more coherent care pathway and improved managerial continuity.38,41,44
In two studies, patients, GPs, and oncologists believed that such integrated consultations contributed to better continuity of care and thus health outcomes, with all involved gaining a better understanding of how to optimise managerial and informational continuity,38,44 although such structures may be considered to be pushing the boundaries of traditional general practice activities, relating more to the primary–secondary care interface.
Furthermore, one study reported health policy experts’ opinions that the relationship of trust between a GP and patient, often formed over ‘a long time’ (that is, reflecting relational continuity), could help motivate patients to engage in remote consultations with mental health specialists,41 while oncologists reported how the ‘long-established relationships [between GP and patient] could help overcome mistrust of specialists or the wider system’ .38
Finally, informational continuity was deployed strategically to contact vulnerable patients proactively by telephone, demonstrating the value of combining continuity and remote approaches.40
Other studies reported patients’ concerns about the implementation of remote approaches in systems, such as telephone triage or same-day appointments, which could make it more difficult to access their preferred GP. This resulted in frustration, distress, harm, and increased inefficiencies.33,34,47
One older male patient with complex conditions reported an attempt to contact his preferred GP: ‘I said what was wrong and that I needed to see the Doctor. She says well Doctor [X] is not in today — phone tomorrow. Bump [phone being hung up]. So I phoned the next morning at 8 o’clock. Phones off. I phoned every 5 mins till 8.30 am — it came on, “surgery’s now full’, phone Monday … It’s that bad you couldn’t make it up. If they had someone to report it to I’d prosecute them.’33
Similarly, another user of an online platform reported multiple consultations because, ‘I have high blood pressure. I’ve been trying to get in touch with the doctor to explain what I need to do … I’ve had two blood tests in the space of 2–3 weeks and have no idea what’s going on.’47
The patient–doctor relationship.
Many patients and healthcare practitioners believed that remote consultations in the context of pre-existing relationships were easier, safer, and of higher quality.33–35,38,42,44,46,49 There was a general recognition that continuity was only one aspect in such relationships, with mutual trust, respect, active listening and communication, compassion, empathy, and rapport building all thought to be important.
Many healthcare professionals considered relational or episodic continuity essential for eliciting the subtleties in patients’ concerns. Verhoeven et al40 found that, while the focus of a telephone triage may be on obvious complaints, where GPs knew patients well they could detect other aspects. As one GP responder stated, ‘most of the time the consultations are about a physical symptom … but when you ask a bit more you hear they are actually very worried’. ‘Very worried’ might represent psychological distress or serious patient or parent concern about any complaint. Similarly, Johnsen et al43 demonstrated that video consultations were deemed more suitable for follow-up consultations rather than first presentations (even when there were high levels of relational and/or episodic continuity), reflecting a concern that remote approaches may miss information that would be obtained in person, which is potentially more important in first presentations.
Remote approaches also affected presentation rates according to whether individuals thought their health needs were met, for example, patients with mental health or chronic conditions reported missing the social cues and body language or struggling with digital systems in times of deterioration. They were concerned about their ability to form a relationship with the clinician, resulting in less satisfying/successful encounters, and reduced presentations.33,36
In contrast, high-frequency users of an online platform — again who often had complex chronic or mental health conditions — perceived a lack of continuity of care, generating repeated consultations because of a perception of unmet health needs.47
However, the BGPaH evaluation reported a high level of patient satisfaction, with participants rating that their needs had been met, the clinician had listened and treated them with care and concern, and that they had confidence and trust in the clinician.47 Despite methodological concerns about recruitment bias, this suggests that relational continuity is not essential for a successful consultation. This finding was supported in a study by Imlach et al,34 in which patients reported successful remote consultations in the absence of a pre-existing relationship and unsuccessful ones in its presence, depending on whether an effective rapport was generated.
Risks of the impact of remote care on continuity.
Several studies highlighted the potential for remote approaches (or their implementation) to exacerbate inequities of care by reducing relational or episodic continuity for patients who value such care and for whom continuity is likely to significantly impact outcomes, such as those with complex or chronic conditions.33,34,39,42,45
Similarly, Swedish GPs expressed concern at the trade-off between ease of access and a resultant increased workload, which might impair continuity for those needing it by overwhelming the system.42 They described digitalisation as a ‘stressful time thief’, explaining that if ‘health care becomes too accessible only minor ailments can be dealt with. Because health care resources are insufficient, this contact method takes resources from those who need it better’, in other words, older people with multimorbidity.42 Remote approaches targeting long-term conditions, such as asynchronous blood glucose or blood pressure monitoring, could compromise safety if the submission processes did not identify an appropriate clinician with sufficient time to deal with them.42
Flexibility was highlighted as essential for effective implementation of remote approaches, with contrasting views as to whether patient choice or need should predominate.33,35,37,39
One GP from a practice with a highly deprived population described the problems of universal, centralised, and inflexible policy decisions about technology and access, ‘in terms of the technology that Matt Hancock [the UK Secretary of State for Health and Social Care at the time] seems to think is the way forward and just because him and all his peers, you know have access to all the technology, and it’s very convenient for them to consult with their GP via Zoom, that is not how it is for the people where I work’.39 Not only did remote care reduce managerial continuity but also generated barriers between the practice and the wider community.
Patients and clinicians also expressed clinical safety concerns with remote approaches, which could be mitigated but not eliminated through continuity. Despite high episodic and relational continuity, and a large number of follow-up appointments, 15% of the video consultations reviewed in Johnsen et al’s study43 were believed to risk missing serious illness, a sentiment echoed by patients, particularly when they were unable to see their usual GP.35,37 Moreover, continuity cannot make up for technical or contextual factors that limit remote care such as digital poverty, lack of safe spaces for consultations, or the impact of illness itself such as mental health crises. 36,39