Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England

We thank Deeny, Gardner, and Steventon for their interest in our research and the constructive suggestions to improve continuity of care.

Deeny, Gardner, and Steventon propose physicians and those commissioning services should proactively use strategies to improve continuity of care, for example using prompts when making appointments, and they should monitor continuity of care in their practices. We agree with both these points. Indeed, we are testing strategies to improve continuity of care (including prompts for both patients and receptionists) in our 3D trial on improving care for multimorbidity(1) and we have also created a tool to help practices in the UK to monitor continuity (http://www.bristol.ac.uk/primaryhealthcare/resources/continuityaudit/).

However longitudinal continuity, as measured using routine records, is only part of the story and we would argue that a patients' perspective is also needed to monitor relational continuity. This might highlight among others the role of patients' trust in physicians and patients' experience of interpersonal care, whether an assigned GP is actually their preferred GP, and how accessible this assigned or preferred GP is. Though research by the Health Foundation showed no improvement following the initial rollout of the named GP scheme for older patients(2), follow-up quantitative research is needed to evaluate the named GP scheme now a few years after its introduction as it might take some time to have its effect; such research is currently being conducted at Bristol Medical School. Both monitoring and further research is needed to understand the implementation of continuity of care and its underlying mechanisms to enhance high quality primary care.

1. Man M-S, Chaplin K, Mann C, et al. Improving the management of multimorbidity in general practice: protocol of a cluster randomised controlled trial (The 3D Study). BMJ open. 2016;6(4):e011261.
2. Barker I, Lloyd T, Steventon A. Effect of a national requirement to introduce named accountable general practitioners for patients aged 75 or older in England: regression discontinuity analysis of general practice utilisation and continuity of care. BMJ Open. 2016;6(9):e011422.

Competing interests: None declared

In their recent study,[1] Tammes and colleagues found that among older patients, decreased continuity of care with a general practitioner was associated with an increased risk of hospital admission. Their results strengthen the growing evidence that seeing the same primary care physician over time is beneficial for patients, and also associated with reduced utilisation of secondary care,[1,2] which is a priority in many health systems.

Unfortunately, it seems to be increasingly difficult for patients to consistently see the same primary care physician over time. In England, the number of people always or almost always able to see their preferred primary care physician has fallen from 65.3% to 55.6% over the last five years.[3] While high quality primary care is increasingly recognised as playing an important role in reducing utilisation of secondary care, interventions to enhance primary care have largely focused on providing timely access. For example, in England the current policy is to ensure access to routine GP appointments in evenings and at weekends.

We know that continuity of care is valued among older patients (those most likely to experience hospital admission), and physicians alike. Studies such as that by Tammes et al. have demonstrated that it is also associated with better outcomes for patients and reduces pressure on the secondary care system. We would therefore suggest a practical way forward is now needed for front-line clinical teams, commissioners and policy makers to improve continuity of care.

In their conclusion, the authors reference a recently introduced policy to appoint a named accountable GP for every patient in England; they suggest that this may be a mechanism to improve continuity of care. In fact, a recent evaluation found that there was no demonstrable improvement in either continuity of care and patient outcomes following the initial rollout of this intervention for all over 75 year olds.[4] As an alternative we would call for further support for primary care physicians and those commissioning services to monitor continuity of care in their practice, and implement locally appropriate initiatives for those most likely to benefit.[5] For example, to improve continuity for patients, practices who are not already doing so could implement interventions such as setting prompts on their booking systems-- encouraging receptionists to book patients to their usual physician, and encouraging patients to request their usual physician.[5] Practices and those commissioning care could monitor the success of such interventions, and any other changes in the practice, by calculating the continuity of care that patients receive from their electronic health records.[2]

Continuity of care is important to many patients, and is highly valued by primary care physicians who consider it integral to their profession. The increasing body of evidence now suggests that is also a key component of high quality care, and may reduce utilisation of costly secondary care.

1. Tammes P, Purdy S, Salisbury C, et al. Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England. Ann Fam Med 2017;15 :515-22. doi:10.1370/afm.2136
2. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data. BMJ 2017;358:j84.
3. NHS England GP Patient Survey 2017 https://www.england.nhs.uk/statistics/2017/07/06/gp-patient-survey-2017/
4. Barker I, Lloyd T, Steventon A. Effect of a national requirement to introduce named accountable general practitioners for patients aged 75 or older in England: regression discontinuity analysis of general practice utilisation and continuity of care. BMJ Open 2016;6:e011422. doi:10.1136/bmjopen-2016-011422
5. Deeny S, Gardner T, Al-Zaidy S, et al. Briefing: Reducing hospital admissions by improving continuity of care in general practice. Heal Found Published Online First: 2017. http://www.health.org.uk/sites/health/files/ReducingAdmissionsGPContinuity.pdf

Competing interests: None declared