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Research ArticleOriginal Research

Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007

Stephen M. Campbell, Evangelos Kontopantelis, David Reeves, Jose M. Valderas, Ella Gaehl, Nicola Small and Martin O. Roland
The Annals of Family Medicine November 2010, 8 (6) 499-506; DOI: https://doi.org/10.1370/afm.1145
Stephen M. Campbell
PhD
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Evangelos Kontopantelis
PhD
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David Reeves
PhD
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Jose M. Valderas
PhD
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Ella Gaehl
MPhil
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Nicola Small
MPhil
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Martin O. Roland
DM
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  • This stepchange in continuity will not self-correct
    George K FREEMAN
    Published on: 18 November 2010
  • Interdisciplinary Teamwork and the Continuity-Access Tradeoff
    Hector P. Rodriguez
    Published on: 15 November 2010
  • Published on: (18 November 2010)
    Page navigation anchor for This stepchange in continuity will not self-correct
    This stepchange in continuity will not self-correct
    • George K FREEMAN, Reading, England

    When Stephen Campbell presented an outline of these findings at the Annual Scientific Meeting of the UK Society for Academic Primary Care in July 2009, he referred to a ‘step- change’ in patients’ perception of continuity. This paper fills in a lot of the details and elegantly shows the ability of a committed and well-funded long-term research programme, repeatedly reviewing a large enough sample of practitioners and pa...

    Show More

    When Stephen Campbell presented an outline of these findings at the Annual Scientific Meeting of the UK Society for Academic Primary Care in July 2009, he referred to a ‘step- change’ in patients’ perception of continuity. This paper fills in a lot of the details and elegantly shows the ability of a committed and well-funded long-term research programme, repeatedly reviewing a large enough sample of practitioners and patients, to document their experiences through successive changes (both intended and otherwise) in service delivery.

    All the NHS changes have worked both singly and together to reduce the personal element in clinical practice, and yet we know that making care personal and encouraging therapeutic relationships is a key selling point for our specialty.

    There is no reason to suppose that this step-change will automatically correct itself. All the factors inducing it remain in place; also, over time, patients may less for personal care which they do not experience. Meanwhile there are other negative pressures such as increasing numbers of young, often part-time doctors on short-term contracts and little incentive for practices to invest in long-term partners. Clinicians on long term contracts have more to gain from investing in therapeutic relationships with patients. Investment in multiple access points to primary care such as the NHS Direct telephone response service and in walk-in centres where patients need not register, also discourage longer term relationships.

    Relationship continuity is not necessarily always best for patients and it is not always top of patients’ priorities for excellent primary health care, but in the English context there is no doubt that patients want for more of it than they are currently getting. Hughes and I have recently reviewed this evidence for the London based King’s Fund, which is about to publish the report of its ‘Inquiry into the Quality of General Practice in England’ (1). We have concluded that relationship continuity needs a far higher profile – including both incentives and practical help in how to maximise it, together with greater political awareness in policy makers and other key stakeholders. Continuity can no longer assumed to ‘just happen’ as an integral part of General Practice/Family Medicine. We must all actively work for it.

    Reference 1

    Freeman GK, Hughes J. Continuity of care and the patient experience. An Inquiry into the Quality of General Practice in England commissioned by The King’s Fund July 2010. http://www.kingsfund.org.uk/current_projects/gp_inquiry/dime nsions_of_care/continuity_of_care.html (accessed November 2010).

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (15 November 2010)
    Page navigation anchor for Interdisciplinary Teamwork and the Continuity-Access Tradeoff
    Interdisciplinary Teamwork and the Continuity-Access Tradeoff
    • Hector P. Rodriguez, Los Angeles, CA, USA

    Campbell and colleagues conduct a rigorous assessment of changes in primary care patients’ experiences stemming from recent National Health Service reforms (1). Their results highlight an important tension between improving access to primary care and achieving continuity of primary care. The implementation of changes to the delivery of chronic illness care resulted in improved access to care scores for patients’ with chro...

    Show More

    Campbell and colleagues conduct a rigorous assessment of changes in primary care patients’ experiences stemming from recent National Health Service reforms (1). Their results highlight an important tension between improving access to primary care and achieving continuity of primary care. The implementation of changes to the delivery of chronic illness care resulted in improved access to care scores for patients’ with chronic illness (3 points out of a 100-point scale). At the same time, continuity reports and ratings declined by approximately 7 and 5 points, respectively, for patients with chronic illness and a by a similar amount for general primary care patients.

    Previous research has underscored the challenges and tradeoffs associated with employing interdisciplinary primary care team approaches (2). For example, a previous study indicates that patient-reported experiences of primary care were lower for patients who had less visit continuity with their primary care physician irrespective of whether or not the visits with other clinicians were with primary care team members (3). The Campbell study results underscore the importance of making interdisciplinary primary care teams “real” and “visible” to patients. Shared care arrangements need to be organized and presented to patients in ways that support the physician-patient relationship rather than distract from it.

    It would be very interesting to explore the extent to which there is clinic-level variation in the access and continuity changes over time. For example, a practice that was more successful with implementing interdisciplinary primary care team approaches might be able to achieve access improvement without compromising continuity ratings. The teamlet model of primary care (4), for example, attempts to maximize the clinician and staff scope of practice using a relationship-centered approach that includes pre- and post-visit self-management support. Multidisciplinary primary care teams are a core feature of the patient-centered medical (PCMH) model (5) and more attention should be devoted to understanding the factors that enable their effectiveness.

    References

    1. Campbell SM, Kontopantelis E, Reeves D, et al. Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007. Annals of Family Medicine 2010;8:499-506

    2. Safran DG. Defining the future of primary care: what can we learn from patients? Annals of Internal Medicine 2003;138:248-255

    3. Rodriguez HP, Rogers WH, Marshall RE, et al. Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care. Medical Care 2007;45:19- 27

    4. Bodenheimer T, Laing BY. The teamlet model of primary care. Annals of Family Medicine 2007;5:457-461

    5. Nutting PA, Miller WL, Crabtree BF, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Annals of Family Medicine 2009;7:254-260

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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The Annals of Family Medicine: 8 (6)
The Annals of Family Medicine: 8 (6)
Vol. 8, Issue 6
1 Nov 2010
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Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007
Stephen M. Campbell, Evangelos Kontopantelis, David Reeves, Jose M. Valderas, Ella Gaehl, Nicola Small, Martin O. Roland
The Annals of Family Medicine Nov 2010, 8 (6) 499-506; DOI: 10.1370/afm.1145

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Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007
Stephen M. Campbell, Evangelos Kontopantelis, David Reeves, Jose M. Valderas, Ella Gaehl, Nicola Small, Martin O. Roland
The Annals of Family Medicine Nov 2010, 8 (6) 499-506; DOI: 10.1370/afm.1145
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