Relational continuity of care, the extent to which patients have an ongoing relationship with a specific clinician in their GP practice, is perhaps one of the most well researched aspects of primary care service delivery.
The evidence is as clear as it gets in this complex territory. Care continuity leads to improved patient outcomes, lower healthcare use, and increased job satisfaction for GPs. It’s good for everyone, but especially for patients with complex needs. And yet care continuity has been in decline for as long as we’ve been measuring it. As David Haslam puts it, continuity has become “an unrealistic dream”. The trend has been so consistently downward, that you would be forgiven for thinking that there must be something inevitable about it. Some force of nature, or some aspect of modernity, that means that this trend cannot be resisted: that all we can do is work around it and minimise the consequences.
Two pieces of research have been published in the last few weeks, that remind us that this is not the case: that there is nothing inevitable about the decline in relational care continuity.
First, the latest of a series of surveys about the care of older people conducted in ten high-income countries, and published by the Health Foundation. Survey respondents were asked if there was “one doctor you usually go to for medical care?”. The same question was asked of a fresh cohort of patients in 2014, 2017, 2021 and 2024. The UK saw a 20-percentage-point reduction in the proportion of respondents answering positively to this question between the first and last survey. Levels were steady in all other countries. So, whatever is driving down care continuity in the UK, it is not being experienced in France, Germany, Switzerland, Netherlands, Sweden, Canada, the US or New Zealand.
Second, a paper published in BJGP by a consortium of authors, including the Strategy Unit, led by Professor Tom Marshall at the University of Birmingham, about the role of continuity in efficient and sustainable primary care. The paper proposes that the decline in care continuity in the UK is driven in part by the policies we have adopted to improve access. The authors reference “growing use of non-GPs in primary care, fragmentation of primary care into on-call services, walk-in centres, and the use of pharmacies for first-contact care”. The growth in telephone and digital triage, along with mergers and federation of GP practices, could be added to this list. On this basis we should perhaps regard the decline in continuity as a policy choice, rather than as an irresistible external force.
The policy choice is often presented as a simple trade-off between patient access and care continuity. The argument goes that we can either have good access to GP services or care continuity, but we can’t have both. In this context, policy makers favour what patients appear to shout loudest for, improved access, and care continuity is sacrificed. Choosing between two mutually exclusive and incomparable goods is never easy. There is no technocratic solution. Only an appeal to values will cut the mustard, and this is the realm of elected politicians. We might disagree with the choice that they have made, but it is their choice to make.
Unfortunately, this presentation of the problem, is misleading. There is no simple choice between access and continuity. We have prioritised access through the many policies set out above, and sacrificed continuity, but we have not seen any improvements in access. In fact, access has also deteriorated. In 2012, around 4 in 5 patients found it easy to get through to their practice by telephone. This has fallen to around 1 in 2 patients. Some might argue that if it hadn’t been for our policies, access would have been even worse than it is now. I don’t recall the policy decisions being framed this way when they were proposed. And I don’t think we can claim that this is a failure of implementation. We have seen massive change in the structure and operations of primary care over the last 20 years in line with the policy objectives. So, what can explain these counter-intuitive results?
Work by Tom Marshall, Denis Pereira Gray, and the Strategy Unit, point to the answer. Second-order effects introduce an asymmetry between policies that seek to improve access and those that priortise care continuity, overwhelming any short-term trade-offs. The second order effects of seeking improvements in access at the expense of care continuity, erode any improvements in access over the long-term, by increasing demand and reducing supply. Demand increases because patients who do not see their usual GP, return sooner to the practice for their next appointment. And supply reduces because it is more difficult to recruit and retain permanent, fully-qualified GPs in a context where care continuity has been displaced. We walk towards our goal, but the wind is blowing in our face (the second order effect) pushing us in the opposite direction despite our best efforts. This is the route we are on, and the harder we push, the stronger the wind gets, always taking us away from our goal. This is why access has steadily declined, despite 20-years of primary care policy aimed at addressing this problem.
The alternative, seeking to improve care continuity, is a longer route, perhaps initially facing away from our goal. This policy choice also has second order effects, but these effects slowly improve access by reducing demand and increasing supply, through the same mechanisms that have defeated our access-based policies. The route may be longer, but the wind is at our back, working with us, and, given time, resolves the apparent conflict between continuity and access.
Changing direction would be brave at this stage. It would mean acknowledging that the current policy was theoretically flawed. Many staff have invested a huge amount of time and effort, with good intentions, to pursue our access-based policies. This has not been entirely in vain. We have learnt a lot in the process. The evidence in favour of the continuity route is building, and a growing number of researchers and practitioners are getting behind the idea. If it turns out we are on the wrong path, then the longer we stay on it, the longer it will be before we see sustainable improvements.
A new qualitative study by Patrick Burch and colleagues at the Universities of Manchester and Keele, concludes with a stark assessment of the urgency of our predicament.
“We may be reaching a tipping point where a critical mass of patients view general practice solely as a method of accessing biomedical services from whatever staff member is available. If we want to improve continuity, we need to act before changes in attitudes and care delivery make change an impossibility.”
Many reading the 10-year plan for the NHS will be pleased that it acknowledged the importance of care continuity. The delivery plan, expected later this year, provides an opportunity to break from the past, and make continuity the north star for GP services.