Relational continuity of care

DEMAND for GP locums is at an all-time high – that is, judging by the recent flurry of media stories about a GP recruitment "crisis" and reports of more practice vacancies than ever before. A shortage of primary care staff poses undoubted risks for the NHS but does an over-reliance on locums come with a different set of risks and a reduction in continuity of care for patients?

The benefits of “relational continuity” of care – that is management of a patient by the same clinician over a long period of time – are undoubted. It leads to greater “clinical situational awareness” of the patient with increased knowledge about them and their specific needs, greater trust, higher patient satisfaction and increased emotional support. Evidence has shown that when one clinician takes responsibility for the care of a patient this leads to better health outcomes with increased adherence with treatment plans, lower levels of DNAs and improved uptake of preventative care, in addition to reducing risk in relation to a missed or delayed diagnosis. It is also more cost efficient.

Analysis of the causes of claims at MDDUS finds that a very large proportion of negligence claims are associated with missed or delayed diagnosis. A significant proportion of these cases are characterised by failures in communication between several clinicians involved in the treatment of a patient. This can be worse in mental health conditions as research shows that these patients are less likely to have continuity but are one of the groups for which it is most beneficial.

So creating the conditions within which you can provide continuity of care in the absence of relational continuity is essential.

Mitigating risk: informational and management continuity

As continuity of care becomes increasingly limited due to a range of factors, taking steps to build what is often termed as "clinical management continuity" across a team of clinicians is important, as this can help to mitigate negative factors associated with the loss of relational continuity and increased risk.

Practices must ensure that record-keeping across clinicians is consistently good (providing differential diagnosis and plans for management within the consultation note). Communication between clinicians must also be both accurate and timely, with well-organised patient management systems and shared guidelines and protocols used to the maximum to support effective care.

But it is important not to forget that there are also risks associated with high levels of continuity of care and these should also be examined.

Hidden risks of continuity

There are case examples where relational continuity itself can cause risk. In some negligence cases, the level of patient harm has been reduced when a patient has been required by circumstance to consult with a different GP. “Fresh eyes” have led to a change in approach and better outcomes for some patients.

In other cases a "difficult" patient may choose to see the same clinician at every visit, leading to frustration or other negative emotions which can interfere with the primary task of managing the consultation. A clinician’s normal consultation practices may become eroded, for example by not listening effectively or trying to reduce the length of the consultation. This may lead to important clinical flags being missed.

Patient dependence on one particular GP can also lead to unnecessary delays in access to care (i.e. holding out for an appointment with a named doctor).

Action points

• Continuity may matter more with some patients or in some situations. Try to organise services with this in mind (including the way appointments are made available) and empower staff to support relational continuity for these patients.
• Good record-keeping and high levels of management continuity are essential to maintain continuity of patient care. This is even more important when relational continuity is not possible and includes recording differential diagnoses and a management plan where appropriate.
• Consider whether it might be beneficial to encourage some patients to see a colleague if you work in a team. Transparency is important and discussing the positives of this with colleagues and the patient can ensure trust is maintained. Good informational continuity via the medical records will support the patient’s confidence in this approach.