Summary of main findings
Patients regarded and used primary care in a variety of ways in relation to continuity of provider and access to care. Their use was shaped by their own preferences, by the organisation and culture of their primary care practices, and by their own and their provider's efforts to achieve their preferences. Different configurations of these factors gave rise to different types of continuity. Patients were not always able to achieve the type they wanted. Patients with apparently similar consulting patterns could experience them differently.
Strengths and limitations of the study
Participants were recruited to the study from a wide range of primary care contexts and included those with diverse social and demographic characteristics. Multiple types of data were collected from different sources, which meant that the details of specific consultations could be placed in a broader context, and information from the patient could be compared with medical records provided by the practice. Patients were followed longitudinally, which enabled us to look in detail at how different types of continuity of care were achieved and maintained over an extended period.
However, the sample size is small and the follow-up period limited to a year. While the patterns described are likely to be enduring at the population level, at an individual level we found examples of patients who showed signs of changing the way that they used services in the context of their evolving experience and circumstances. A longer study period with a larger sample would have allowed a fuller exploration of how and why some patients alter the way they use primary care services.
Comparison with existing literature
All the types of continuity described by Haggerty et al16
were found in our study and our analysis allows a further consideration of the distinctions and relationships among them.
In the UK, where patients register with a general practice, informational continuity is institutionalised in medical records. For at least some of our participants (for example, Mr D), access to medical records was seen as a sufficient basis for good medical care. However, this might be better regarded as the context or foundation for continuity of care, as Saultz suggests, since patients themselves did not appear to experience it as continuity of care. Its limitations are also reflected in the frustration with their care expressed by some participants (for example, Mr F) who relied on it.
Similarly, in the one example of management continuity in the study, Mr C regarded the efforts of known members of his general practice and the mental health team to maintain a consistent approach to his care as a poor substitute for continuing care from his ‘own’ providers.
Several participants (for example, Mrs E) received care from a single GP over the study year but without preferring or ‘choosing’ to do so. These patients received what Saultz referred to as longitudinal care: care from the same doctor over time but without an ongoing personal relationship between patient and provider. This was continuity produced by the way practices operated and was not recognised or experienced as such by patients. The attitudes of patients in this group support the distinction Saultz made: where patients are indifferent to which doctor they see, continuity of provider over time does not constitute interpersonal continuity.
By contrast, patients (for example, Mrs A) who both valued and achieved continuing care from their ‘own’ GP experienced this as personal care. These patients received what Saultz described as interpersonal continuity, distinguished from ‘lower’ forms of continuity by a sense of personal trust and responsibility. This type of continuity required commitment and effort from patient and doctor alike and appeared to produce a mutually rewarding relationship.
Two patterns found in this study help to address questions raised by Saultz as to how long and under what circumstances interpersonal continuity can survive when a patient does not see the same provider. Patients (for example, Mrs G) who saw a preferred GP for some conditions and looked for swift access for others, nonetheless succeeded in maintaining a relationship with their ‘own’ GP, which suggests that interpersonal continuity need not be exclusive. Where patient and doctor regard each other as their ‘own’ and see each other regularly, their personal relationship can withstand a good deal of selective and instrumental use of other services and practitioners. However, the experience of patients who preferred to see their own GP but were unable to do so suggests that some indication of mutual loyalty is needed to sustain interpersonal continuity over the longer term. As the example of Mr C illustrates, patients who do not receive continuity may include those with social and psychological problems and those who have difficulties in forming satisfactory personal relationships.23
It is these patients in particular for whom commitment from their ‘own’ doctor, supported by receptionists carrying out practice policies, may be most necessary (although most difficult to sustain) if the interpersonal continuity they desire is to be achieved.21
Implications for policy and clinical practice
The place of continuity of care in today's increasingly complex primary care services is under debate. Underlying this debate are simplistic models of access to care24
and unjustified assumptions about access to information as a sufficient basis for continuity of care. Our findings, like those of Rubin and colleagues,25
suggest that while patients may prefer shorter waiting times, convenience of appointment may be more important to some and an appointment with their ‘own’ provider more important to others. Flexibility is necessary to take account of the preferences and priorities of different patients, particularly when they experience barriers to obtaining the type of continuity they seek. Policymakers should seek ways to reward GPs' commitment to responding to patients' preferences and choices in this respect and adopt policies that promote flexibility rather than introduce uniformity. GPs can then give less attention to debating the respective merits of continuity and access, and more to fostering commitment to meeting the preferences of different patients with flexibility and understanding.