I’m looking for a long-term relationship

Finding and sticking with one health professional you can trust is an important part of health care.  With the move to a more team-based approach in many health services, is this still possible and what are the implications for long-term relationships?  How is the tension between quick access to health care when needed (or wanted) consistent with patient-health professional relationships and continuity of care?

Traditionally, in those countries that have a strong primary care system, the general practitioner (GP) or family physician has been the health professional with whom to maintain a relationship over time.  

I was a GP in England in the same general practice for 16 years with several of my GP partners working there for over 30 years.  The paper medical records went back for some patients to the early part of the 20thcentury.  A high proportion of our elderly patients had lived in the practice area all their lives. Of course, with a patient population of 18000 amongst 8-10 doctors I could not know everyone who consulted or that I visited when on-call.  Patients tended to be loyal to ‘their’ GP but had the option of seeing another GP, or practice nurse, as necessary, particularly when theirs was away from the practice.  The continuity was good.

Continuity of care has been defined in 1985 as ‘care from one doctor, usually spanning an extended time and more than one episode of illness’.[1]  There are several reasons why such continuity is difficult to achieve in the 21st century.  Many consumers and doctors are more mobile, moving from place to place and job to job.  It is unusual for GPs to provide 24-hour care to their patients, for work-life balance and safety reasons.  

Team-based care recognises that a doctor may not be the most appropriate person for the patient for each episode of care.  Continuity is perhaps best reconsidered as ‘care from one team of health professionals…’ To work, and avoid fragmentation of care, this means that patient records are comprehensive, up-to-date, understandable by all and accessible when required. Patients need to be helped to understand the role of each health professional and be advised, as necessary, who is most appropriate for the problem/condition.  This of course does depend on the health system and any cost to the patient. 

Where possible, within the constraints of modern primary care, patients should be able to see the health professional of their choice.  This will be difficult if the patient needs a same day appointment, but again the patient records should be helpful.  

In the UK patient records are transferred when a registered patient moves from one general practice to another. In other countries, records may remain with a practice or practitioner until requested by another practitioner.  The move to electronic records that are stored in a more central (cloud-based) system than a practice’s database help with continuity.  Patient-held records and patient portals also contribute to a comprehensive picture of a person’s health history. 

There is a wealth of evidence that indicates continuity of care in general practice is linked to higher patient satisfaction, improved medicine taking and lower numbers of hospital visits.A recent review concludes that patient-doctor continuity is also associated with significant reductions in mortality in different populations and healthcare systems.[2]

Continuity of care is aspirational in many healthcare settings and communities.  It is perhaps possible as one or more of the types of continuity described below.  For both consumer and health professional, there will be a mix of very short, short and longer-term relationships.

Types of continuity[3] [4]

Longitudinal (care over time) by one professional or one team

Personal (care of an individual): nature and quality of interactions more important than the quantity

Informational continuity: information sharing amongst health professionals and the patient; high quality accessible records

Management continuity: a consistent and coherent approach to the management of a particular health condition but that is responsive to the patient’s needs and choices

Relational continuity: an ongoing therapeutic relationship between a patient and one or more professionals (in a team or wider collaboration) 

[1] Freeman G. Priority given by doctors to continuity of care.  Journal of the Royal College of General Practitioners 1985; 5: 423-426.

[2] Pereira Gray DJ, Sidaway-Lee K, White E, et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJOpen 2018; 8e021161. doi: 10.1136/bmjopen-2017-021161 

[3] Haggerty JL, Reid RJ, Freeman GK et al. Continuity of care: a multidisciplinary review. BMJ 2003; 327: 1219-1221

[4] Thistlethwaite J, Morris P.  The patient-doctor consultation in primary care.  London: RCGP, 2006.

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