Ongoing Decline in Continuity With GPs in English General Practices: A Longitudinal Study Across the COVID-19 Pandemic.

PURPOSE: Relationship continuity of care has declined across English primary health care, with cross-sectional and longitudinal variations between general practices predicted by population and service factors. We aimed to describe cross-sectional and longitudinal variations across the COVID-19 pandemic and determine whether practice factors predicted the variations. METHODS: We conducted a longitudinal, ecological study of English general practices during 2018-2022 with continuity data, excluding practices with fewer than 750 patients or National Health Service (NHS) payments exceeding £500 per patient. Variables were derived from published data. The continuity measure was the product of weighted responses to 2 General Practice Patient Survey questions. In a multilevel mixed-effects model, the fixed effects were 11 variables' interactions with time: baseline continuity, NHS region, deprivation, location, percentage White ethnicity, list size, general practitioner and nurse numbers, contract type, NHS payments per patient, and percentage of patients seen on the same day as booking. The random effects were practices. RESULTS: Main analyses were based on 6,010 practices (out of 7,190 active practices). During 2018-2022, mean continuity in these practices declined (from 29.3% to 19.0%) and the coefficient of variation across practices increased (from 48.1% to 63.6%). Both slopes were steepest between 2021 and 2022. Practices having more general practitioners and higher percentages of patients seen the same day had slower declines. Practices having higher baseline continuity, located in certain non-London regions, and having higher percentages of White patients had faster declines. The remaining variables were not predictors. CONCLUSIONS: Variables potentially associated with greater appointment availability predicted slower declines in continuity, with worsening declines and relative variability immediately after the COVID-19 lockdown, possibly reflecting surges in demand. To achieve better levels of continuity for those seeking it, practices can increase appointment availability within appointment systems that prioritize continuity.

Does shortage of GPs matter? A cross-sectional study of practice population life expectancy.

BACKGROUND: There are not enough GPs in England. Access to general practice and continuity of care are declining. AIM: To investigate whether practice characteristics are associated with life expectancy of practice populations. DESIGN AND SETTING: A cross-sectional ecological study of patient life expectancy from 2015-2019. METHOD: Selection of independent variables was based on conceptual frameworks describing general practice's influence on outcomes. Sixteen non-correlated variables were entered into multivariable weighted regression models: population characteristics (Index of Multiple Deprivation, region, % White ethnicity, and % on diabetes register); practice organisation (total NHS payments to practices expressed as payment per registered patient, full-time equivalent fully qualified GPs, GP registrars, advanced nurse practitioners, other nurses, and receptionists per 1000 patients); access (% seen on the same day); clinical performance (% aged ≥45 years with blood pressure checked, % with chronic obstructive pulmonary disease vaccinated against flu, % with diabetes in glycaemic control, and % with coronary heart disease on antiplatelet therapy); and the therapeutic relationship (% continuity). RESULTS: Deprivation was strongly negatively associated with life expectancy. Regions outside London and White ethnicity were associated with lower life expectancy. Higher payment per patient, full-time equivalent fully qualified GPs per 1000 patients, continuity, % with chronic obstructive pulmonary disease having the flu vaccination, and % with diabetes with glycaemic control were associated with higher life expectancy; the % being seen on the same day was associated with higher life expectancy in males only. The variable aged ≥45 years with blood pressure checked was a negative predictor in females. CONCLUSION: The number of GPs, continuity of care, and access in England are declining, and it is worrying that these features of general practice were positively associated with life expectancy.

Primary medical care continuity and patient mortality: a systematic review.

BACKGROUND: A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care. AIM: This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care. DESIGN AND SETTING: Systematic review of studies published in English or French from database and source inception to July 2019. METHOD: Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality. RESULTS: Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated. CONCLUSION: This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

'Falling through gaps': primary care patients' accounts of breakdowns in experienced continuity of care.

BACKGROUND: Experienced continuity is important for good quality primary care but may be challenging to achieve. Little is known about how discontinuities or gaps in care may arise, how they impact on patients' experiences and how best to understand them so that they can be avoided or managed. OBJECTIVES: Using the theoretical framework of candidacy, we aim to explore patients' experiences of discontinuities in care and to gain insight into how gaps come to be bridged and why they might remain unresolved. METHODS: A secondary analysis was undertaken of interview data from a large study into continuity in primary care, involving a diverse sample of 50 patients, recruited from 15 general practices, one walk-in centre and community settings in Leicestershire, UK. Analysis was conducted using a constant comparative approach. RESULTS: Experiences of gaps in care were common, arising from failures in communication and coordination of care. Although some gaps were easily bridged, many patients described 'falling through gaps' because of difficulties establishing their candidacy for ongoing care when gaps occurred. These patients commonly had complex, chronic conditions and multi-morbidity. Bridging gaps required resources; relationship continuity was a valuable resource for preventing and repairing gaps in care. When gaps were not bridged, distress and dysfunctional use of health services followed. CONCLUSION: This study demonstrates that some patients with complex chronic conditions and multi-morbidity may be unable to get the continuity they need and highlights the potential for relationship continuity to help prevent vulnerable patients falling through gaps in care.

Generalist solutions to complex problems: generating practice-based evidence--the example of managing multi-morbidity.

BACKGROUND: A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? DISCUSSION: Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a 'complex intervention' (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. SUMMARY: Answers to the complex problem of multi-morbidity won't come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary.

PURPOSE: Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients' experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity. METHODS: From an initial list of 514 potential studies (1997-2007), 33 met our criteria of using qualitative methods and exploring patients' experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes. RESULTS: For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians. CONCLUSION: Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confidence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity.

Service users' and caregivers' perspectives on continuity of care in out-of-hours primary care.

Modernization policies in primary care, such as the introduction of out-of-hours general practice cooperatives, signify a marked departure from many service users' traditional experiences of continuity of care. We report on a case study of accounts of service users with chronic conditions and their caregivers of continuity of care in an out-of-hours general practice cooperative in Ireland. Using Strauss and colleagues' Chronic Illness Trajectory Framework, we explored users' and caregivers' experiences of continuity in this context. Whereas those dealing with "routine trajectories" were largely satisfied with their experiences, those dealing with "problematic trajectories" (characterized by the presence of, for example, multimorbidity and complex care regimes) had considerable concerns about continuity of experiences in this service. Results highlight that modernization policies that have given rise to out-of-hours cooperatives have had a differential impact on service users with chronic conditions and their caregivers, with serious consequences for those who have "problematic" trajectories.

Examining the practice of generalist expertise: a qualitative study identifying constraints and solutions.

OBJECTIVES: Provision of person-centred generalist care is a core component of quality primary care systems. The World Health Organisation believes that a lack of generalist primary care is contributing to inefficiency, ineffectiveness and inequity in healthcare. In UK primary care, General Practitioners (GPs) are the largest group of practising generalists. Yet GPs fulfil multiple roles and the pressures of delivering these roles along with wider contextual changes create real challenges to generalist practice. Our study aimed to explore GP perceptions of enablers and constraints for expert generalist care, in order to identify what is needed to ensure health systems are designed to support the generalist role. DESIGN: Qualitative study in General Practice. SETTING: UK primary care. MAIN OUTCOME MEASURES: A qualitative study - interviews, surveys and focus groups with GPs and GP trainees. Data collection and analysis was informed by Normalisation Process Theory. DESIGN AND SETTING: Qualitative study in General Practice. We conducted interviews, surveys and focus groups with GPs and GP trainees based mainly, but not exclusively, in the UK. Data collection and analysis were informed by Normalization Process Theory. PARTICIPANTS: UK based GPs (interview and surveys); European GP trainees (focus groups). RESULTS: Our findings highlight key gaps in current training and service design which may limit development and implementation of expert generalist practice (EGP). These include the lack of a consistent and universal understanding of the distinct expertise of EGP, competing priorities inhibiting the delivery of EGP, lack of the consistent development of skills in interpretive practice and a lack of resources for monitoring EGP. CONCLUSIONS: WE DESCRIBE FOUR AREAS FOR CHANGE: Translating EGP, Priority setting for EGP, Trusting EGP and Identifying the impact of EGP. We outline proposals for work needed in each area to help enhance the expert generalist role.

Progress with relationship continuity 2012, a British perspective.

This perspective paper makes a brief conceptual review of continuity and argues that relationship continuity is the most controversial type. Plentiful evidence of association with better satisfaction and outcomes urgently needs to be supplemented by studies of causation. The scope of these has been outlined in this paper. Evidence strongly suggests that patients generally want more relationship continuity than they are getting and that relationship continuity is linked with better patient and staff satisfaction. This is reason enough to justify improving relationship continuity for patients.

Management continuity in local health networks.

INTRODUCTION: Patients increasingly receive care from multiple providers in a variety of settings. They expect management continuity that crosses boundaries and bridges gaps in the healthcare system. To our knowledge, little research has been done to assess coordination across organizational and professional boundaries from the patients' perspective. Our objective was to assess whether greater local health network integration is associated with management continuity as perceived by patients. METHOD: We used the data from a research project on the development and validation of a generic and comprehensive continuity measurement instrument that can be applied to a variety of patient conditions and settings. We used the results of a cross-sectional survey conducted in 2009 with 256 patients in two local health networks in Quebec, Canada. We compared four aspects of management continuity between two contrasting network types (highly integrated vs. poorly integrated). RESULTS: The scores obtained in the highly integrated network are better than those of the poorly integrated network on all dimensions of management continuity (coordinator role, role clarity and coordination between clinics, and information gaps between providers) except for experience of care plan. CONCLUSION: Some aspects of care coordination among professionals and organizations are noticed by patients and may be valid indicators to assess care coordination.

Validation of a generic measure of continuity of care: when patients encounter several clinicians.

PURPOSE: Patients who regularly see more than one clinician for health problems risk discontinuity and fragmented care. Our objective was to develop and validate a generic measure of management continuity from the patient perspective. METHODS: Themes from 33 qualitative studies of patient experience with care from various clinicians were matched to existing instruments to identify potential measures and measurement gaps. Adapted and new items were tested cognitively, and the instrument was administered to 376 adult patients consulting in primary care for a variety of health conditions but seeing clinicians in a variety of settings. After initial psychometric analysis, the instrument was modified slightly and readministered after 6 months. The analysis identified reliable subscales and their association with indicators of continuity. RESULTS: Observed factors correspond to 8 intended constructs, with good reliability. Three subscales (12 items) relate to the principal clinician and cover management and relational continuity. Four subscales (13 items) are related to multiple clinicians and address team relational continuity and problems with coordination and gaps in information transfer. Two (11 items) pertain to the patient's partnership in care. Subscales correlate well and in expected directions with indicators of discontinuity (wanting to change clinicians, suffering, and sense of being abandoned, medical errors) and degree of care organization. CONCLUSION: The instrument reliably assesses both positive and negative dimensions of continuity of care across the entire system, and the subscales correlate with continuity effects. It supports patient-centered and relationship-based care and can be used as a whole or in part to assess coordination and continuity in primary care.

Synthesis and evaluation of 2-phenyl-1,4-butanediamine-based CCR5 antagonists for the treatment of HIV-1.

We describe the synthesis and potency of a novel series of N-substituted 2-phenyl- and 2-methyl-2-phenyl-1,4-diaminobutane- based CCR5 antagonists. Compounds 7a and 12f were found to be potent in anti-HIV assays and bioavailable in the low-dose rat PK model.