The investigation that underpinned the report identified that there is no specific requirement within the current GP contract to ensure GP practices provide continuity of care for their patients.
They can do voluntarily but the investigation also showed there is no standard framework to help to deliver this, resulting in variation across England. Some practices have effectively implemented systems, but many have not, and our investigation has set out what the impact of having no formal system has on patient safety, on GP welfare and on the operational efficiency of the practice.
The report states it is ‘well documented’ that continuity of care has many benefits for patients and that it is important in recognising patterns of symptoms to aid timely diagnosis or referrals to other services. During our investigation we spoke to a sample of patients and GPs from surgeries that did operate systems of continuity of care (as well as those surgeries that do not). They reiterated the positive benefits of having that system. For example, patients said they had a relationship with their GP which allowed them to know them and their health and personal circumstances. They could see the same person and not have to explain their long-term condition each time.
All GP’s that we spoke to are aware of the benefits of continuity of care, but some did not believe it was possible to deliver that system of care in their practice. They cited many challenges from the complex social conditions of their geographical area to staff stability and availability. In relation to essential requirements coming from the GP contract, practices told us that this creates competing priorities and that if there is no explicit requirement to adopt a system of continuity of care, it will ‘slip down’ the priority list when there are other challenges coming to the fore.
In the context of the investigation, continuity of care was referring to personal (a relationship with a specific doctor) but also informational, meaning how information is managed in the practice to allow any doctor to care for the patient.
Many GP surgeries use electronic patient records and our investigation reinforces that if any GP can access the relevant clinical history and information quickly, then it can help to aid effective decision making in practices. This is especially important when personal continuity is not possible.
However, we heard from many GP’s that IT systems do not present information in a way that enables them to quickly see if a patient is returning with ‘unresolved symptoms.’ The investigation found there is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information to GPs.
The issues identified in the wider investigation had been drawn from the exploration of a real patient case. We told the story of Brian, a 67-year-old male, for whom a reduced continuity of care at his GP surgery resulted in a delayed diagnosis of secondary breast cancer.
Brian had developed severe back pain two years after finishing cancer treatment. He had been seen at a local emergency department (ED) before being referred to his practice. He saw his named GP who ordered a blood test and referred him to the practice physiotherapist who gave him advice on stretches and exercise to help his back pain.
His pain was not relieved and over eight months he saw two out-of-hours GPs and six practice GPs, a nurse, and a physiotherapist at the GP practice. At the end of the eight months, a GP spotted a lump on his spine and advised that he go to the ED, where a CT revealed breast cancer that had spread to the spine.
Brian was placed on palliative care and sadly passed away during our investigation. One of the key findings in his case was that while breast cancer was considered at each of Brian’s attendances, the lack of internal processes and the way in which GP IT systems presented this information meant the opportunity for information continuity was lost.
Our investigation, whilst focusing on patient safety impact, also emphasises GP welfare. The report noted that they saw a visible difference in the demeanour between staff in practices that operate continuity of care and those that did not. The investigation observed first-hand the personal impact, as many became visibly upset when speaking about their workload and work environment.
Some of the examples shared by GP’s included:
- not having time to process technically difficult consultations resulting in cognitive fatigue, making decision making harder as the day progressed
- feeling unable to do all the tasks required during a consultation
- taking work home and into days off and weekends.
Patients in GP practices which did not have a formal model also told us they ‘rarely or never’ saw their named GP and they had to “re-tell’ their history which was frustrating and could be traumatising in some cases.
As a result of the investigation findings, two safety recommendations have been made in relation to the GP contract and GP IT standard:
- HSSIB recommends the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information.
- HSSIB recommends NHS England updates the GP IT standards to ensure patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms.
Neil Alexander, Senior Safety Investigator, says: “What struck our team during the investigation was the clear differences in patient experience and GP welfare between those practices that operate a model continuity of care and those that don’t.
“We could see that all want to deliver the best care they can but the extreme pressure of workloads and having to prioritise other essential requirements makes it very difficult. Even though practices with systems could see benefits, they told us they had often implemented without proper frameworks, guidance, and explicit funding. It became clear to us that in order for GP practices to be able to prioritise continuity of care in a consistent way, it must become part of the essential services they need to deliver.
“Brian’s case was a stark example of what can happen when there is a breakdown in that continuity - it was incredibly distressing for him and his family. He told our team ‘when I am gone, no-one else should have to go through what I did.’ The emotional impact was also seen in interviews with his practice, with one GP describing the current system as ‘brutal’. Wider conversations with other GPs and focus groups with patients also reflected the importance of reducing the variation that they see on daily basis.
“Our findings and safety recommendations are a call to action to those at a national level, to help prevent the delayed diagnosis of serious health conditions, and ensure patients get safe and efficient care wherever they are in the country.”