Family Practice Vol. 19, No. 5, 496-499
© Oxford University Press 2002
Health Services Research |
Continuity in UK general practice: a multilevel model of patient, doctor and practice factors associated with patients seeing their usual doctor
Department of Community Health Sciences-General Practice, MacKenzie Medical Centre, 20 West Richmond Street, Edinburgh EH8 9DX, UK; E-mail: b.guthrie{at}ed.ac.uk
Guthrie B. Continuity in UK general practice: a multilevel model of patient, doctor and practice factors associated with patients seeing their usual doctor. Family Practice 2002; 19: 496–499.
Received 27 July 2001; Revised 22 January 2002; Accepted 13 May 2002.
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Abstract |
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Background. Personal continuity is a ‘core value’ for UK general practice, but often appears ignored by organizational change.
Objectives. The aim of the present study was to examine practice, GP and patient factors associated with personal continuity of care.
Methods. A cross-sectional survey was carried out of 25 994 people aged >15 consulting over a 2-week period in 53 general practices in four regions of the UK. The outcome measure was whether or not the patient was seeing their usual or regular doctor.
Results. Compared with the smallest quintile of practices, the odds ratios [95% confidence interval (CI)] for patients seeing their usual doctor for the two largest quintiles of list size (6337–11 036 and >11 037) were 0.24 (0.12–0.46) and 0.19 (0.10–0.37). Patients in the five practices with personal list systems were more likely to be seeing their usual doctor (odds ratio 3.27, 95% CI 1.87–5.70). Older patients were considerably more likely to be seeing their usual doctor. Young men were less likely, but by middle age there were no differences between men and women. Compared with patients who only wished to discuss a new or urgent physical problem, those wishing to discuss psychological (odds ratio 2.28, 95% CI 2.01–2.58) or longstanding physical problems (odds ratio 1.92, 95% CI 1.78–2.08) were more likely to be seeing their usual doctor.
Conclusions. In this study, list sizes over ~6000–6500 were associated with marked reductions in personal continuity. If GPs are serious about the importance of personal continuity, then the size of the primary care team needs to be examined. There may be potential in separating the administrative functions of the practice from the clinical functions of the primary care team.
Keywords. Continuity of patient care, family practice, professional–patient relationships, quality of health care, UK.
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Introduction |
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Continuity of care is a central feature of all UK and most international definitions of general medical practice.1 Usually, ‘continuity’ is taken to mean personal continuity in the sense of an ongoing relationship between a patient and a doctor. There is good evidence that seeing the same doctor is associated with greater patient satisfaction, and some evidence that it leads to better medical outcomes.2,3 Major National Health Service (NHS) organizational changes including the growth in size of practices and the creation of general practice out-of-hours co-operatives have largely ignored potential effects on personal continuity, perhaps because policymakers have focused more on other kinds of continuity such as the consistency and co-ordination of care. Seeing the same doctor is one way to achieve these, but policy has emphasized others such as guidelines and communication between professionals.4
Published studies of who gets personal continuity in the UK have been small, and in particular have not examined the relationship between practice structure and personal continuity.5,6 The aim of this study is to investigate the association of practice, GP and patient factors with personal continuity.
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Methods |
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The analysis uses data from a cross-sectional study of patients aged >15 consulting their GP in the surgery in 53 general practices in four UK regions over a 2-week period in early 1998. A pre- and post-consultation questionnaire was completed by both patients and GPs. Further information about GPs and practices was collected subsequently by a separate questionnaire.7
Because of the hierarchical nature of the data, multilevel regression analysis was used, and a three-level model constructed (patients clustered within GP seen, clustered within practices). The analysis assumes that patients exert preferences for seeing particular doctors within the context of the practice they are registered with. The problems the patient wants to discuss and patient demography are being used as proxies for these preferences. The outcome variable was whether or not the patient was seeing their usual or regular doctor, and a logistic regression model for binary response was therefore used. Analysis was carried out in MLwin using restricted iterative generalized least squares estimation of second order penalized quasi-likelihood.8 Model assumptions of binomial variance, and the residuals being normally distributed with constant variance were checked and found to be plausible.
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Results |
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Overall, 61.6% of patients were seeing their usual or regular doctor. Within practices, the percentage varied from 39 to 98%. The full model is shown in Table 1
. The intracluster correlation co-efficient for patients within GP seen was 28.4%, and for patients within practices 34.7%. One interpretation is that 65.3% of variation in the outcome is due to differences between patients; 28.4 and 6.3% is due to differences between GPs and practices, respectively. Overall, this model explains 26.1% of the variation in outcome. Almost all of the variation attributable to practice factors is explained by the two practice factors included.
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At practice level, patients in the largest 40% of practices have only one-fifth the odds of seeing their usual doctor compared with those in the smallest 20%. Patients in practices with personal lists are three times more likely to be seeing their usual doctor than patients in practices where they can see any doctor. At patient level, older patients of both sexes are progressively more likely to be seeing their usual doctor. There is an interaction between patient age and sex. Younger men are less likely to be seeing their usual doctor than younger women, but this reverses in older age groups. Patients wanting to discuss emotional or longstanding physical problems have about twice the odds of seeing their usual doctor. Patients being fitted into a fully booked surgery as extras are less likely to be seeing their usual doctor, and patients who had been asked to attend by a doctor more likely.
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Discussion |
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The results confirm much of what is generally believed about who gets personal continuity, although a limitation is that actual patient preferences for personal continuity or access have not been measured directly. There are implications for the organization of general practice.
In this study, increasing age is strongly associated with seeing the usual doctor. Recent policy appears to assume that this is a cohort effect, i.e. older people have higher expectations and preferences for personal continuity as a result of their past experiences of general practice. The assumption appears to be that as the population ages, the desire for personal continuity will decline ‘naturally’. From this perspective, prioritizing access and ignoring effects on personal continuity makes sense. Two obvious examples are the creation of centralized telephone advice services such as NHS Direct, and primary care walk-in centres.4
An alternative perspective is that it is a life cycle effect. As people age, they are increasingly likely to develop chronic, often multiple problems. Their preferences then change as their circumstances change. From this perspective, health services must be responsive to changing needs. Improving access is important, but so is promoting personal continuity for those who want it. It is not possible quantitatively to disentangle cohort and life cycle effects with cross-sectional data such as these, but the changing effect of patient sex with age seen here suggests that life cycle is important. Patients are likely to prioritize access and personal continuity according to their individual circumstances, and services should strive to meet different needs appropriately.
Several authors have called for a return to personal lists to promote personal continuity,2 but these are increasingly uncommon, possibly because GPs are less willing to be available continuously.9 One option might be to operate personal lists for those with chronic disease where care is more plannable, while still sharing care across a practice for acute (and generally less serious) problems. Arguably, this model is of the kind promoted by health service developments such as NHS Direct and walk-in centres. Others have argued that continuity with a team is what really matters, although there has been little discussion of how large such teams should be. Given these results, it seems likely that care will also be more fragmented in larger teams.
Currently, UK primary health care teams usually consist of a single general practice plus attached professionals including district nurses and health visitors. From these data, in terms of personal continuity, a team of GPs, nurses, health visitors and other staff caring for up to ~6000 patients would offer reasonable levels of personal continuity with the GP, and a reasonably sized core primary health care team (<10–12 professionals). In larger practices, one option would be to create two or more clinical teams.10 This would allow
the administrative advantages of size for the practice, without reducing the clinical advantages of personal continuity for the patient.
Truly evidence-based planning of services to match needs will require longitudinal research into how patients’ preferences and use of services change over time. However, this study shows that larger practices are much less likely to provide personal continuity to all groups of patients. If GPs are serious about their stated core values, then they need to ensure that general practice organization continues to promote personal continuity for those patients who want, and benefit from it.
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Acknowledgments |
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The paper was written using data from a study originally designed and carried out by John Howie, David Heaney, Margaret Maxwell, George Freeman, Jeremy Walker and Harbinder Rai. Sally Wyke and John Forbes read and commented on previous drafts of this paper. At the time of analysis, BG was employed as an MRC Health Services Research Training Fellow.
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References |
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1 McWhinney IR. Primary care: core values. Core values in a changing world. Br Med J 1998; 316: 1807–1809.
2 Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. Br J Gen Pract 1995; 45: 654–659.[Web of Science][Medline]
3 Wasson JH, Sauvigne AE, Mogielnicki RP et al. Continuity of outpatient medical care in elderly men. A randomized trial. J Am Med Assoc 1984; 252: 2413–2417.
4 Department of Health. The NHS Plan: A Plan for Investment, a Plan for Reform. London: HMSO, 2001.
5 Freeman GK, Richards SC. How much personal care in four group practices? Br Med J 1990; 301: 1028–1030.
6 Sweeney KG, Gray DP. Patients who do not receive continuity of care from their general practitioner—are they a vulnerable group? Br J Gen Pract 1995; 45: 133–135.[Web of Science][Medline]
7 Howie JG, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. Br Med J 1999; 319: 738–743.
8 Rasbash J, Browne W, Goldstein H et al. A user’s guide to MLwin. London: Multilevel models project, Institute of Education, 2001.
9 Freeman G, Hjortdahl P. What future for continuity of care in general practice? Br Med J 1997; 314: 1870–1873.
10 Waine C. The primary care team. Br J Gen Pract 1992; 42: 498–499.[Medline]
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