1. Access & Continuity Londonwide LMCs 12 th February 2014 George Freeman Emeritus Professor of General Practice Imperial College London

2. relationship continuity continuity is about care of individuals over time - three types Relationship (or interpersonal) Management (or coordination) Informational Everyone wants management & informational continuity but GPs face two ways on relational continuity 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs2

3. ambivalence about relationship continuity it’s a cornerstone of general practice but we haven’t time for a personal service these days - especially given current access pressures 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs3

4. benefits of relationship continuity satisfaction for patients and staff most patients want it – more than they can get –especially in London lower costs –admissions (emergency & elective) –tests –referrals better problem recognition easier care of people with multimorbidity 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs4

5. why continuity is essential for generalists seeing the same doctor promotes mutual trust –encourages a therapeutic relationship fills in generalist picture with –context –history & knowledge – tacit as well as recorded –personal values and priorities compensates for less specialist expertise 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs5

6. multi-morbidity care enhanced by shared experience of identifying and coping with problems over time familiarity with relevant factors for prioritising care options for example back in 1980 Howie found that if mothers were on psychotropic drugs then their children were more likely to get antibiotics for URTI ! 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs6

7. multimorbidity increasingly prevalent more prevalent with advancing age but most multimorbidity seen in under 65s associated with deprivation 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs7

8. access & continuity -1 patients want both but it’s partly a trade- off! actually most patients understand this –seeing the same doctor is prioritised for serious and chronic conditions –by all age groups –and patients will wait several days to see the right doctor –any clinician will do for short-term or minor problems 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs8

9. access & continuity - 2 not all a trade-off – better continuity can both reduce demand and make it more appropriate practices can improve continuity to manage access pressures –reduces repeat consultations –patients happier to wait a few days 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs9

10. how to improve relationship continuity receptionists & appointments –prioritising and training telephone and e-consultation –best for follow-up – and with known doctor in the consulting room –set an example smaller teams for large practices –too much choice is confusing 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs10

11. discussion questions what are the issues for continuity in your practice? how to address these? for example personal availability and longer opening hours? part-timers & continuity? continuity and commissioning? QOF and availability? 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs11

12. assess your own continuity! How much do patients actually see the same doctor in your practice? - for a simple guide on how to audit your own performance from your records system, we suggest the following link to the work of colleagues in the University of Bristol http://www.bristol.ac.uk/primaryhealthc are/resources/continuityaudit/ 12th Feb 2014Access & Continuity - George Freeman for Londonwide LMCs12