1. Continuity of Care Lessons from two Major Research Programs in UK and Canada 1999-2006 George Freeman Emeritus Professor of General Practice

2. research team George Freeman, Maria Woloshynowych, Josip Car – Imperial College London Jeannie Haggerty – University of Sherbrooke, Quebec, Canada Bruce Guthrie – University of Dundee Richard Baker – University of Leicester Mary Boulton– Oxford Brookes University consultant Ewan Ferlie- Royal Holloway, University of London

3. international expert advisers USA Dmitri Christakis Seattle John Saultz Portland Barbara Starfield Baltimore Canada Carol Adair Calgary Norway Per Hjortdahl Oslo Netherlands Henk Schers Nijmegen

4. why continuity? 1.top priority in SDO’s 1999 start up listening exercise 2.scoping study 3.six major studies 2001-7 –all with strong user perspective http://www.sdo.nihr.ac.uk/cpcontinuity.html The Service Delivery and Organisation Programme is part of the National Institute for Health Research

5. UK - six long term projects four diseases diabetes community cancer hospital stroke hospital severe mental illnesscommunity general primary care community organizational cross boundary study young people with learning disabilitycommunity older people with a strokecommunity

6. what we did standardised data collection –site visits –protocols, reports, presentations, publications draft report reviewed by –expert advisors –project leaders common analytic framework –based on Canadian programme review - Haggerty

7. Canada - 34 projects wider variety of settings/methods findings match and extend UK programme intervention trials for severe mental illness

8. what is continuity? two essential elements care of –an individual patient –delivered over time three continuity types Informational - timely appropriate information Management – co-ordination between providers Relationship - ongoing therapeutic relationship between a patient and one or more providers

9. lessons learned - 1 all continuity types link with greater satisfaction

10. Our earliest experience of sickness is usually in a family context. We learn how to be sick within the family

11. lessons learned - 2 all continuity types link with greater satisfaction most users want more involvement & responsibility vulnerable minority need help

12. Our earliest experience of sickness is usually in a family context. We learn how to be sick within the family

13. lessons learned - 3 all continuity types link with greater satisfaction most users want more involvement & responsibility vulnerable minority need help the access trade-off

14. advanced medical home all types of continuity offered relationship continuity is key feature -each patient has an ongoing relationship with a personal physician -continuous and comprehensive care

17. the access trade-off - how long to wait? to see physician rather than nurse someone you know & trust someone with access to full medical history

18. how many extra days to wait? vignette minor newroutine to seefamiliaruncertaincheck-up doctor1.03.53.5 known & trusted0.92.44.2 full medical history1.63.97.8

20. primary care findings patients are well aware of clash between access and relationship continuity have clear views on when they need relationship continuity expect good informational continuity

21. Sick elderly woman living alone

22. overall lessons patient-centred care is fundamental –most users want more involvement –more vulnerable need help which type of continuity? – Relationship, Informational, Management give specific priority to relationship as well as to informational and management continuity of care when reorganising services

23. outstanding questions Management and Informational continuity are almost self-evident goods how to deliver the goods? case for Relationship continuity is less clear how to measure it and reward it? more about trade-offs with rapid access specialist expertise intervention trials needed

24. thank you for your attention! questions?

26. primary care findings - 2 patients value relationship continuity more if they are older, iller or vulnerable some patients get less of what they want –non-white –socially isolated or disadvantaged –in full time work