Continuity of care.
The political restructuring of the NHS is increasing the range of hospital and community health care providers. This fragmentation of care risks what Michael Balint referred to as the “collusion of anonymity” in which different parts of the patient’s health are cared for by different specialists and consequently important aspects are neglected because they fall outside the specialist’s remit.  Consequently, now more than ever, a comprehensive, generalist primary care physician providing continuity of care, is essential.
Continuity of care is the care of an individual patient over time. Various attempts have been made to define continuity, many of which try break down comprehensive continuity of care into subsets of continuity, for example, informational, management and relational continuity.
All subsets are essential components of patient care. Continuity of information on the electronic record and continuity of management through the use of shared guidelines and protocols get more attention because they are more easily assessed than relational continuity which is complex and difficult to measure. Relational continuity is the basis of the doctor-patient relationship and requires doctors and patients to understand each other’s personalities and remember past experiences and not simply recognise professional roles and clinical features. 
I would define relational continuity as the therapeutic relationship between a doctor and a patient, developed over time in which the doctor takes responsibility for coordinating the patient’s care.
In measuring the effects of continuity of care, the question might not be, “Does continuity of care make a difference at a population level?” but rather, “Are there specific sub-populations for which continuity of care is especially valuable?”For most healthy, wealthy, young individuals, contact with aphysician is unlikely to have a measurable impact on their already good health.”
Approximately 75% of all GP consultations are with people over the age of 70 and 75% of these people have multiple chronic conditions. In a deprived inner city environment where we work, the incidence of serious mental illnesses, drug and alcohol addiction and chronic stress due to social determinants such as unemployment, poor housing, crime and violence results in high re-attendance rates from a significant proportion of our practice population. For these people relational continuity is particularly important. 
Multiple conditions interact in ways that fall outside the remit of clinical guidelines. For example deterioration in mental health or social stress may result in a patient with diabetes neglecting their diet and medication with a subsequent loss of diabetic and hypertensive control. Regaining control of one disease is inextricably bound up with recognising and supporting them as they deal with the others. A frail patient with multiple problems may appear to a clinician with whom they have a relationship to look seriously unwell or their usual frail self the moment they walk through the consulting room door depending on their usual appearance and levels of stoicism or distress.
“The implicit choice between personal continuity and modern care is false; what evidence there is suggests that patients prefer services providing personal continuity, and this may also reduce the use of investigations and admissions to hospital”  There is also evidence that improved continuity of care results in better preventative care and lower costs.  Other benefits include:
- Greater efficiency due to better communication and trust, facilitating information gathering.
- Increased safety because communication and awareness of subtle changes not included in the electronic record or clinical guidelines. Many critical incidents we have investigated involve lack of continuity and have resulted in changes to improve relational continuity.
- Higher patient satisfaction because of better reassurance and confidence in care. In patients with serious mental illness this is particularly important because the individual nature of the illness.
I believe that continuity of relationship is essential to organise and coordinate the increasingly fragmented care that patients receive. Continuity of relationship is most important in the care of patients with multiple chronic diseases, mental illnesses and social distress. These are the greatest users of the NHS. Prioritising speed of access and choice of provider risks damaging continuity of care for those who most need it.
Jonathon Tomlinson October 7th 2009
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