Continuity of Care work at RCGP

Continuity of care can be defined as the extent to which a person experiences an ongoing relationship with a clinical team, or member of a clinical team. It means coordinated clinical care, that progresses smoothly as the patient moves between different parts of the health service.

It can consist of relational continuity – seeing the same people or team, management continuity – management and coordination of care and informational continuity – continuity of patient records and information.

Continuity of care is a critical element of general practice, particularly, continuity of the personal relationship between patients and their general practitioner. Many patients are looking to general practice as the keepers of their story, the clinician or team of clinicians that know them and their circumstances.

Continuity of care resources

Explore this page for resources which will help you learn more about continuity and how to increase it in your practice, including webinars, guidelines and community support.

Continuity of Care toolkit

Take a look at our Continuity of Care Toolkit which shares the learning and experiences from practices who have been improving their continuity over a two-year period with support from the Health Foundation.

Based around 6 steps from setting out your ambition to implementation. The practices involved in bringing this resource Toolkit to you range from 35,000 to 45,000 patients, located in:

• urban,
• rural,
• affluent or
• deprived areas.

The result is a resource that can be tailored to your practice.

Including Five Steps to Improving Continuity of Care In the Modern Practice (originally published 2014, updated 2019.

• RCGP Guidelines for Continuity of Care (PDF file, 518 KB)
• Personal lists (PDF file, 603 KB): In addition, to the comprehensive toolkit above developed by two research sites. A third research site funded by the Health Foundation. Worked on a project in which the emphasis was on the importance of measuring the GP continuity. And increasing continuity through the use of personal lists. This resource draws on comments from several different practices all using personal lists. It includes detailed advice about the practicalities of developing and using personal lists.

Publications

Patients who receive continuity of care in general practice have better health outcomes, higher satisfaction rates and the healthcare they receive is more cost effective.

In 2011, the College published a 'Promoting Continuity of Care in General Practice' report (PDF file, 319 KB) demonstrating why continuity of care is important to general practice. The power of the therapeutic relationship between a clinician and a patient were considered and its importance in building trust, care and compassion were clear.

The RCGP's 'Continuity of care in modern day general practice' report (PDF file, 3.6 MB) published in 2016, expanded on this work. It asked whether continuity is still important in modern day practice and assessed how it can be delivered. In the context of changing demographics, work patterns and models of care. In addition, the paper established key principles that general practice should adhere to. If continuity is to remain at the core of the primary care as it continues to evolve.

Following these two papers, we published our 'Fit for the Future' report in May 2019, setting out the RCGP’s vision for the future of general practice. The vision sets out that by 2030, while general practice will be operating at scale, the experience of care will not feel impersonal to patients.

Continuity of care will remain a core value of general practice. GPs will still provide hands-on care and establish long-term, therapeutic relationships with patients. Particularly with those with complex needs or multiple health conditions. Practice teams will work together to provide new forms of relational continuity. For example, between patients and micro-teams or named key workers. All professionals involved in a patient’s care will be able to access their electronic care record.

Webinars

Hear directly from projects sites that participated in the Health Foundation’s Increasing Continuity of Care in General Practice Programme.

In our first webinar, GPs and project managers spoke about the importance of continuity, five key tips for implementation, and the need for measurement and evaluation.

• Part 1: Continuity landscape - Why are we discussing continuity? Is it relevant in a modern-day setting? Is it expected from patients? Does everyone need continuity? What questions are we facing around continuity in modern general practice?
• Part 2: Five key tips on implementing or improving continuity of care - How can you make improvements without extra funding?
• Part 3: Evaluation and Measurement - The importance of looking at evidence-based policy and initial findings of what patients and healthcare professionals are saying about continuity. How do you practically measure in your organisation? What are different measures of continuity (SLICC, UPC, etc), how can you implement them, and how can you combine them? What would we recommend if you wanted to do a baseline in your practice?

In our second webinar, we come back to the benefit of continuity and what project sites have learned about increasing continuity over the last 3 years.

• Part 1: Evidence, benefits, tools, and case studies from One Care. - The One Care team recaps the evidence for continuity and the benefits for clinicians and patients and provides insights on the challenges, successes, and practical tools that can help you increase continuity.
• Part 2: Pier Health's road to continuity, including a case study from Tudor Lodge. - The Pier Health team discusses how continuity of care can help practices deliver high-quality personalised care more efficiently and effectively as well as reduce health inequalities.
• Part 3: Q&A from our second webinar

Working in partnership

Support Partnership with the Health Foundation

In 2019, the Health Foundation launched a new funding programme to help to improve patient care and outcomes by exploring the potential to increase continuity of care within general practice. 

This programme is inspired by a study published in August 2018, conducted by the Health Foundation team. This study concluded that "strategies that improve the continuity of care in general practice. May reduce secondary care costs, particularly for the heaviest users of healthcare […]. And that promoting continuity might also improve the experience of patients and those working in general practice."

Five projects were awarded up to £250,000 to carry out targeted quality improvement work over 18-24 months, to increase continuity in their practices.

The Health Foundation and RCGP understand the pressures faced by professionals working in general practice. And wanted to know whether an increased focus on continuity of care could help bring benefits to both staff and patients.

About the writer

RCGP Innovation team - drop us an email innovation@rcgp.org.uk