Patient satisfaction with access to primary care in England has declined significantly over the past decade. One way the National Health Service is trying to address this is by increasing appointments in primary care at a supra-practice level (i.e., incentivising practices to work together to provide appointments in a single location for patients from several practices). At the same time there is increasing evidence that relational continuity of care (patients seeing the same clinician) produces better outcomes for patients and the health service. More care delivered to patients away from their general practice, at a supra-practice level is likely to result in reducing relational continuity. However, continuity, as experienced by patients, consists of more than just seeing the same clinician. This thesis uses extended access as an exemplar of contemporary changes in the delivery of primary care that are likely to reduce relational continuity of care for patients. It examines the operationalisation of extended access policy, how continuity is delivered and experienced by those using extended access, how this might affect health outcomes and whether the introduction of extended access has affected relational continuity and patient experience in the wider patient population. The literature relating to extended access and continuity of care are reviewed. A concept of continuity of care that can be applied when patients are seen by multiple providers is developed. A systematic review examines the relationship between patient experienced continuity and health outcomes. The studies retrieved are limited to mostly small studies and are insufficient to draw firm conclusions from. In sensitivity analysis there is an association between continuity and reduced emergency department use/re-admissions in larger studies. A quantitative observational study examines whether, at a practice population level, the introduction of extended access impacted upon patients' experience of accessing primary care or affected the relational continuity they received in practice. The results show no evidence of an impact. A two-site case study explores the operationalisation of extended access and how continuity is delivered and experienced by patients using the service. The results demonstrate that extended access is effective at dealing with acute non-complex issues and provides additional primary care capacity. However, it is providing a different service to general practice, is not being used as the policy originally envisaged, and sometimes struggles to deal with complex patients and the co-ordination of ongoing care. The experience of continuity in extended access, and the mechanisms underlying continuity are explored and demonstrate the importance of system, patient, and clinician attributes in the delivery of continuous, seamless care. The importance of co-ordination mechanism to continuity and how continuity has the potential to influence patient outcomes is also demonstrated. The work presented in this thesis examines how continuity of care operates in an extended access environment, what influences this and what the effects are. It demonstrates that extended access is not simply an extension of a patient's general practice and that the delivery of seamless care between different primary care providers is context specific and potentially problematic. These findings have ramifications for policy makers considering the continued expansion of primary care through increasing supra-practice level funding and capacity.
- primary care
- general practice
- continuity of care
- health systems
Understanding continuity of care in primary care extended access hubs
Burch, P. (Author). 1 Aug 2024
Student thesis: Phd