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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 13-December-2002, Vol 115 No 1167

Continuity through change, a threat or a promise?
Ngaire Kerse and Arch Mainous III
New Zealand is implementing the Primary Health Care Strategy1 and relationships between patients and providers of healthcare will be influenced by these changes. The advent of the reform presents the opportunity to consider continuity of care as an essential element of primary healthcare and how the implementation of the strategy may challenge rather then reinforce this continuity. The New Zealand reform recognises that a strong primary healthcare system is key in ensuring population health. Countries with robust primary healthcare have, in the main, better health outcomes than those with less developed primary care.2 Availability of primary healthcare doctors is independently associated with life expectancy in the USA.3 Moreover, enhancing primary healthcare improved overall and infant mortality in at least one country.4 Whether the New Zealand strategy reinforces or challenges continuity in the short and long term will depend on several issues.
Continuity of care is a core component of primary healthcare5 and is explicitly included in the definition of general practice adopted in the United Kingdom,6 Australia,7 New Zealand,8 and Europe.9 Moreover, training programmes in a variety of specialties have suggested that continuing care with a group of patients throughout the years of training is essential.10
Continuity of care has become a concept that everyone can agree is good, like “motherhood and apple pie”. Patients rate continuity of care with a provider as one of their highest priorities in their receipt of medical care,11 especially those with chronic illness.12 Continuity not only is linked to patient satisfaction13 but to specific patient outcomes, including: improved preventive care;14 increased childhood immunization rates;15, 16 patient empowerment;17 improved recognition of problems;18 reduced medication use;19 and improved patient compliance.20 Health services also benefit from continuity between patient and provider, as reduced hospitalisations,21, 22 reduced emergency department use,23,24 and reduced total costs25 were associated with continuity of care. Despite the various studies each using different definitions of continuity, there were universally positive associations found between continuity of care and outcome.
Continuity of care features frequently in the scientific literature, with more than 800 English-language citations on Medline between 1998 and June 2001, and more than 1900 since 1995 for the MeSH heading of continuity of patient care. These original research articles and viewpoints are disseminated via a variety of sources from around the world (eg, BMJ, Medical Journal of Australia, New Zealand Medical Journal, American Journal of Public Health, Pediatrics, Medical Care, Archives of Family Medicine, European Journal of General Practice). Review articles have periodically attempted to summarise the literature on continuity of care.26,27
The precise definition of continuity of care is uncertain, and authors have called for clarity.28 Various definitions include the following scenarios: interactions between patients and providers that span different episodes of care;22 continuity limited to a single episode of care (eg, surgical procedure);29 the use of mathematical formulas to create an index based on interactions between patients and providers for all of their utilisation in a given time;23 whether a doctor has seen a patient on more than two occasions;30 and the use of single-item survey questions to patients about whether they have a usual provider.31,32 Moreover, continuity of care has also been defined as something completely distinct from the doctor–patient relationship such as transfer of information between hospital pharmacies and general practitioners about patient medication use.33 It is apparent that the situations and concepts measured in these studies are all important, yet they seem to represent different things.
These overlapping and inconsistent definitions make the concept available for use by all stakeholders in healthcare reform debates, even for the discussion of substantially different programmes. There is a need for clarity, as the nature of the healthcare delivery system or aspect to be evaluated may be quite different, and a common understanding in evaluation would enable meaningful comparisons. As the patient–provider relationship is the core of this concept, the most appropriate definition would appear to be the concept of a long-term sustained relationship between a patient and a healthcare provider, spanning time and more than one episode of illness, as well as involving the majority of the patient’s health care needs.5
Can the definition of continuity of care be extended to a relationship with a team of providers? Most of the evidence of the value of continuity has studied the primary care doctor as the healthcare provider, and further research is needed to evaluate the value of continuity with groups, sites and other healthcare providers. The data comparing patient continuity with a location of care versus continuity with an individual show there is greater value in continuity with an individual provider than with multiple providers at the same site.16,34

What will happen to continuity of care in the next ten years?

The Primary Health Care Strategy seeks to provide co-ordinated care to an enrolled population through a Primary Health Organisation (PHO).1 The necessity for continuity with a provider is emphasised and, if comprehensively implemented, the strategy should promote continuity of care with its consequent benefits.
Gatekeeping arrangements that limit patients’ ability to access specialists have been suggested to have the advantage of improved continuity of care with a provider.35 In systems in which gatekeeping has been the norm, rather than an introduced concept, patient satisfaction is high.36 However, in the USA, patients dislike gatekeeping37 that impedes access to specialists and may undermine patients’ trust and confidence in their primary care doctors. In New Zealand, the gatekeeping role of the general practitioner has been undermined in the last decade by, among other things, the ACC reform allowing direct access to allied health providers. The proliferation of primary providers of services for different parts of the lifespan, without the necessity or mechanism to liaise or share information with the main provider (traditionally the GP), has also weakened continuity of care in New Zealand. The proposed PHO has the potential to strengthen continuity by placing all primary providers together in one organisation, therefore promoting shared information and liaison.
During the next decade of implementation, there will be a phase where existing continuity of care is threatened by differential access to the new primary healthcare funding. Enrolment of patients with a provider within a PHO is planned to ensure access to providers for patients in a defined population. However, the development of the PHO precedes noticeable public debate about enrolment or the dissemination of mechanisms to facilitate enrolment. There is not room or funding for all providers to form, and patients to enroll in, PHOs immediately.
Two levels of PHO are currently planned: ‘high needs’ and ‘interim’. All patients enrolled in a ‘high needs’ PHO will have access to low-cost primary care, irrespective of need, while all patients attending general practices not yet in a PHO will not. A proposed interim funding formula to allow increased funding to high need, interim PHO, patients may increase equity. However, as PHOs will not have geographical boundaries, general practices situated across the street from general practices in the ‘high need’ PHOs may see considerable shifts in patient populations, particularly currently non-subsidised patients. These new organisations will be potentially attractive to patients because of the reduced out-of-pocket payment. It is well established that high cost restricts access and reducing out-of-pocket payment enables access, especially for low income patients38,39 – an assumption on which the primary heathcare reform is based. Shifts in patient numbers may cause, during the implementation period, both overloading in the PHO and instability in the existing small business-based providers.
The value of continuity to outcomes may lie in the shared knowledge built from sheer frequency of patient and provider interactions. The value may also be related to the quality of the doctor–patient relationship, as the trust of the patient in his or her general practitioner is correlated with continuity of care.40 Policy planners and health system administrators can facilitate the ability of patients to consult the same provider on a longitudinal basis through mechanisms like gatekeeping and equity of out-of-pocket cost for primary healthcare. A fully implemented Primary Health Care Strategy should facilitate continuity. However, during a decade of transition, continuity with current providers is likely to be disrupted for New Zealanders.
Models of service delivery vary throughout the world, thus there is a need for a common set of definitions in order to accurately identify important changes over time and as a result of reform. The UK and Australia have made substantial investment in primary care groups and academic departments of general practice, with subsequent development of infrastructure for research and development. This has allowed the opportunity for evaluation of the effect of systematic change on quality issues such as continuity. We contrast the situation in New Zealand where there has been no such investment. The ability to provide continuity of care is becoming more challenging. Society and health systems are changing and the traditional model of primary care delivery, in which a doctor lived on site and cared for a regionally defined group of patients, is seldom possible.41
Adequate evaluation of the effects of changes in primary healthcare on continuity and other relevant outcomes will only be possible with a common understanding of important concepts and an investment in infrastructure to support research and development, alongside service delivery, of primary healthcare.

Conclusion

In conclusion, we have attempted to clarify and suggest limits to a concept that is essential to primary healthcare and of high importance to policy makers, investigators and clinicians. Continuity of care should be seen as a long-term sustained relationship between a patient and a healthcare provider spanning time and more than one episode of illness.5 A common language is needed to allow focused debate and for realistic evaluation of the impact of reform.
As quality measures for primary and secondary care are developed and utilised, let us not neglect the longitudinal personal relationship between provider and patient. The Primary Health Care Strategy1 seeks to improve access to primary healthcare through reduction in patient out-of-pocket payment. However, the current planned implementation, by allowing differential access to the new primary healthcare funds during a 10-year transitional period, threatens existing continuity with providers. A commitment to investment in research and development for primary healthcare in order to evaluate the potential impact of this reform on continuity and health outcome is needed.
Author information: Ngaire Kerse, Senior Lecturer, Department of General Practice and Primary Health Care, University of Auckland, Auckland; Arch G Mainous III, Professor and Director of Research, Department of Family Medicine, Medical University of South Carolina, Charleston, SC, USA
Acknowledgements: This study is supported in part by a grant from the Auckland Medical Research Foundation and the Commonwealth Fund.
Correspondence: Ngaire Kerse, Harkness Fellow in Health Care Policy, Center for Health Studies, Group Health Cooperative of Puget Sound, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448, USA. Email: kerse.n@ghc.org
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