One of the cornerstones of the NHS Five Year Forward View (5YFV) is the ambition to develop sustainable and integrative care that incorporates all levels of healthcare provision. The aim is to streamline care to patients and improve coordination of services and communication between providers. It is not surprising then that continuity of care has featured widely in the 44 Sustainability and Transformation Plans (STPs) that have been drawn up across England to fulfil the aims of the 5YFV and, amongst other things, ‘stabilise primary care’ and support ‘out of hospital collaboration.’ However, there is little sign that the complexity of continuity of care or the challenges involved in implementing and improving it, are recognised in the current collection of STP documents.
The STP for Shropshire and Telford and Wrekin is typical of the way continuity of care is treated within the broader plans for NHS reform. It states an ambition to:
“move care out of hospitals to the community, wherever possible, and enable better access to and continuity of care by aligning primary, community and mental health care teams, breaking down the existing barriers and providing integrated solutions to deliver improved health outcomes for our population.”
Here continuity of care is treated as a catch all term for promoting service integration, generating efficiencies and improving outcomes. Cost savings associated with continuity of care in the US context have been seized on by STPs, especially where better care coordination has been identified as a means of reducing redundant or unnecessary services. For instance, in North West London, continuity of care is one of the aims set for a £3.4 million investment which is estimated to save £6.2 million by 2020/21 through improvement of “self-management and ‘patient activation.’”
However, assumptions that improving continuity of care will deliver these benefits need to be questioned. Research has shown the link between continuity of care and efficacy, particular in reducing key outcomes such as hospitalisation and symptom severity, has been inconsistent at best. Continuity of care is also is largely dependent on other factors such as healthcare providers working full time, smaller practices and demands of a patient’s’ disease management. So, while aims to improve continuity of care are laudable there are significant but barely acknowledged challenges involved in realising continuity of care in the context STP reforms. For this reason, proposals in STPs that depend on the alleged savings from continuity of care need to be subject to greater scrutiny.
To better understand the complexity in this area it helps to recognise that there are three distinct forms of continuity of care: relational, managerial and informational. Relational continuity of care refers to the ongoing therapeutic relationship between healthcare provider and patient measured either by the length of a patient’s relationship with a healthcare provider, or by the frequency of a patient’s visits to a healthcare provider. Relational continuity appears as a key concern in many STPs. Informational continuity refers to whether or not healthcare providers have access to the medical records of the patients they are treating. Management continuity of care refers to ensuring that services at different levels or on different settings of care management provide services in an efficient order and in a timely manner. Given the importance of each of these three strands of continuity of care it will be worth examining the extent to which STPs have plans in place to deliver on them. However, the current lack of detail makes this task difficult. While more information is expected to emerge as planning progresses, many STPs are light on detail, with plans for realising continuity of care coming across as vague aspiration. Currently it is not clear what priority relational continuity of care will have within the planned reforms, and where it will sit within the wider changes being implemented.
Where continuity of care is present within STP plans, the focus tends to be on relational continuity. For instance, North Central London’s STP recognises that there are breaks in continuity of care in General Practice: “there are issues within NCL in accessing primary care during routine and extended hours, and only 75% of people in NCL have a named GP to provide continuity of care.” While attention to problems surrounding relational continuity of care is important, STPs must also recognise the barriers to improving informational and managerial continuity of care to the community within their footprint area. There are already well-recognised challenges involved in improving information and managerial continuity with the NHS. For example, West, North and East Cumbria’s STP notes the challenge that high staff turnover – which comes from having small and isolated provider groups and a reliance on temporary workers – poses for continuity of care. It is a strength that each STP will have the opportunity to respond to the particular problems in their own footprint area, but this means each STP must adequately recognise the complexity involved in achieving the three elements of continuity of care. A key concern here is that informational and managerial continuity of care are routinely marginalised. This cannot be taken for granted: as a 2010 systematic review of 18 English cohort studies illustrated, while relational continuity of care is consistently measured, informational continuity was only measured once and managerial continuity was completely ignored.
Currently very few STP proposals recognise the complexity of continuity of care, or indeed the challenges involved in implementation and improvement. It cannot be assumed that continuity of care can be straightforwardly implemented, or that doing so will deliver cheaper, more efficient and effective care. We must demand that STPs recognise the necessary thought and resources required to implement new regimes of continuity of care effectively.