Continuity of primary care

Continuity of care consists of relationship continuity and management continuity (Hill & Freeman, 2011). Relationship continuity implies that patients benefit from having a long-term relationship with a primary care provider that goes beyond specific episodes of illness or disease. Some definitions also speak of personal or family continuity, where the continuity of care between a single provider or a family is stressed. The quality of the longitudinal relationship between primary care providers and patients, in terms of accommodation of patients’ needs and preferences, such as communication and respect for patients, determine relationship continuity. Management continuity involves coordination and teamwork between caregivers and across organizational boundaries. It includes an organized collection of each patient’s medical information readily available to any health care provider caring for the patient.

This can be reached through medical record-keeping, clinical support and referral systems. The next section will discuss these features of continuity of primary care in each of the countries analysed (see Appendix I for an overview of the Continuity of Care features, indicators and additional information items).

Table 3.2 provides an overview of results of the continuity of primary care by country.

Table 3.2 Continuityofprimarycareservices,overviewofselectionofresultsbycountry

Country Useofpatientlist

systembyGPs Averagepopulation sizeperGP

%patientsreported visitingusualPC providerforcommon healthproblems

Availabilityof computerin GP’soffice Purposeofcomputer

ingeneralpractice¹ Useofreferralletters byGPs Incomingclinicalinfo.

proceduresabout after-hours patientcontacts

Specialist–GP communicationon completed patientcare Patients’freedomto

chooseaPCcentre (PCC)andGP toregister

%patientssatisfiedwith:

relationwiththeir GP/PCphysician

availabletime duringvisitsto GP/PCphysician trustintheirGP/

PCphysician explanationby GP/PCphysician ontreatment

AustriaNo200065(Almost) alwaysADM;MED; RECOccasionallyOccasionallyOccasionallyPCC:Yes GP:Yes–––– BelgiumNo71880UsuallyAPP;MED; REC;INT;SPEUsuallyOccasionallyUsuallyPCC:Yes GP:Yes85809085 BulgariaYes165485(Almost) alwaysADM;MED; REC;INT(Almost) alwaysOccasionallyUsuallyPCC:Yes GP:Yes80607070 CyprusNo––UsuallyADM;MED; REC–––PCC:Yes GP:Yes90859590 CzechRepublicYes161393(Almost) alwaysADM;MED; RECUsuallyUsually(Almost) alwaysPCC:Yes GP:Yes–––– DenmarkYes1583–(Almost) alwaysAPP;ADM; MED;REC; INT;SPE;PHA(Almost) always(Almost) always(Almost) alwaysPCC:Yes GP:Yes8677–79 EstoniaYes159670(Almost) alwaysADM;MED; REC(Almost) always(Almost) alwaysUsuallyPCC:Yes GP:Yes92–9896 FinlandYes1900–(Almost) alwaysAPP;ADM; MED;REC; INT;SPE;PHA

(Almost) alwaysUsuallyUsuallyPCC:No, assigned GP:Yes90758080 FranceNo80090(Almost) alwaysADM;MED; REC(Almost) alwaysSeldom/neverUsuallyPCC:Yes GP:Yes–90–91 GermanyNo200095(Almost) alwaysADM;MED; REC(Almost) alwaysUsuallyUsuallyPCC:Yes GP:Yes92909290 GreeceYes––(Almost) alwaysADM;MED; REC;INT;SPE; PHASeldom/ neverOccasionally–PCC:No, assigned GP:Yes90809997

Country Useofpatientlist systembyGPs Averagepopulation

sizeperGP

%patientsreported visitingusualPC providerforcommon healthproblems

Availabilityof computerin GP’soffice Purposeofcomputer ingeneralpractice¹ Useofreferralletters

byGPs Incomingclinicalinfo.

proceduresabout after-hours patientcontacts Specialist–GP communicationon completed patientcare Patients’freedomto

chooseaPCcentre (PCC)andGP toregister

%patientssatisfiedwith:

relationwiththeir GP/PCphysician availabletime duringvisitsto GP/PCphysician trustintheirGP/

PCphysician explanationby GP/PCphysician ontreatment

HungaryYes153090(Almost) alwaysMED;RECUsuallyOccasionallyUsuallyPCC:Yes GP:Yes84408060 IcelandYes155085(Almost) alwaysADM;MED; REC;INTUsuallyUsuallyUsuallyPCC:Yes GP:Yes–––– IrelandNo1680–UsuallyAPP;ADM; MED;REC(Almost) alwaysUsually(Almost) alwaysPCC:Yes GP:Yes93–9372 ItalyYes1094–UsuallyAPP;MED; REC;INT;SPESeldom/ neverOccasionallyUsuallyPCC:Yes GP:Yes–––– LatviaYes158580OccasionallyAPP;ADM; REC;INT(Almost) alwaysSeldom/ neverUsuallyPCC:Yes GP:Yes93797287 LithuaniaYes155080OccasionallyAPP;ADM; REC;INT(Almost) alwaysOccasionallyUsuallyPCC:Yes GP:Yes70506060 LuxembourgNo500-–UsuallyADM;MED; RECUsuallySeldom/ neverUsuallyPCC:Yes GP:Yes–––– MaltaNo250080OccasionallyADM–Seldom/ neverUsuallyPCC:Yes GP:Yes–––– NetherlandsYes232271-(Almost) alwaysADM;MED; REC;PHA(Almost) alwaysOccasionally(Almost) alwaysPCC:Yes GP:Yes70267470 NorwayYes121971(Almost) alwaysADM;MED; REC(Almost) alwaysUsuallyUsuallyPCC:Yes GP:Yes94739378 PolandYes153985(Almost) alwaysADM(Almost) alwaysOccasionallyUsuallyPCC:Yes GP:Yes8688–– PortugalYes150067(Almost) alwaysAPP;MED; REC;INT;SPE(Almost) alwaysOccasionallyUsuallyPCC:Yes GP:Yes75––– RomaniaYes200085UsuallyADM;REC(Almost) alwaysOccasionally(Almost) alwaysPCC:Yes GP:Yes80757560

Country Useofpatientlist

systembyGPs Averagepopulation sizeperGP

%patientsreported visitingusualPC providerforcommon healthproblems

Availabilityof computerin GP’soffice Purposeofcomputer

ingeneralpractice¹ Useofreferralletters

byGPs Incomingclinicalinfo.

proceduresabout after-hours patientcontacts

Specialist–GP communicationon completed patientcare Patients’freedomto chooseaPCcentre (PCC)andGP toregister

%patientssatisfiedwith:

relationwiththeir GP/PCphysician

availabletime duringvisitsto GP/PCphysician trustintheirGP/

PCphysician explanationby GP/PCphysician ontreatment

SlovakiaYes216398(Almost) alwaysADM;MED; REC(Almost) alwaysUsually(Almost) alwaysPCC:Yes GP:Yes84859087 SloveniaYes178993UsuallyADM;REC(Almost) alwaysOccasionallyUsuallyPCC:Yes GP:No, assigned8192–49 SpainYes150072(Almost) alwaysADM;MED; REC;SPE;PHA(Almost) alwaysUsually–PCC:Yes GP:Yes95889290 SwedenNo––UsuallyADM;MED; REC;INT;PHA(Almost) alwaysOccasionally(Almost) alwaysPCC:No, assigned GP:Yes55––– SwitzerlandNo–88UsuallyADM;REC;INTUsually(Almost) always(Almost) alwaysPCC:Yes GP:Yes–––– TurkeyYes368778(Almost) alwaysREC;INTOccasionallyOccasionallySeldom/ neverPCC:Yes GP:Yes94865988 UnitedKingdomYes174577 (ENG)(Almost) alwaysAPP;ADM; MED;REC(Almost) always(Almost) always(Almost) alwaysPCC:Yes GP:Yes85909579 1 APP=Bookingappointmentswithpatients;ADM=Writingbills/financialadministration;MED=Prescriptionofmedicines;REC=Keepingmedicalrecordsofpatients; INT=SearchingexpertinformationontheInternet;SPE=Communicatingpatientinformationtospecialists;PHA=Communicatingprescriptionstopharmacists.

Continuity of care over time

Continuity of primary care is facilitated in primary care by GPs having a list of patients for whose medical care they are responsible, either personally or as a group. Such lists of registered patients are the norm in most countries of Europe, and mandatory in all countries except Austria, Belgium, Cyprus, France, Germany, Ireland, Luxembourg, Malta, Sweden and Switzerland. In some of these countries, registration with a GP is compulsory for some patients (e.g. those who are state funded in Ireland) or incentivized (e.g. by a reduction of co-payments in Belgium).

The average population size served by GPs is 1687 patients. GPs have the largest average list size in Turkey (3687), Malta (2500), the Netherlands (2322) and the Slovakia (2163); and the smallest in Luxembourg (500), Belgium (718), France (800), Italy (1094) and Norway (1219).

There is potentially a trade-off between choice and continuity. Patients are free to register with any primary care centre and GP in their locality in all countries except Finland, Greece and Sweden, where patients are assigned to a primary care centre, and Slovenia, where patients are assigned to a GP. Continuity is best achieved by patients visiting their usual primary care provider for their common health problems rather than attending multiple primary care providers or medical specialists. Interpretation of results regarding this aspect is difficult as some national data sets define the usual provider as an individual clinician, whereas in others it is defined as an organization. The extent to which other professionals (e.g. pharmacists and nurses) are used for common health problems also varies between countries. In all 23 counties where data were available, it was found to be “usually the case” that patients consulted the same provider for their common health problems, although this varied from a high of over 90% in the Czech Republic and Slovakia to lows of below 70% in Austria and Portugal.

Management continuity

Management continuity relies on good information systems, both within primary care and between primary and secondary care. GPs’ offices in all countries (except Latvia, Lithuania and Malta) are usually equipped with a computer for keeping medical records, financial administration and prescription of medicines. In only a minority of countries computers are also used for researching expert information on the Internet, booking appointments, and for communication with medical specialists or pharmacists. Finland and Denmark have the highest use of computers in general practice. Referral letters are usually used by all GPs in Europe, except in Austria, Greece, Italy and Turkey (no data available for Cyprus and Malta). In most (18) countries it takes more than 24 hours to receive information about out-of-hours contacts for patients.

Relationship continuity

On average 85% of patients in Europe are satisfied with their relationship with their primary care physician and trust their primary care physician. Satisfaction with the patient–primary care physician relationship is lowest in Sweden (55%), Lithuania (70%) and the Netherlands (70%); and patients least trust their primary care physician in Turkey (59%), Lithuania (60%), Bulgaria (70%) and Latvia (72%). On average, only 79% of patients in Europe were satisfied with the explanation given by their primary care providers of problems, procedures and treatments. This is lowest in Slovenia (49%), Hungary (60%), Lithuania (60%) and Romania (60%).

Overall continuity of primary care by country

Fig. 3.2 shows the total score of continuity of primary care by country (see Appendix II for the applied scoring system). Variation between countries appears to be very small. Only Turkey, Malta and Austria have lower scores.

The difference between the other countries is negligible.

In countries where GPs have a high patient load, relationship continuity can be improved by limiting the average population size per GP. This would reduce the work load and increase possibilities for building a high-quality relationship with patients. Patient satisfaction with several aspects of their relationship with their GP (e.g. consultation duration) could be improved in many countries.