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Title: Continuity of care in UK general practice
Author: Guthrie, Bruce
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2003
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'Continuity' is frequently cited as a core value for UK general practice, and in this context usually appears conceptualised in terms of personal continuity or ongoing relationships between patients and general practitioners (GPs). Formal definitions include other dimensions such as continuity of information, and the co-ordination of care, and these are more promoted in recent UK policy documents and by organisational change. Two studies were conducted for this thesis. The first used multilevel regression analysis of survey data from over 25,000 patients in 53 general practices to explore the distribution of 'continuity' in the sense of whether or not patients were seeing their 'usual or regular' GP. The key findings were that measured 'continuity' was lower in larger practices and those with shared lists where patients can see any GP. Younger patients and those without chronic disease were less likely to be seeing their usual or regular GP, although whether the age association represents a cohort or lifecycle effect cannot be addressed with cross sectional data. In the second study, thirty-two patients and sixteen GPs were interviewed about what they valued about general practice. Interviews were semi-structured, and the data were analysed qualitatively. A thematic analysis of which dimensions of 'continuity' were valued by patients and GPs, and how these related to other valued processes and outcomes of general practice care was developed. Further analysis focused on the ways that GPs used 'continuity' to construct a particular kind of professional identity, and whether patients accepted or rejected the claims to a particular identity made by GPs. Both GPs and the majority of patients emphasised the importance of personal continuity. A key difference was that patients talked about routinely balancing personal continuity against access, with their preference varying with the nature of the problem to be discussed. The majority of patients said that they usually preferred to wait to see 'their' GP, but a few solely prioritised speed or convenience of access. GPs and patients ascribed a similar range of advantages to personal continuity, but GPs focused on benefits in terms of better diagnosis and management of problems, whereas patients emphasised feeling more at ease, being able to be more active in consultations, and increased trust and legitimacy. In formal definitions, the different dimensions of'continuity' are made conceptually distinct. But for these GPs and patients, different dimensions of continuity were interwoven. Personal continuity (an ongoing relationship) and longitudinal continuity (seeing the same GP) were routinely conflated, and GPs described complex interactions between the different ways of knowing the patient associated with personal continuity and with continuity of information embodied in the medical record. Personal continuity was frequently deployed by GPs to distinguish themselves from hospital doctors. This boundary was repeatedly constructed without prompting throughout the GP interviews, suggesting that it was a problematic area. This appeared to be because of hospital doctors' greater expertise in diagnosis and management of particular diseases or problems, something acknowledged by GPs and taken for granted by patients. In contrast, GPs appeared to assume that their control of medical knowledge made their identity with regard to nurses unproblematic. Supporting this, patients talked about nurses' work largely in terms of the tasks done, and said they did not greatly value ongoing, personal relationships with nurses. Underpinning both of these boundaries was a shared assumption of medical work as primarily being the diagnosis and management of problems, with a stronger biomedical emphasis than was immediately apparent in talk about 'personal continuity'. The data are used to discuss the ways in which personal continuity appeared central to patients' and GPs' experience of general practice, and to the construction of a stable professional identity for GPs. The usefulness of 'continuity' as a research or policy concept is then explored. Although formal definitions of'continuity' are conceptually helpful, different dimensions of'continuity' are likely to be interdependent within an individual health care system. Understanding 'continuity' therefore requires a sensitivity to this wider context. Finally, possible implications of current organisational change for the experience of 'continuity' by patients and the professional identity of GPs and general practice are examined.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available