Continuity of care: delayed diagnosis in GP practices

Background

Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient.

While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices.

This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS.

As an example, which is referred to as ‘the reference event’, the investigation reviewed the care of Brian, who had had treatment for breast cancer and later developed severe back pain.

The reference event

Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Initially the pain was so severe that Brian visited his local emergency department (ED). He was discharged from the ED with pain relief and was advised to contact his GP practice.

A month later, Brian telephoned his GP practice and saw his named GP. The GP referred Brian to the GP practice’s physiotherapist and requested a blood test. Brian saw the physiotherapist, who gave him advice about exercises to help relieve the back pain. The exercises did not relieve Brian’s pain and over the following 8 months he saw two out-of-hours GPs and six practice GPs, a nurse and a physiotherapist at the GP practice.

Brian also had consultations with healthcare professionals during this time for other conditions not relating to his back pain. When Brian saw a GP at end of the 8-month period, the GP found a lump on his spine and advised Brian to go to the local ED.

At the ED, Brian had a computerised tomography (CT) scan. A lump was found on his spine which was later diagnosed as metastatic breast cancer (that is, breast cancer that had spread to his spine).

The investigation

The investigation worked with Brian, the GP practice, local ED and oncology services and national bodies to identify the themes for the national investigation. The investigation focused on:

How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system.
Workload pressures that affect the ability of GP practices to deliver continuity of care.

Findings

The GP contract, which sets out the mandatory requirements for GP services commissioned by the NHS, does not specifically require GP practices to adopt an approach that ensures continuity of care, but practices can do so voluntarily.
Many GP practices do not operate a formalised system of continuity of care.
There is no standard framework to deliver continuity of care in GP practices, so it is done differently across the country.
Many GPs understand the benefits of continuity of care; however, some practices did not believe that it was possible to deliver such a system. Other practices were able to maintain continuity of care through systems developed by those practices.
There is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information (that is, identify and flag up relevant patient information) to GPs when they see a patient with unresolving symptoms.
Patients told the investigation that they found it beneficial to see their named GP for long-term health conditions, including mental health conditions.
GPs working in a practice with a system of continuity of care had more time to process information during consultations and to carry out any follow-on actions to ensure patients received the care they needed.
GP practices that operated a system of continuity of care reported to have better staff welfare and retention, and fewer recruitment issues, than those that did not.

Safety recommendations

Department of Health and Social Care

HSSIB recommends that the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information.

This Government has committed to bring back the family doctor so patients can see the same doctor at each appointment. This is what patients and doctors want, and what the evidence says is best for patient care and can improve efficiency and productivity.

Doing so will be achieved by incentivising GPs to see the same patients, so ongoing or complex conditions are dealt with effectively. We will work with the profession and engage stakeholders to inform how this is delivered.

The 2024/25 GP contract explicitly requires continuity of care to be considered when determining the appropriate response when a patient contacts their practice. We will consider how to best use the GP contract to embed continuity in future years.

There are other wider enablers, beyond the contract, that we will leverage to drive improvements in the provision of continuity of care. For instance, building capacity in general practice by training thousands more GPs; guaranteeing face-to-face appointments for all those who want one; delivering a modern appointment booking system; and shifting resources to primary and community care services.

We welcome this report and thank the HSSIB for highlighting this issue. We look forward to working with the profession and stakeholders to bring back the family doctor.

Actions planned to deliver safety recommendation:

Explore how the GP contract can embed continuity. By: on-going.
Explore incentivisation of continuity of care. By: on-going.
Engage the profession and stakeholders on bringing back the family doctor and the approach to incentivising GPs to see the same patients so ongoing or complex conditions are dealt with effectively. By: Summer/Autumn 2024.

Response received on 3 September 2024.

NHS England

HSSIB recommends that NHS England updates the GP IT standards to ensure that patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms.

Electronic patient record (EPR) systems used in general practice are functionally rich and contain extensive data concerning a patient’s care over time, which makes them a valuable resource to support continuity of care. The standards to which all practice EPRs are required to adhere include a number that support continuity of care, for example capabilities that trigger alerts or provide enhanced information sharing.

We will consider how to enhance digital support for continuity of care in two ways:

Review existing capabilities to determine how they are currently configured and used by practices, covering (for example) appointment booking and management, alerting capabilities, risk stratification (identifying patients based on different risk factors), shared care records and patient access to records. We will work with system suppliers and other delivery partners to identify areas for improvement, focused on new or improved guidance, awareness and training for frontline staff, and optimising systems to maximise usefulness and utilisation.
Identify new capabilities. This includes looking at areas such as surfacing of alerts in response to potential lapses in care continuity (for example, alerting the GP to cases where a patient has been seen 3+ times for the same condition with no resolution of symptoms); easier integration of notes and outcomes from encounters with other care settings into the patient record; identifying patterns from electronic prescribing; and simplifying proxy access to patient records. We will work with policy and operations teams to develop an overall view of how digital solutions may most effectively support continuity of care. This may include enhancements to standards and/or new standards, as well as other digital enhancements, and have reference to guidance such as the RCGP Continuity of Care Toolkit. We will work with stakeholders, including professional representative bodies, and consider other changes resulting from this HSSIB report, in particular broader best practice recommendations (e.g. ‘Named GP’ provision) to avoid confusion or duplication, and avoid making any potentially inconsistent or counter-productive changes.

Actions planned to deliver safety recommendation:

Review implementation of existing capabilities (April-June 2024).
Review overall current landscape with policy/operational teams and develop improvement plan (October-December 2024).
Deliver enhancements/new capabilities (from January 2024).

Response received on 5 March 2024.

Safety observations

HSSIB makes the following safety observation:

GP practices can improve patient safety by aligning their staff wellbeing and patient safety policies to those of NHS England’s proposed patient safety strategy.

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