Against the grain

Emilie Couchman is an NIHR Clinical Lecturer in General Practice with the Division of Primary Care Palliative Care and Public Health at Leeds University, and a salaried GP with Sarum Health Group in Wiltshire. She has recently completed her PhD relating to continuity within the primary palliative care context.

I am pro-continuity. This does not mean that I apply a blanket rule of continuity to all patients that I see, above all other considerations. Being an advocate for continuity involves comprehensive decision-making as to whether a particular individual, presenting with a particular complaint, at a particular point in time (based on the context of who they are and how they live their life), would benefit from continuity. Their perception of, and preferences regarding continuity, are obviously considered too. Continuity is therefore not binary. It is a complex phenomenon that needs to be responsive to individual need, and is instrumental in the delivery of personalised medical care.

Continuity is so much more than seeing the same doctor every time. It is a dynamic decision-making process, which involves balancing the benefit of the additional insight conferred from truly knowing a patient; with a firm adherence to the GMC guidance of knowing one’s own limitations and recognising boundaries of clinical competence, which permits the insight and courage to act if continuity needs to be broken and a patient needs to consult with an alternative clinician.¹

There is a small body of evidence suggestive of negative outcomes arising from continuity. A study by Ridd et al. aimed to “…estimate associations between patient-doctor continuity and time to diagnosis and referral for three common cancers…” using data from an English general practice database. The authors report an association between patient-doctor continuity in the preceding two years to a 7-day delay in the diagnosis of colorectal cancer.² In an earlier paper, Ridd et al. suggested that familiarity with patients may lead clinicians to misassign new medical problems to existing issues, resulting in a delay to appropriate diagnosis.³

I suggest that the above ‘negative’ potential of continuity could be reframed as a key aspect of continuity.  For instance, the recently published patient safety initiative, ‘Jess’s rule’, reinforces the perspective that a key aspect of continuity is that clinicians know when to break it.⁴ For instance, when they need a fresh pair of clinical eyes for a patient consulting frequently with the same issue, they ask an appropriate colleague (either generalist or specialist) to provide insight. Patients too can initiate this process.

Clinicians want to do the best for their patients, thus any initiative that advocates for patient safety is going to be respectfully considered by benevolent clinicians. However, the failings in cases such as that highlighted by ‘Jess’s rule’, do not usually stem from individual clinicians, but from issues within the wider healthcare system.⁴ The reason that continuity feels like an uphill battle is that if we try to implement it within our own clinical practice, we are antagonised and obstructed by the inner workings of the system dictated by policy that has focussed on access over recent decades. Access and continuity are often pitted against each other, considered as two opposing ends of a spectrum. Hence, I found it particularly interesting that a Clinical Nurse Specialist in my PhD study entitled, ‘Rethinking continuity in general practice for people with mesothelioma’, defined continuity by including access to care as a key component:⁵

‘I think continuity probably means having a point of contact, somewhere, from somebody in your care pathway, in terms of the patient being able to reach out to speak to somebody.’

Access and continuity are in fact intertwined in a complex co-dependent relationship. For example, without access, there can be no continuity; but at the same time, if access is prioritised above all else, continuity is compromised. In the Fuller Stocktake report, access and continuity are considered as “two sides of the same coin”: it is suggested that if people have access to prompt, urgent care services, space is then created for the delivery of better continuity for select individuals.⁶ However, Pereira Gray et al. have expressed concern that such proposals to manage patients with acute and chronic conditions separately could further decrease continuity.⁷

Particularly in general practice, effective access depends firstly on practicalities of accessibility, but secondly on an individual’s or practice’s willingness to be accessible. This further significant part of effective continuity requires individuals to take responsibility, and requires practices to function in a way that permits flexible responsiveness to patient needs. This hones in on the micro- and meso-level factors involved in facilitating or presenting a barrier to continuity. Clinicians need to realise the potential and value of continuity, and be prepared to swim against the tide of the macro-level system. Given all the other requirements of clinicians working within general practice, expecting them to go above and beyond when they may well be just trying to keep their head above water, is perhaps unrealistic.

Policy often cites the GP staffing crisis as the main reason that continuity is not possible. The NHS 10 year plan will hopefully change the healthcare system for the better (so that clinicians do not have to go against the grain), permitting the attitudes and micro- level barriers to continuity to resolve, leading to the amelioration of recruitment and retention in general practice.⁸

References

1. General Medical Council (2024) Good Medical Practice: The duties of medical professionals registered with the GMC. good-medical-practice-2024—english-102607294.pdf [accessed 10/10/25]
2. Ridd MJ, Ferreira DLS, Montgomery AA, et al. Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice. British Journal of General Practice. 2015;65(634):e305-e11.
3. Ridd M, Shaw A, Salisbury C. ‘Two sides of the coin’ – the value of personal continuity to GPs: a qualitative interview study. Family Practice. 2006;23(4):461-8.
4. NHS England. Jess’s Rule: Three strikes and we rethink (2025) NHS England » Jess’s Rule: Three strikes and we rethink [accessed 10/10/25]
5. Couchman, E (2025) Rethinking continuity in general practice for people with mesothelioma. [Unpublished doctoral dissertation] University of Sheffield
6. Fuller C. Next steps for integrating primary care: Fuller stocktake report. NHS England; 2022.
7. Pereira Gray D, Sidaway-Lee K, Johns C, et al. Can general practice still provide meaningful continuity of care? British Medical Journal. 2023;383:e074584.
8. NHS Department of Health and Social Care. (2025) Fit for the Future: 10 Year Health Plan for England. Fit for the future: 10 Year Health Plan for England [accessed 10/10/25]

Featured Photo by Aleksey Oryshchenko on Unsplash