To revitalize primary care policy, focus on relationships
Growing up, I knew there was something special about the relationship I had with my family doctor, the only physician I knew for my first two decades of life.
For those two decades, our family doctor formed my ideas of what it was like to be a health professional. I distinctly remember the kind face and unhurried tone, but also the multiple roles played – at once scientist, advisor and connector. Most importantly, my doctor worked to understand my values and earn my trust. We built this relationship slowly, over countless visits and many years, and although unspoken, my doctor, my family and I all understood the immeasurable value from this relationship in keeping me and my loved ones healthy.
Now as a family physician myself, I know there really is something special about the relationships we develop with the people and families we serve. I know that my understanding of Mr. X and his family, for instance, will allow me to care for him in a way that is more human, has higher quality and ultimately is less likely to do harm. I also understand that these relationships are not unique.
In fact, continuity of care is a foundational element in family practice. Continuity of care captures several ideas but at its most basic involves the concept of seeing the same clinician or team over time, thereby building understanding and trust.
Forms of continuity
People need care at different times, from unique sets of expertise, and in various access points to the healthcare system. There are different forms of continuity that capture these needs. Informational continuity, for example, is the idea that all health professionals involved in a person’s care should be able to access and contribute to the health record and have a shared understanding of a person’s care goals. Team-based continuity involves care that is continuous within a highly collaborative and often co-located team of health professionals.
It is easy to see how there are benefits and drawbacks to the various forms of continuity. No matter how dedicated, a single family doctor cannot be available at all times and in all places. On the other hand, an unfamiliar doctor who has access to a record but no prior understanding or has not built trust with a person may have a hard time sharing in decision-making and, worse, runs the risk of missed preventive care, delayed diagnosis or incorrect treatment.
In other words, an unfamiliar clinician may be good enough for an uncomplicated urinary tract infection but not ideal for a sensitive dialogue or important diagnosis. Continuity of care has many forms and each form may contribute to good care in different ways.
Benefits of continuity
A continuous relationship with a family doctor or care team comes with immense rewards. People who can see the same doctor live longer. In a forthcoming paper, my research team and I show the qualitative evidence around continuity bringing person-centeredness, quality and confidence in care. Continuity also has systems-level outcomes. A classic 2005 paper on its contributions describes primary care’s six most significant impacts: access, quality, prevention, early management, whole-person care and appropriate specialist use. There has since been an abundance of literature on continuity supporting cost savings, lower hospitalizations, improved health and higher quality care. It is no surprise that the lack of continuity can be devastating. A focus on continuity in primary care is core to a health system that strives to be person-centred, safe, effective, equitable, accessible and efficient.
Continuity versus access
When discussing primary care, it is critical to note the contrast between accessible and continuous care. Many people are fortunate to receive continuous and ultimately meaningful care through their lives. They receive quality well-baby care, up-to-date vaccinations, wise preventive and lifestyle coaching, chronic disease and mental health care and end-of-life planning. Tragically, this kind of care is not guaranteed for many Canadians. In Ontario, more than 1 million people are without a family doctor or primary care professional. People living in central Toronto live in an area with convenient access to primary care (via numerous walk-in clinics), for example, but one in nine still lack continuous care. Walk-in clinics are, of course, an important safety net. Unfortunately, people without some form of continuity will receive fragmented care by multiple professionals and often no longitudinal health guidance. Policy failures in our healthcare system let countless Canadians without continuity fall through the cracks.
Continuity is a matter of equity
Location, language, office hours, legal status, trust and a variety of other factors all play a role in access to continuity of care. Primary care policy failures disproportionately impact newcomers to Canada and those already poorly served by the healthcare system. In the Hamilton Spectator’s Code Red series, the investigators found that neighbourhoods with the fewest residents connected to a family doctor were also the ones with the most emergency visits for mental health crisis, lowest incomes, highest rates of poverty and the worst maternal health outcomes. Without these continuous relationships with a care team, health disparities worsen in those already impacted by the social determinants of health. Continuous relationships matter because of their immense impact on equitable quality.
The way forward
In all of its forms, continuity of care brings humanity, quality and equity to clinical care. The onus should not be on people, families or caregivers to ask for the same clinician or care team, to repeat traumatic stories at each point of care, or to compile tomes of health information to bring to appointments. Our current state is failing many and it is the responsibility of provincial ministries of health to ensure that every Canadian has a continuous medical home, regardless of location, language, status or determinants of health. As we shift to a more digital system and seek to integrate existing care silos, we must commit to providing every Canadian with meaningful primary care with the strength of continuity in all its forms. Continuity of care matters. It is beyond time that we incorporate continuity as a core value for the care of all Canadians, in all contexts, with all clinicians.