Continuity of care 2006: what have we learned since 2000 and what are policy imperatives now?

Freeman, G., Woloshynowych, M., Baker, R., Boulton, M., Guthrie, B., Car, J., Haggerty, J. and Tarrant, C. 2007. Continuity of care 2006: what have we learned since 2000 and what are policy imperatives now? NCCSDO.

TitleContinuity of care 2006: what have we learned since 2000 and what are policy imperatives now?
AuthorsFreeman, G., Woloshynowych, M., Baker, R., Boulton, M., Guthrie, B., Car, J., Haggerty, J. and Tarrant, C.
TypeProject report
Abstract

Background
In 2000, the SDO commissioned a Scoping Exercise on Continuity of Care following their initial Listening Exercise among managers and consumers. The aim was to describe and limit the concept, and to summarise previous research and suggest priority areas. The scoping report recommended that research needed to focus on continuity from the patient’s perspective and that a much clearer definition of continuity was required.
After considering the scoping report the SDO commissioned a major programme of research. This included six major empirical projects of three to six year duration1 as well as several brief reviews. The six empirical projects covered the following topic areas: diabetes (type 2), primary care, cancer, cross-boundary issues (exemplified by learning difficulty and stroke), acute severe stroke (main stroke) and severe mental illness (mental health). (The abbreviations in italics are the shortened project titles used throughout this report). By 2005 the SDO needed to evaluate this programme and it commissioned the present review to synthesise and interpret findings to date. This project ran for six months from June 2006.
The Canadian Health Services Research Foundation also commissioned a programme of research into continuity of care over a similar time period (1999-2005). This comprised over 70 projects, generally smaller but covering a wider range of topics. We welcomed the opportunity to link up with the evaluation of the Canadian programme.

Method
The multidisciplinary project team met monthly. One member (JH) was also the evaluator of the Canadian programme. Two members of the group (GKF & MW) collected most of the ‘data’ – this was from project reports, publications (where available) and from site visits to the research teams of the major projects.
While the original intention was a formal synthesis of project outputs with the aim of generating findings common to all projects, this proved impracticable for two reasons: first, three projects were incomplete, second, methods and contexts were so heterogeneous that formal data synthesis techniques could not be applied. Instead we conducted a series of case studies and synthesised the narrative findings using established methods. Subsequent interaction with the research teams encouraged us to focus particularly on issues of measurement of continuity arising in the projects.

Findings
A continuity research programme of unprecedented scope
This programme has been the largest and longest of its kind, with particular focus on the experiences of patients and their carers. Each project has seen substantial user involvement in its design and execution. Continuity of care is a phenomenon experienced over time – it is in essence longitudinal. It therefore particularly needs study over the longer time periods that this farsighted programme has enabled. Unfortunately one paradox is that these longer term findings are not yet available for us to report and comment on!

Concept and definition
The projects have developed a range of new measurement scales for continuity as experienced by patients and carers. As a result continuity was conceptualised broadly, to include other aspects of quality of care such as access and availability of services. There has not been a particular convergence of definitions between projects. An important new finding has been the extension of the concept of informational continuity to include information transfer from professionals to patients. Some professional aspects of informational and management continuity were clearly less salient to patients. Thus both groups must be sampled to gather data as a basis for improving and monitoring services.
The cancer project developed the concept of continuity as an outcome rather than a process. This is useful because it improves our understanding of what patients are looking for but it does not directly help providers identify the process changes that are needed to improve care.

User and carer experience
The experience of continuity was often estimated as good in these projects. But each area revealed minorities with poorer experience. A common thread across many projects was the disadvantage of vulnerable groups who were less able to negotiate better continuity or other aspects of better care for themselves. In the case of cancer this appeared to be those who were either too ill (therefore unable) or else reluctant (due to cultural, class or language barriers) to be more directly involved as ‘partners’ in their care. In primary care it could take great persistence to achieve continuity with the patient’s chosen doctor.
For people with learning disability struggling with the transition from school to adult life, problems of continuity across health, social care and educational boundaries were far more common. This appears to relate to a combination of shortage of resources (services) and low policy priority on the one hand, with years of ‘organisational turbulence’ on the other. The creation of new coordinating structures does not necessarily compensate for lack of resources and brings a heavy cost in transitional disruption.

Effects of continuity
Few of these results were available at the time of this report, but the diabetes project reinforces evidence that both relationship and management continuity are associated with satisfaction for both patients and staff. On the other hand there was no association between either type of continuity and improved clinical indicators of diabetes (lower blood pressure or blood sugar levels). This could be because services respond to deteriorating diabetes by offering better continuity.
In the case of cancer, high experienced continuity was associated with lower physical and psychological health needs, better quality of life and less psychological distress at each subsequent follow-up point over the 12 month study.

Enhancing and frustrating continuity
The diabetes project found best continuity for primary care patients when care was led and co-ordinated by a named lead clinician in their practice. Continuity was assessed as less good without this lead person, and least good when care was led from secondary care.
Both in primary care and in mental health, users voiced a need for adaptability and flexibility in access to services. In the case of cancer, good planning at the initial stages seems vital. The project team are engaged in a second phase of their study planning to test an intervention designed to improve the effectiveness of initial multidisciplinary team planning meetings by helping them be more sensitive to individual patients’ needs, and ability and willingness to be involved in various aspects of their care.

Insights from the parallel Canadian programme
This review covered 34 continuity studies. Five focussed on the concept of continuity from the patient perspective. As with the SDO projects, patients emphasised extra dimensions of care quality beyond strict continuity: access to services, and the interpersonal and perceived technical skills of providers. Patients were keen to be participants and saw their continuity role as complying with treatment and using appropriate self management – but also in advocating for access to recommended services. Flexibility of access was again emphasised to facilitate the achievement of desired relationship and management continuity.
Systems to facilitate information transfer were found to be necessary but not sufficient in improving care delivery. There was some evidence of specialist care savings being partially off-set by extra community expenditure. The most successful interventions were accompanied by improvements in quality of life and general functioning for patients with mental illness.

Conclusion
The term continuity of care has a number of meanings and therefore needs explaining or qualifying whenever it is used. It applies to individual patients (rather than groups) over time. We now distinguish three major types –management, informational and relationship. Management continuity involves the communication of both facts and judgements across team, institutional and professional boundaries, and between professionals and patients. Informational continuity concerns the timely availability of relevant information. Relationship continuity means a therapeutic relationship of the patient with one or more health professionals over time.
Access is closely linked with continuity and patients may have to trade off one for the other. This is particularly true for patients in primary care, where they have significant control over appointment making. In other settings, patients have less control over access. Perceived professional quality, both interpersonal and technical, is a vital influence on patients’ choices about access and relationship continuity, so access needs to be assessed alongside continuity when reviewing a service.
The SDO programme, together with the parallel Canadian one, has added much to our understanding of the working of different types of continuity and confirmed that better continuity of both management and relationship are associated with better satisfaction for patients and staff, and with just a few improved outcomes.
More evidence is still needed on the causal links between continuity, particularly relationship continuity and better outcomes. This needs evidence from carefully designed trials.
These projects have greatly extended our understanding of continuity as experienced by patients and by their carers. There is strong support here for the concept of patients as partners in their own care and for professionals to devote more effort in working with patients rather than delivering a service to them. At the same time important groups of patients are more vulnerable and need extra professional help to achieve better continuity on the way to better care. In particular they need flexible access systems and help in negotiating these, together with adequate resources to deliver the advertised service.
While these projects had some success at identifying vulnerable groups it is likely that these were underrepresented. Future studies need more specific focus and original approaches.
All these projects except primary care focussed on single, if serious,
problems. Increasingly patients have co-morbidities and future work needs to focus on the role of various types of continuity in providing better care for them.

Year2007
PublisherNCCSDO
FunderNational Coordinating Centre for the Service Delivery and Organisation (NCCSDO) research programme
Web address (URL)https://njl-admin.nihr.ac.uk/document/download/2027553

Related outputs

A correlational analysis of COVID-19 incidence and mortality and urban determinants of vitamin D status across the London boroughs
Borna, M., Woloshynowych, M., Schiano-Phan, R., Volpi, E. and Usman, M. 2022. A correlational analysis of COVID-19 incidence and mortality and urban determinants of vitamin D status across the London boroughs. Scientific Reports. 12 (1) 11741. https://doi.org/10.1038/s41598-022-15664-y

Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents
Usman, M., Woloshynowych, M., Britto, J.C., Bilkevic, I., Glassar, B., Chapman, S., Ford-Adams, M.E., Desai, A., Bain, M., Tewfik, I. and Volpi, E. 2021. Obesity, oxidative DNA damage and vitamin D as predictors of genomic instability in children and adolescents. International Journal of Obesity. 45, p. 2095–2107. https://doi.org/10.1038/s41366-021-00879-2

Food and Mood: Exploring the determinants of food choices and the effects of food consumption on mood among women in Inner London.
Leeds, J., Keith, R. and Woloshynowych, M. 2020. Food and Mood: Exploring the determinants of food choices and the effects of food consumption on mood among women in Inner London. World Nutrition. 11 (1), pp. 68-96. https://doi.org/10.26596/wn.202011168-96

Work conditions, mental workload, and patient care quality: a multisource study in the emergency department.
Weigl, M., Müller, A., Holland, S., Wedel, S. and Woloshynowych, M. 2016. Work conditions, mental workload, and patient care quality: a multisource study in the emergency department. BMJ Quality and Safety. 25, pp. 499-508. https://doi.org/10.1136/bmjqs-2014-003744

A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills
Flowerdew, L., Gaunt, A., Spedding, J., Bhargava, A., Brown, R., Vincent, C. and Woloshynowych, M. 2013. A multicentre observational study to evaluate a new tool to assess emergency physicians' non-technical skills. Emergency Medicine Journal. 30 (6), pp. 437-443. https://doi.org/10.1136/emermed-2012-201237

Teams under pressure in the emergency department: an interview study
Flowerdew, L., Brown, R., Vincent, C. and Woloshynowych, M. 2012. Teams under pressure in the emergency department: an interview study. Emergency Medicine Journal. 29 e2. https://doi.org/10.1136/emermed-2011-200084

Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the Literature
Flowerdew, L., Brown, R., Vincent, C. and Woloshynowych, M. 2012. Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the Literature. Annals of Emergency Medicine. 59 (5), pp. 386-395. https://doi.org/10.1016/j.annemergmed.2011.11.021

Development and Validation of a Tool to Assess Emergency Physicians' Nontechnical Skills
Flowerdew, L., Brown, R., Vincent, C. and Woloshynowych, M. 2012. Development and Validation of a Tool to Assess Emergency Physicians' Nontechnical Skills. Annals of Emergency Medicine. 59 (5), pp. 376-385. https://doi.org/10.1016/j.annemergmed.2011.11.022

The ABC of Handover: Impact on shift handover in the Emergency Department
Farhan, M., Brown, R., Vincent, C. and Woloshynowych, M. 2012. The ABC of Handover: Impact on shift handover in the Emergency Department. Emergency Medicine Journal. 19, pp. 947-953. https://doi.org/10.1136/emermed-2011-200201

The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department.
Farhan, M., Brown, R., Woloshynowych, M. and Vincent, C. 2012. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emergency Medicine Journal. 29, pp. 941-946. https://doi.org/10.1136/emermed-2011-200199

Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study
Monroe, K., Wang, D., Vincent, C., Woloshynowych, M., Neale, G. and Inwald, D.P. 2011. Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study. BMJ Quality and Safety. 20, pp. 863-868. https://doi.org/10.1136/bmjqs.2010.048504

Stress Management Training for Surgeons - a randomised controlled intervention study
Wetzel, C.M., George, A., Hanna, G.B., Athanasiou, T., Black, S.A., Kneebone, R.L., Nestel, D. and Woloshynowych, M. 2011. Stress Management Training for Surgeons - a randomised controlled intervention study. Annals of Surgery. 253 (3), pp. 488-494. https://doi.org/10.1097/SLA.0b013e318209a594

Factors compromising safety in surgery: stressful events in the operating room
Arora, S., Hull, L., Tierney, T., Nestel, D., Woloshynowych, M., Darzi, A. and Kneebone, R. 2010. Factors compromising safety in surgery: stressful events in the operating room. The American Journal of Surgery. 199 (1), pp. P60-65. https://doi.org/10.1016/j.amjsurg.2009.07.036

The Imperial Stress Assessment Tool (ISAT): A feasible, reliable and valid approach to measuring stress in the Operating Room
Arora, S., Tierney, T., Sevdalis, N., Aggarwal, R., Woloshynowych, M., Nestel, D., Darzi, A. and Kneebone, R. 2010. The Imperial Stress Assessment Tool (ISAT): A feasible, reliable and valid approach to measuring stress in the Operating Room. World Journal of Surgery. 34, pp. 1756-1763. https://doi.org/10.1007/s00268-010-0559-4

The impact of stress on surgical performance: A systematic review of the literature
Arora, S., Sevdalis, N., Nestel, D., Woloshynowych, M., Darzi, A and Kneebone, R 2010. The impact of stress on surgical performance: A systematic review of the literature. Surgery. 147 (3), pp. 318-330. https://doi.org/10.1016/j.surg.2009.10.007

Reflective analysis of safety research in the hospital accident & emergency departments
Wears, R.L., Woloshynowych, M., Brown, R. and Vincent, C.A. 2010. Reflective analysis of safety research in the hospital accident & emergency departments. Applied Ergonomics. 41 (5), pp. 659-700. https://doi.org/10.1016/j.apergo.2009.12.006

The effect of stress and coping on surgical performance during simulations
Wetzel, C.M., Black, S.A., Hanna, G.B., Athanasiou, T., Kneebone, R.L., Nestel, D., Wolfe, J.H.N. and Woloshynowych, M. 2010. The effect of stress and coping on surgical performance during simulations . Annals of Surgery. 251 (1), pp. 171-176. https://doi.org/10.1097/SLA.0b013e3181b3b2be

Managing Intra-operative stress: What do surgeons want from a crisis training programme?
Arora, S., Sevdalis, N., Nestel, D., Tierney, T., Woloshynowych, M. and Kneebone, R. 2009. Managing Intra-operative stress: What do surgeons want from a crisis training programme? The American Journal of Surgery. 197 (4), pp. 537-543. https://doi.org/10.1016/j.amjsurg.2008.02.009

The Care Homes Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people
Barber, N.D., Alldred, D.P., Raynor, D.K., Dickinson, R., Garfield, S., Jesson, B., Lim, R., Savage, I., Standage, C., Buckle, P., Carpenter, J., Franklin, B., Woloshynowych, M. and Zermansky, A.G. 2009. The Care Homes Use of Medicines Study: prevalence, causes and potential harm of medication errors in care homes for older people. BMJ Quality and Safety. 18, pp. 341-346. https://doi.org/10.1136/qshc.2009.034231

Methodological variability in detecting prescribing errors when evaluating computerised physician order entry
Dean Franklin, B., Birch, S., Savage, I., Wong, I., Woloshynowych, M., Jacklin, A. and Barber, N. 2009. Methodological variability in detecting prescribing errors when evaluating computerised physician order entry. Pharmacoepidemiology and Drug Safety. 18 (11), pp. 992-999. https://doi.org/10.1002/pds.1811

Communication Patterns in a UK Emergency Department
Woloshynowych, M., Davis, R., Brown, R. and Vincent, C. 2007. Communication Patterns in a UK Emergency Department. Annals of Emergency Medicine. 50 (4), pp. 407-413. https://doi.org/10.1016/j.annemergmed.2007.08.001

Patient safety and iatrogenesis
Woloshynowych, M. and Vincent, C. 2007. Patient safety and iatrogenesis. in: Ayers, S., Baum, A., McManus, C., Newman, S, Wallston, K., Weinman, J. and West, R. (ed.) Cambridge Handbook of Psychology, Health and Medicine. 2nd edition Cambridge University Press.

Incident reporting in one UK accident and emergency department
Tighe, C.M., Woloshynowych, M., Brown, R., Wears, B. and Vincent, C. 2006. Incident reporting in one UK accident and emergency department. Accident and Emergency Nursing. 14 (1), pp. 27-37. https://doi.org/10.1016/j.aaen.2005.10.001

The effects of stress on surgical performance.
Wetzel, C. M., Kneebone, R., Woloshynowych, M., Nestel, D., Moorthy, K., Kidd, J. and Darzi, A. 2006. The effects of stress on surgical performance. The American Journal of Surgery. 191 (1), pp. 5-10. https://doi.org/10.1016/j.amjsurg.2005.08.034

Techniques used in the investigation and analysis of critical incidents in healthcare
Rogers, S, Taylor-Adams, S. and Woloshynowych, M. 2006. Techniques used in the investigation and analysis of critical incidents in healthcare. in: Walshe, K. and Boaden, R. (ed.) Patient Safety: Research into Practice Maidenhead, UK Open University Press. pp. 130-143

The investigation and analysis of critical incidents and adverse events in healthcare
Woloshynowych, M., Rogers, S., Taylor-Adams, S. and Vincent, C. 2005. The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment. 9 (19). https://doi.org/10.3310/hta9190

Error Reduction in Medicine: Final report to the Nuffield Trust
Lyons, M., Woloshynowych, M., Adams, S. and Vincent, C. 2004. Error Reduction in Medicine: Final report to the Nuffield Trust. Nuffield Trust.

Retrospective case record review: a blunt instrument that needs sharpening
Neale, G. and Woloshynowych, M. 2003. Retrospective case record review: a blunt instrument that needs sharpening. BMJ Quality and Safety. 12 (1), pp. 2-3. https://doi.org/10.1136/qhc.12.1.2

Exploring the causes of adverse events in British NHS hospital practice.
Neale, G., Woloshynowych, M. and Vincent, C. 2001. Exploring the causes of adverse events in British NHS hospital practice. Journal of the Royal Society of Medicine. 94, pp. 322-220. https://doi.org/10.1177/014107680109400702

Adverse events in British hospitals: preliminary retrospective record review
Vincent, C., Neale, G. and Woloshynowych, M. 2001. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 322, pp. 517-519. https://doi.org/10.1136/bmj.322.7285.517

Immediate Recovery of Psychomotor Function After Patient-Administered Nitrous Oxide/Oxygen Inhalation for Colonoscopy
Trojan, J., Saunders, B.P., Woloshynowych, M., Debinsky, H.S. and Williams, C.B. 1997. Immediate Recovery of Psychomotor Function After Patient-Administered Nitrous Oxide/Oxygen Inhalation for Colonoscopy. Endoscopy. 29 (1), pp. 17-22. https://doi.org/10.1055/s-2007-1004055

The Patient Requests Form: a way of measuring what patients want from their general practitioner.
Valori, R., Woloshynowych, M., Bellenger, N., Aluvihare, V. and Salmon, P. 1996. The Patient Requests Form: a way of measuring what patients want from their general practitioner. Journal of Psychosomatic Research. 40 (1), pp. 87-94. https://doi.org/10.1016/0022-3999(95)00548-X

The measurement of beliefs about physical symptoms in English general practice patients
Salmon, P., Woloshynowych, M. and Valori, R. 1996. The measurement of beliefs about physical symptoms in English general practice patients. Social Science & Medicine. 42 (11), pp. 1561-1567. https://doi.org/10.1016/0277-9536(95)00263-4

Psychological aspects of gastrointestinal endoscopy: a review
Woloshynowych, M., Oakley, D.A., Saunders, B.P. and Williams, C.B. 1996. Psychological aspects of gastrointestinal endoscopy: a review. Endoscopy. 28 (9), pp. 763-767. https://doi.org/10.1055/s-2007-1005602

Permalink - https://westminsterresearch.westminster.ac.uk/item/w6y92/continuity-of-care-2006-what-have-we-learned-since-2000-and-what-are-policy-imperatives-now


Share this

Usage statistics

77 total views
0 total downloads
These values cover views and downloads from WestminsterResearch and are for the period from September 2nd 2018, when this repository was created.