Who cares about continuity?

In 1974, a few pioneers of academic general practice in Europe, better known as the Leeuwenhorst Group, published the first definition of our discipline (1). Its first sentence reads as follows: ‘The general practitioner is a licensed medical graduate who gives personal, primary and continuing care to individuals, families, and a practice population, irrespective of age, sex and illness.’ Since then, ‘continuity of care’ was considered as one of the principles of our discipline and the Leeuwenhorst definition was taught to medical students and young physicians seeking their professional career in family medicine. In 1998, the European Office of the World Health Organization published a document confirming the unique role of continuity in description of care provided by family doctors (2). It is worth noticing that the term ‘continuous’ used in the document to describe one of seven characteristics of general practice was confusing, especially to native English speakers. They argued that in the literal sense ‘continuous’ means the care provided without any break, while ‘continuing’ reflects much better the nature of longitudinal care provided by GPs. Saultz, based on his literature study, proposed a three-dimensional definition of continuity in hierarchical order from informational to longitudinal to interpersonal, emphasizing the importance to general practice of the last dimension (3).

Although the impact of continuity on patient satisfaction has been studied widely, the latest systematic literature review in this field is inconclusive (4). Continuity as a key element of general practice has often been questioned in the past. Critics of the concept stressed that it does not fit modern health care systems. They argued that everybody likes continuity at the grocery, local barber or garage and also at a GP's office, but it is not an essential feature of modern health care system anymore. At the turn of the twentieth and twenty-first centuries, Olesen et al., proposed a new definition of general practice, omitting the element of continuity (5). In response, Wonca Europe started a process, which in 2002 resulted in a new European definition of our discipline (6). Among its eleven characteristics, the document clearly lists one stating that general practice/family medicine ‘is responsible for the provision of longitudinal continuity of care as determined by the needs of the patient.’ Further research conducted in the UK, the USA, and the Netherlands confirmed that GPs highly value the concept of continuity (7). In the UK, the Royal College of General Practitioners specifically included continuity of care in its core curriculum statement ‘Being a GP’ (8).

So far the theory, but what about practice? Ten years ago, GPs in Poland protested by closing down their practices and refusing to sign a new contract that prolonged their responsibilities to include out-of-hours care. They won. The government had to change the rules and the whole action was considered a great success for the medical society. Ten years later, the Polish Parliament has changed the law, allowing all internists and paediatricians to practice on an equal basis with family physicians as doctors of first contact (9). Perhaps this is not only a return to the old Soviet pattern of primary care, but also a practical end of continuity, at least at the level of primary health care.

So, who cares about continuity? Readers of the European Journal of General Practice might seek an answer to this question in the current issue. In the original articles section, you will find an interesting Dutch contribution of Uijen et al. exploring the level of experienced continuity of care by patients at risk for depression. A qualitative study from the UK by Jaffray et al., focuses on the question why depressive patients’ discontinue antidepressant therapy early. Another qualitative study, by Wermeling et al., comes from Germany and seeks for factors explaining inappropriate continuation of hospital prescriptions of proton pump inhibitors. Finally, a Dutch paper by Smits et al., explores GPs’ experiences with out-of-hours care. The last topic is also discussed in two background articles, in which the authors present a recently established European research network for out-of-hours primary health care. Continuity is the common ground of all these papers. It seems ‘continuity’ indeed is an issue, at least for researchers. Is anybody else interested?