Continuity of care and general practice utilisation in Australia

Abstract

This thesis explores the notion of continuity of care and its relevance to quality of care in Australian general practice from both the consumer and general practitioner (GP) perspectives. It reports six studies that examine satisfaction with general practice care and the links between quality of care, consumer dissatisfaction and consumers' decisions about choice of general practitioner. From these findings and a prospective study of consumers' use of GP services, a typology of general practice utilisation is developed. The first study was a descriptive epidemiological survey which asked 555 Canberra residents about their use of health services. Twenty-three percent of respondents saw two or more GPs in the preceding year. Multivariate modelling showed that the likelihood of an individual seeing several GPs increased with the number of visits, poorer levels of satisfaction with the last general practitioner visit, for the age group 20-29 years, for women, and for those respondents with tertiary qualifications, and decreased for respondents who mentioned communication as the basis for their satisfaction with GP visits. The second study was a national survey (n= 1,201) to estimate the proportion of respondents who identified with and consulted their 'usual' GP. On their last GP visit, 83% of respondents recorded seeing their 'usual doctor', and a further 4% saw a doctor in their 'usual practice'. In the third study I interviewed GPs (n= 35) and consumers (n= 35) to explore the reasons why some consumers see several GPs annually. Both groups distinguished seeing various doctors from changing doctors. Further they drew a distinction between changing doctors due to circumstances such as moving residence, and changing because of dissatisfaction. The fourth study asked consumers about their choice of doctor prior to a consultation (n=802). Fifty-five percent of patients were seeing their usual doctor and an additional 29% were attending a doctor in their usual practice. Random effects logistic regression modelling showed that doctor-patient relationship issues and technical skill were associated with respondents consulting their usual GP or practice while access issues were associated with respondents seeing two or more GPs. In the fifth study I interviewed GPs (n= 24) and consumers (n= 24) in detail about their experience of general practice care. Consumers' most frequent reasons for changing doctors were moving residence, or following difficulties with access to the doctor, cost of the consultation, or availability of the GP. Problems with communication or feeling that the associated with consumer dissatisfaction and subsequent decisions to change GPs. In the sixth study consumers (n= 68) kept a health diary to record details about their general practice visits and I interviewed them monthly to explore, prospectively, their actual choice of GP. I depicted each participant's consultations along a timeline to produce a 'trajectory' of general practice use. The trajectories were grouped into patterns that formed the basis of a typology of general practice utilisation comprising four approaches to general practice care. These are visits to one GP, visits to one practice, visits to a variety of GPs in different practices, and visit-by-visit use where decisions about whom to consult are made when the need for a visit becomes apparent). Some consumers changed their type of utilisation with the advent of illness or when their life circumstances altered.I convened two reference groups; one consumer group (n=12) and another of GPs (n= 12). Each reference group met with me on five occasions during 1993-1994 to examine the research findings, develop collaborative interpretations, and identify differences in their perspectives on quality of general practice care. The sequence of six studies showed that 'continuity' is best understood, not as an entity provided by doctors, but rather as an interaction over time, constructed jointly by consumers and their GPs. The majority of consumers preferred, and by and large achieved, constructed continuity with one GP, at least for periods of time. Continuity was also possible when consumers visited one practice and had visits to a variety of GPs. The essential pre­ conditions for continuity of care were ready access, GP competence, good communication, and a mechanism for bridging one consultation to the next. The benefits of constructed continuity were coordination, familiarity and openness in the therapeutic relationship, and review of progress; together these form a framework for high quality care in general practice.