Tidemark

Why continuity of care matters

Most capacity conversations are about how much work comes in: how many contacts, how many hours, how far over a safe limit. Continuity is about a different thing — how much of that work comes back.

When a patient sees the doctor who already knows them, the consultation does not usually take longer. What changes is what happens next: how soon they need to be seen again, how many tests get ordered, how likely they are to end up somewhere more expensive than your surgery.

That makes continuity one of the few things a practice can change that affects demand rather than just absorbing it.

What it does to the work coming back to you

The largest study of this used 10 million consultations from 381 English practices over 11 years. When a patient saw their usual GP, the interval before their next appointment was 18.1% longer. Consultation length was no different.Kajaria-Montag 2024

The same research group looked at what happens after a single acute consultation. Seeing the regular GP lengthened the gap to the next visit by about 9% — roughly one fewer appointment for every ten consultations. Seeing a GP who was not the patient's regular GP was associated with 11.1% more emergency admissions within seven days and 19.1% more tests ordered.Kajaria-Montag 2025

The word for this is failure demand: work that exists only because the first attempt did not finish the job.

Scale it up and the numbers are modest but real. If every practice in that dataset had reached the continuity of the best-performing practices, and had directed it at the patients who benefit most, total consultation demand would have fallen by up to 5.2%.Kajaria-Montag 2024

That is not a solution to a workforce gap. It is about a fortnight of appointments a year, found without hiring anyone.

What it does for patients

A systematic review published in 2025 pooled 18 studies covering around 15 million patients. Higher personal continuity with a GP probably reduces premature mortality by 10-15%, hospital admissions by 10-15%, and emergency department attendances by 10-20%. The authors rated all three as moderate certainty, and found the effect was dose-dependent — more continuity, more benefit — across different countries and different ways of measuring it.Engström 2025

Norway can measure this over a lifetime, because patients are listed with a named GP. Across 4.55 million people, those who had been with the same GP for more than 15 years, compared with one year, had 30% less out-of-hours use, 28% fewer acute hospital admissions, and 25% lower mortality.Sandvik 2022

In England, among 230,000 patients aged 62 to 82, seeing the usual GP two more times out of every ten visits was associated with 6% fewer admissions for conditions that good primary care is supposed to keep out of hospital — asthma, diabetes, chest infections.Barker 2017

The pattern across all of these is the same: the sicker and more complex the patient, the more continuity is worth. The gains in the English productivity study were largest for older patients, patients with several long-term conditions, and patients with mental health diagnoses.Kajaria-Montag 2024

Continuity and access are not opposites

The usual objection is that continuity costs access — that protecting a patient's link to one GP means someone waits longer.

The Health Foundation funded five projects across more than 45 practices and 500,000 patients to test exactly that. Between 2018 and 2020, patient-reported continuity fell nationally from 49% to 45%. The practices in the programme held theirs at 49%, with no measured detriment to timely access. When patients were asked, 61% said they would wait longer to see the GP they preferred.Health Foundation 2022

The evaluation's own conclusion was that continuity and timely access are not opposing principles. The mechanism is the one in section 2: a practice with better continuity has less demand arriving at it, and lower demand is what access is made of.

Why it is getting harder

Continuity in England has been falling for years. In the GP Patient Survey, the share of patients who said they always or almost always saw their preferred GP was 26% in 2018 and 16% by 2023. It reads as 19% in 2025 — but the question changed that year, from "preferred GP" to "preferred healthcare professional". Your practice's number will look better than its own history for reasons that have nothing to do with your practice.GP Patient Survey

Between September 2015 and December 2024 the number of full-time-equivalent GPs in England fell by 2%, while non-medical clinical staff in general practice rose by 428% from 2020. More clinicians, seen by each patient less often.Marshall 2025

And the patients who gain most from continuity get least of it. That pattern has a name in the literature — the inverse continuity law.Dineen 2025

The 2025/26 GP contract in England asks Primary Care Networks to risk-stratify their patients and identify those who would benefit most from continuity. It does not ask anyone to measure continuity, or say how to deliver it to the patients identified.Dineen 2025

The same pattern outside the UK

This is not a UK finding. A review of 22 studies from nine countries — England, the US, Canada, Israel, South Korea, Taiwan and the Netherlands — found lower mortality with higher continuity in 18 of them.Pereira Gray 2018

In Denmark, a national cohort found higher continuity at clinic level was associated with lower mortality and fewer hospital admissions.Prior 2025In Norway, breaks in the relationship with a regular GP were associated with higher mortality among patients with chronic disease.Pahlavanyali 2024

In the United States, patients in the highest quartile of continuity with a primary care physician had lower costs and fewer hospitalisations than those in the lowest.Bazemore 2018In New South Wales, more regular GP contact went with fewer unplanned diabetes admissions.Youens 2019

Two findings matter for how a practice is run. Across 34 countries, the places with both good access and good continuity had fewer emergency department visits for problems general practice can treat — the two go together rather than trading off.van den Berg 2016And in Ontario, continuity varied more by how practices were paid and organised than by anything about the patients.Kiran 2023Dutch work found the same: continuity is partly a property of the practice.te Winkel 2022

On appointment systems specifically, a review of same-day (advanced) access found it improves how quickly people are seen, while its effect on continuity and other measures of performance varied between studies. How the booking system is designed decides whether the two can hold together.Adadja 2026

How good is this evidence?

All of it is observational. None of it is a randomised trial, and a trial of this would be very hard to run. That means confounding cannot be ruled out: patients who see the same GP repeatedly may differ from those who do not in ways the analyses could not fully adjust for.

What raises the confidence is consistency. The same direction of effect turns up across different countries, different health systems, different continuity measures, and different decades — and it gets stronger as continuity increases rather than appearing all at once. That dose-response is why the 2025 review rated mortality, admissions and emergency attendances at moderate certainty rather than low.Engström 2025

The honest summary: the association is large, consistent and hard to explain away, and the causal claim is probable rather than proven.

What these measures mean

Tap a term to open it.

UPC= Usual Provider of Care index

The share of a patient's contacts that were with the clinician they see most.

For each patient, take the number of contacts with the clinician they saw most often over the window and divide it by their total contacts. A UPC of 70% means seven in ten contacts were with that one clinician.

UPC says nothing about who that clinician is or whether the patient wanted to see them — only how concentrated their care was.

Sources:Health Foundation 2022

SLICC= St Leonard's Index of Continuity of Care

Over one month, the share of GP consultations that were with the patient's own named GP.

A practice-level measure developed at St Leonard's Practice, Exeter (Freeman and Hughes, published in the BJGP in 2019). It is deliberately simple: over a one-month window, take the number of GP consultations that were with the patient's own named or usual GP and divide by the total number of GP consultations.

It was designed to be computable from routine appointment data by practices already running a personal-list system. That is also its main limitation, since it assumes a personal GP is already recorded.

Sources:Freeman & Hughes 2019Continuity Counts

aSLICC= adapted St Leonard's Index of Continuity of Care

SLICC as adapted for the Scottish GP in-hours dashboard: the usual GP is derived from the record rather than a named list.

The adaptation used for the Scottish GP in-hours dashboard and Public Health Scotland's national publication. It follows the continuity of care measure specification v0.1 held with this project.

It differs from the original SLICC in five ways: the usual provider is derived rather than taken from a named list, using the most frequently seen GP over the preceding two years; the figure is the proportion of contacts with that GP over the preceding 30 days; all direct consultations count (face to face, telephone, home visits and e-consultations), not just face to face; numerator and denominator are restricted to GPs and GP trainees — partners, salaried, locum and trainees, not Foundation Year doctors; and a patient must reach a minimum consultation count in the 30-day window to be included.

In the data model it is held as metric type SLICC with a 30-day lookback, alongside UPC and Bice-Boxerman. The three are kept separate, and no difference is ever calculated between one metric type and another.

Open questions on the specification

  • Whether a three-consultation threshold excludes too many patients.
  • Whether a two-year lookback for the usual provider makes sense when trainees rotate at twelve months.

Sources:Freeman & Hughes 2019Continuity CountsHealth Foundation 2022

Bice-Boxerman= Bice-Boxerman Continuity of Care index

How spread a patient's contacts were across the whole team, allowing for how often they attended.

Rather than looking only at the single clinician seen most, this index measures how concentrated a patient's contacts were across everyone they saw. A patient who saw one clinician six times scores 1; a patient who saw six clinicians once each scores 0.

It corrects for attendance frequency, so patients who attend rarely do not distort the figure in the way a simple ratio can.

Sources:Health Foundation 2022

Felt continuity= the daily 1–5 score recorded in this app

How well the clinician felt they knew the patients they saw that day, scored 1 to 5.

A single question answered at the end of a recorded day. It captures the clinician's experience of continuity, which the appointment data cannot show.

It sits beside the published indices rather than replacing them. Where the two point in different directions, that is a prompt for a conversation — not evidence that either figure is wrong.

Usual provider= the clinician a patient's continuity is measured against

Either the GP named on a personal list, or the GP a patient has seen most often over the lookback window.

The original SLICC uses the named GP from a personal-list system. The Scottish adaptation derives it instead, taking the most frequently seen GP over the preceding two years, so practices without a personal list can still be measured.

Sources:Continuity Counts

Lookback window= the period a measure covers

How far back the contacts counted in a measure reach.

aSLICC uses two windows: two years to identify the usual provider, and the preceding 30 days for the proportion of contacts with that provider. A published figure only means something alongside the window it was calculated over, so each period is stored with the number.

Minimum consultation count= the inclusion threshold

The number of consultations a patient must have in the window before they count towards the figure.

A patient seen once cannot demonstrate continuity either way, so measures set a floor before including them. Raising the floor makes each patient's ratio more meaningful but leaves more patients out of the figure altogether.

Open questions on the specification

  • Whether a three-consultation threshold excludes too many patients.

Sources

  1. Kajaria-Montag H, Freeman M, Scholtes S. Continuity of Care Increases Clinical Productivity in Primary Care. Management Science 2024;70(11):7943-796010 million consultations, 381 English practices, 11 years.
  2. Kajaria-Montag H et al. Continuity and locum use for acute consultations: observational study of subsequent workload. Br J Gen Pract 2025;75(752):e181observational study of acute consultations and subsequent workload.
  3. Engström S et al. Personal GP continuity improves healthcare outcomes in primary care populations: a systematic review. Br J Gen Pract 2025;75(757):e518systematic review of 18 observational studies, approximately 15 million patients.
  4. Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care. Br J Gen Pract 2022;72(715):e84national registry study, 4,552,978 Norwegian patients, 2018.
  5. Barker I, Steventon A, Deeny SR. Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions. BMJ 2017;356:j84230,000 patients aged 62-82 in England.
  6. Increasing Continuity of Care in General Practice: final independent evaluation. The Health Foundation, 2022independent evaluation of 5 projects, 45+ practices, over 500,000 patients, 2019-2021.
  7. GP Patient Survey, Ipsos for NHS EnglandGP Patient Survey, England.
  8. Marshall M et al. What makes general practice work: the role of continuity in efficient and sustainable primary care. Br J Gen Pract 2025;75(757):373editorial on continuity, efficiency and sustainability.
  9. Dineen M et al. Delivering relational continuity of care in light of recent GP contract changes. Br J Gen Pract 2025;75(757):342analysis of relational continuity under recent GP contract changes.
  10. Tammes P et al. The impact of a named GP scheme on continuity of care and emergency hospital admission. BMJ Open 2019;9:e029103cohort study of older patients in England, 2012-2016.
  11. Coombs C et al. Primary care micro-teams: an international systematic review of patient and healthcare professional perspectives. Br J Gen Pract 2023;73(734):e651international systematic review of 24 studies of primary care micro-teams.
  12. Saxionis I et al. Is Adopting a Microteams Model a Solution to Delivering Continuity of Care in Modern Primary Care? J Prim Care Community Health 2026single PCN of 46,500 patients across 8 sites, Southampton, before-and-after, March 2022 to March 2024.
  13. Fox C et al. Delivering relational continuity of care in UK general practice: a scoping review. BJGP Open 2024;8(2)scoping review, UK general practice.
  14. Freeman G, Hughes J. A method for measuring continuity of care in day-to-day general practice. British Journal of General Practice 2019method paper, St Leonard's Practice, Exeter.
  15. Continuity measurement within general practices — Continuity Countspractice guidance.
  16. Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors — a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8(6):e021161systematic review of 22 studies across England, the US, Canada, Israel, South Korea, Taiwan and the Netherlands.
  17. van den Berg MJ, van Loenen T, Westert GP. Accessible and continuous primary care may help reduce rates of emergency department use. An international survey in 34 countries. Fam Pract 2016;33(1):42-50QUALICOPC survey of practices and patients across 34 countries.
  18. Pahlavanyali S, Hetlevik Ø, Baste V, Blinkenberg J, Hunskaar S. Continuity and breaches in GP care and their associations with mortality for patients with chronic disease. Br J Gen Pract 2024;74(742):e347national registry cohort, Norway.
  19. Prior A, Rasmussen LA, Virgilsen LF, Vedsted P, Vestergaard M. Continuity of care in general practice and patient outcomes in Denmark: a population-based cohort study. Lancet Primary Care 2025national registry-based cohort, Denmark.
  20. te Winkel MT et al. General practice and patient characteristics associated with personal continuity: a mixed-methods study. Br J Gen Pract 2022;72(724):e780mixed-methods study of Dutch general practices.
  21. Bazemore A, Petterson S, Peterson LE, Bruno RL, Chung Y, Phillips RL Jr. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med 2018;16(6):492retrospective claims analysis, United States.
  22. Kiran T et al. Relational continuity, physician payment, and team-based primary care in the Canadian health care system. J Am Board Fam Med 2023;36(1):130administrative data on more than 7 million patients, Ontario, Canada.
  23. Youens D et al. Association between regularity of general practitioner contact and unplanned diabetes-related hospitalisation: a data linkage study in New South Wales, Australia. BMJ Open 2019;9(6):e027158data linkage study, 45 and Up cohort, New South Wales, Australia.
  24. Adadja J et al. Association of advanced access with primary care performance: a systematic review. Ann Fam Med 2026;24(3):239systematic review of advanced access scheduling in primary care, international.

Tidemark measures continuity two ways — felt by your team each day, and matched to your practice's published figures.

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