Continuity by design Pier Health Group

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Run by Pier Health Group, a GP provider based in North Somerset.
Project based in a partnership of eight GP practices serving a population of around 94,000 across Weston-Super-Mare and the surrounding area.
Aimed to improve continuity of care, leading to reduced workload, and improvements in patient and staff satisfaction.
Helped patients to develop a therapeutic relationship with their ‘Usual GP’ by implementing systems that match clinical capacity to demand.
Project ran from January 2019 to November 2021.

Continuity of care has many benefits and, along with accessibility, is a core attribute of primary care. However, in GP practices in Weston-Super-Mare and surrounding areas there have been low levels of continuity, high workloads and wide variation in access to care.

This project, run by Pier Health Group, aimed to increase continuity of care by changing ‘front door’ processes and culture in eight GP practices and maximising opportunities for patients to develop a therapeutic relationship with their named ‘Usual GP’.

Phase one of the project involved matching clinical capacity to demand using a digital access tool (the AskMyGP platform) and shifting focus from patient categorisation to completing daily workload. Phase two included actively promoting the benefits of continuity to patients and staff, developing educational materials and encouraging weekly practice meetings to help GPs manage complex patients.

Key project outputs were a Usual GP Tool designed to match patients with their most-seen clinician and help balance workload, along with a Switching Tool to efficiently update the medical record system (EMIS Web). In addition, a High Impact Users Service run by the British Red Cross was established to reduce GP workload pressures from high-demand patients.

Despite the challenges of COVID-19, discernible improvements in continuity of care and benefits for patients and staff were achieved. Continuity improved for 1,800 patients at one practice, where 47 per cent saw their Usual GP for all consultations in 2021.

By demonstrating the benefits of continuity, this project has influenced the local primary care strategy and resulted in the availability of valuable resources to enable other GP practices to design continuity into their systems and culture.