Continuity of Care – being a PERSON


As a PERSON working in healthcare we should aim to provide Personalised Education, and be Responsive and Sympathetic whilst Overseeing and Networking for the patient.


Personalised means tailored to the individual rather than handle every problem exactly the same way. What will work best for that person


Education is providing information about their illness and how to handle it so that they look after their problems better


Responsive indicates that you address the issues that arise in a Sympathetic way. You have empathy for that person and cover all their questions


Overseeing and Networking is a crucial role. Rather just dealing with todays problem you are ensuring the whole episode of illness is handled smoothly by all people involved. You are a back stop if things go in the wrong direction and you refer and Network with the necessary people to keep things moving forward

Case example – being a PERSON

Its Monday morning and I am listening, again, to a catalogue of problems during my patients admission to hospital. From dirty floors, unfed patients to missed drugs and misunderstood instructions. Each, on their own, understandable and forgiveable, but as a whole dangerous and very frustrating. Potential Adverse Events. Each occuring as a result of care by multiple, well meaning healthcare workers focused on their immediate tasks, but missing the whole picture.

Care in the NHS can be fragmented, leading to failures in healthcare. What a healthcare system needs at its core is continuity. Technology, consumerism and a target driven culture have pushed aside continuity like an old friend left out in the cold by those busy in the midst of a party.

And the same pressures affect primary care. The drive to have immediate access is laudable, but results in additional steps that act as filters and unseen barriers. Triage nurses, duty doctors, urgent appointments with any doctor, conspire against seeing the same person over time.

Over the years the usual doctor gets a picture of their patient. An understanding of their preferred approach, their past life and medical problems and patterns in illness, which give early access to diagnosis and successful treatment. Mrs Antibe with her multiple aches whose arthritis has changed and now has the same polymyalgic symptoms as 5yrs ago. Mr Bellows whose rash has recurred which responds to anti depressants so well and is triggered by marital pressures at home. Simon whose concern about his normal epididymus is heightened by his fathers lymphoma.

All these are short cuts to diagnosis and treatment which an experienced doctor, familiar with their patient, can take, with due care and awareness. All these are scenarios, which could lead to over investigation, wasted resource and delayed treatment.

This is not to say GPs and healthcare workers need to return to the 120hr weeks and the day and night on call. Rather it is to say that the system should encourage continuity over time. Encourage responsibility for one person to oversee care and tie up loose ends. To act as an advocate on behalf of the patient as they negotiate the healthcare system.

All cases are aggregated and names fictional


General Practitioners need to provide Individualised Continuity of Care and act as Advocates for their patients. ICCA. The Healthcare system should encourage these elements alongside the use of practical relevant clinical targets.

Continuity exists in two main forms. Frontstage, which is face to face with the same person, and backstage, which is the medical records and access to results. In practice face to face involves a team, but it requires a co-ordinator who knows the patient over time. Backstage continuity requires a commitment by all the team to provide full and up to date records of every consultation underpinned by an IT system that integrates care and records.

A patient within the hospital setting also requires a PERSON to help them navigate the different elements of the NHS. That PERSON provides Personalised Education, is Responsive and Sympathetic whilst Overseeing and Networking for the patient. Personalised means considering an individuals medical and social history, educating them about the system and their own illness. Responsive and sympathetic is about being aware of the patients current issues and addressing these. Overseeing and Networking relates to ensuring all healthcare comes together as part of a whole. Seeing where the gaps in care are occurring, linking with the key people to co-ordinate care and link between different parts of the healthcare system

GPs often act as a PERSON alongside a patient over many years. Stepping in and out of the role as needed. However a GP is separated from that episode of care in a hospital so a PERSON is also needed during a period of hospital care. This can be any healthcare worker but preferable someone with healthcare experience and already involved in part of a patients care such as a nurse or doctor. Someone who oversees care as a whole.

In conclusion, think about acting as an ICCA or PERSON for your patients.

As an ICCA try to give Individualised Continuity of Care and be an Advocate for your patients over the years.

For each episode of illness consider if you or someone else is best placed to act as a PERSON. Providing that Personalised Education, being Responsive and Sympathetic and also Overseeing and Networking on behalf of that patient.