Explaining the Erosion of Relational Care Continuity : An Empirical Analysis of Primary Care in England

Relational continuity (RC) refers to an ongoing relationship between a patient and a clinician or clinical team beyond a specific service encounter or disease episode. As a defining characteristic of good medical practice, RC has been shown to confer many clinical and operational advantages and is desired by patients, clinicians, and policymakers alike. Yet despite its many benefits, RC in the primary care setting has been in sharp decline over the past decades, contributing to poorer health outcomes and lower efficiency as well as falling patient and provider satisfaction. Anecdotally, this downward trend has been attributed to a sustained increase in workload caused by a growing and aging population and to changes in the workforce composition caused by burnout and workload pressures. However, there is a dearth of evidence to support or contradict this impression, and the key factors that cause changes in RC are not well understood. As a result, little action is being taken to slow or reverse this trend. We fill this gap by empirically examining the main operational factors that can explain variation in RC both between practices and over time. To do so, we use a unique dataset of primary care consultations corresponding to '10% of England's population over ten years. Using a panel ARDL estimation approach, we show that workload and workforce factors have a significant influence on a primary care practice's ability to provide RC, explaining '36% of the residual within-practice variation after inclusion of all other controls. We also find that three factors alone can explain '45% of the decline in RC over the study period: increasing fragmentation of the workforce caused by i) primary care practitioners shifting to part-time work patterns and ii) greater dependence on temporary staff; a sustained increase in workload caused by iii) greater patient volumes without a proportionate increase in physician-hours. Of these, workforce factors appear to be relatively more important than workload factors, with increasing workforce fragmentation driving '33% of the total decline. We discuss the implications of these findings for patients and primary care practice managers, and we suggest strategies for maintaining levels of RC in the face of these industry trends