The Quiet Crisis of Continuity of Care

Last week, I read about a recent international survey that placed the UK near the bottom of high-income countries for continuity of care in general practice. In the UK only 72% of adults aged 65 and over have a regular GP. Compare that to France and Germany, where 98% of older adults have continuity with their doctor. This is despite £1.1 billion of investment and recruitment of two thousand additional GPs in recent years, the reality is that continuity is not being designed or measured as a priority.

I've been around long enough to remember when talking about "my doctor" was common. When my children were young, I would ring up the practice and say "I need to see Dr Smith" rather than "I need an appointment with anyone who's free." I recently had a chance meeting our old GP who remembered me and my children (by name), many years later.

The concept of "my doctor", once a cornerstone of British general practice, is quietly disappearing. We've somehow convinced ourselves that this shift is progress. That seeing any qualified clinician is just as good as seeing the one who knows you well.

For older adults living with multiple conditions, frailty, and complex social needs, this isn't just inconvenient. It's dangerous. And it's affecting over 12 million older adults across the UK.

Here's what we know from the research: sustained GP relationships are a clinical necessity and this necessity grows even more critical as we age. GPs who know their patients over many years can spot the subtle signs of decline that others might miss. A new hesitancy when rising from a chair, unexplained weight loss, shifts in mood or memory that family might not have noticed yet. These early warnings, caught by someone who knows what's normal for that individual, can prevent hospital admissions, reduce unnecessary investigations, and even save lives. Without continuity, these signs might get excused as "normal aging" or lost in the noise of multiple concurrent problems.

Continuity is a vital part of frailty prevention. Frailty is dynamic and, crucially, modifiable. Early interventions in nutrition, physical activity, falls prevention, and social connection can delay or reverse decline. But these interventions can only be actioned when someone recognises it early, and that someone is most often a regular GP, who sees patterns and joins the dots.

Trust is perhaps the most intangible but powerful benefit. Patients are more likely to disclose sensitive issues, such as continence, memory loss, loneliness, when they believe they will be heard without judgment. Continuity fosters that trust, enabling earlier conversations, referrals, and interventions. When life nears its end, continuity makes advance care planning possible, ensuring people die in the place and manner they wish rather than defaulting to an emergency hospital admission.

Research published in BMJ Open demonstrates that continuity of care reduces mortality rates significantly. A systematic review found that patients with high continuity had substantially lower death rates compared to those receiving fragmented care. Another study tracking over 200,000 patients found that those seeing the same GP consistently had 25% fewer emergency hospital admissions. For many patients these are life trajectory changing differences.

The NHS's long-term plan is clear that care should be more community-based, more preventive, and more digitally enabled. These "three shifts", from hospital to community, from analogue to digital, from treatment to prevention, are the backbone of government policy.

And on paper, they make complete sense.

But the lived reality tells a different story.

The digital-first drive has expanded rapidly. These tools do improve access in some respects, particularly for those who are digitally confident and time-pressed. Yet they risk making continuity invisible. Patients are increasingly routed to the first available clinician, not the one who knows them best. When this happens, relationships become fragmented, especially when consultations are short, remote, and transactional.

Evidence suggests that consultation mode, phone, video, or face-to-face, is not the main determinant of continuity. The bigger issue is whether our systems are configured to preserve relationships. At present, most digital platforms are optimised for speed of allocation, not relational safety. That design choice has consequences.

We must also consider digital exclusion. Around 4.7 million people aged 65 and over in the UK lack essential online skills. Older adults are far less likely to navigate apps, chatbots, and online portals with confidence. For them, the shift to digital is not just a barrier to access; it is also a disruption of continuity. Instead of calling "my GP," they are faced with anonymous queues and algorithmic routing.

If continuity is already fragile, digitisation without safeguards risks accelerating this.

This is fundamentally an equity issue, and it's getting worse. Older adults in deprived areas are least likely to have a regular GP, least likely to be digitally confident, and most likely to live with multiple conditions. These are precisely the groups who gain the most from continuity, and lose the most when it erodes. We're creating a two-tier system where digital confidence determines not just access, but the quality of relationships that underpin safe care.

However, this isn't inevitable. We can design continuity back into our systems, and some places are showing how.

We must treat continuity as a measurable outcome. Practices and integrated care systems should track continuity rates for older adults, using relationship quality measures such as the Usual Provider of Care (UPC) index, Already validated in research, and calculated as the proportion of a patient's total appointments during a specific period that were with their usual GP, it can be used to measure and set improvement goals. If we can report on two-week cancer waits, we can report on continuity.

We must design continuity into digital health systems. Online booking should default to the patient's usual GP or team. Electronic records should surface continuity cues which could tell a user "your last three consultations were with Dr Smith; Dr Smith is next available on Thursday." The NHS App should make continuity visible: "my GP and care team," with photos and one-tap re-booking. AI could identify when continuity has been broken and flag patients who might benefit from improved relationship consultations.

Micro-teams offer a practical model for workforce-constrained environments. A small, stable group of clinicians, GPs, nurses, pharmacists, take joint responsibility for a defined older patient list. Patients would get to know their "team"; clinicians would share knowledge about their patients. The Gnosall Medical Centre in Staffordshire implemented a "micro-team" model where small groups of clinicians share responsibility for defined patient lists. Patients know their team; clinicians share information effectively. Continuity rates improved dramatically, and patient satisfaction soared. Staff wellbeing increased too, a result of the emotional reward of longitudinal relationships.

Continuity must be incentivised in commissioning. Such as using enhanced service payments and quality frameworks that reward demonstrable continuity improvements. The workforce plan should explicitly link GP recruitment targets to continuity outcomes, not just raw headcount.

Finally, we need to understand and frame continuity as prevention. Just as we invest in vaccination programmes or smoking cessation, we must invest in relational continuity as a preventive intervention. We know it reduces hospitalisations, prevents frailty escalation, and improves end-of-life outcomes.

The NHS's three shifts, hospital to community, analogue to digital, treatment to prevention, are only safe if we place care continuity as central to these shifts. Community care without continuity is fragmented care. New technologies need to strengthen relationships rather than replace them, and this requires intention, measurement, and accountability.

If we are serious about equity for our older people, continuity must be central to care delivery. That means publishing continuity metrics, funding continuity models, and demanding continuity-aware design in every new digital deployment.

In the end, the question is simple: when you are 85, juggling frailty, cognitive decline and a kitchen cupboard full of medicines, do you want to see the first available clinician or your GP who knows your story, and knows you best, managing your care?

• https://www.commonwealthfund.org/publications/surveys/2025/apr/access-quality-care-older-adults-10-countries-2024-survey
• https://www.pulsetoday.co.uk/news/clinical-areas/elderly-care/proportion-of-older-people-with-a-regular-gp-sees-sharp-decline-in-uk/
• https://www.thetimes.co.uk/article/nhs-older-patients-access-same-gp-cbvllmpl0
• https://bmjopen.bmj.com/content/8/6/e021161
• https://pmc.ncbi.nlm.nih.gov/articles/PMC7425204/
• https://bjgp.org/content/early/2025/07/14/BJGP.2024.0568
• https://sites.exeter.ac.uk/apex/2024/01/05/the-challenge-of-improving-relational-continuity-in-general-practice/
• https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-025-02860-8