Being clear about continuity

I remember the first time I encountered the difference between the terms continuity of care and continuity of carer. I was a student midwife, and a senior midwife was correcting what she felt was my inappropriate use of the term continuity of care. She explained that continuity of care was a misleading term because many people (like me) used it incorrectly when what they were actually describing was continuity of carer. I understood that, but I became slightly confused when she went on to carefully explain to me that continuity of carer wasn’t important at all. As long as all midwives practised in the same way and followed the same policies and gave the same information, she said, it didn’t matter who was with the woman at the time.

I can’t remember how I responded at the time, but I recall trying not to use the word continuity in any context for a few weeks until I had figured out what I thought about the terminology and the issues to which it referred. Twenty years on, I am much clearer about what I think. I think continuity of relationship and knowing your midwife is actually pretty important for many women, and that the kind of continuity of care that focuses on the sharing of the proverbial song sheet isn’t necessarily a good substitute.

Continuity in practice, research and politics

I’m not alone in thinking that. There’s now some great evidence that ‘continuity of care confers important benefits and shows no adverse outcomes’ (Sandall et al 2013) and some equally great, if also sadly isolated and sometimes short-lived, examples of how projects can work in practice (e.g. Wesson and Carter 2014). But we still have a significant problem with the way in which the concept of continuity is defined and (mis)understood. In the past few months, at least two senior statesmen have made public gaffes on this topic. It was pretty clear to midwives that they weren’t at all clear on what they meant by continuity of care, and I suspect they had little sense of the nuanced nature of the issues. But, as tempting as it may be to use such examples as a way to take a swing at unpopular politicians, it is only fair to acknowledge that, as the authors of the Cochrane review on this topic point out:

‘Although continuity of care has been identified as a core component of a model of midwife-led care, there is wide variation in the definition and measurement of continuity of care which will require greater sophistication in future studies.’ (Sandall et al 2013: 19)

Types of continuity

One of the most helpful papers that I have accessed on this subject is the report of an expert panel review by Freeman et al (2007). The areas of health care on which this expert analysis was based included oncology, mental health and the care of people with diabetes. They did not look at maternity care, but several of the types of continuity that were identified are similar to the kinds we talk about in maternity care, and Sandall et al (2013) have also drawn upon it. I want to share it here because I have recently met others who are trying to make sense of these issues, and the distinction that Freeman et al (2007) make between three major types of continuity of care would have been quite helpful to me had I seen it as a confused student. These major types are:

Management continuity, which Freeman et al (2007) described as the communication of facts and judgements across and between teams, professionals and service users. With the caveat that the term ‘management’ may not be ideal within maternity care, we could consider what good management continuity might be by imagining a woman who receives care from a midwife, a GP, an obstetrician and a haematologist. In an ideal world of great management continuity, the woman would find that they all keep each other up-to-date in a timely fashion so that her experience of care is smooth and satisfying. All of her care, any relevant test results, discussions and decisions are recorded appropriately in her notes, so that everybody knows where things are at any given point in time.

Freeman et al (2007) describe informational continuity as the timely availability of relevant information, but in maternity care it is impossible not to also consider the issue that many women have with receiving conflicting advice or information. One of the best-known examples of where informational continuity can be an issue is in the advice that is given to breastfeeding women. Some would argue that, in an idealised world, everybody gives the same advice. One slight problem with the idealised scenario is that women are not all the same, and that is one reason why some practitioners feel that the third type of continuity is so valuable.

When the senior midwife in my story above pointed out that I meant continuity of carer, she was talking about what Freeman et al (2007) have since described as relationship continuity; having a relationship with the same caregiver or small team of caregivers over a period of time. When we talk about continuity of care (or carer), we often mean relationship continuity and, as Sandall et al (2013) noted, this kind of continuity has been shown to have a positive effect in maternity care.

Can we get clearer?

We probably need to tease relationship continuity out even further, though. One difference between childbearing women and people with cancer or diabetes is the existence of a special time – labour and birth – when it might be important not just to have relationship continuity (or to be accompanied by the same birth attendants throughout labour) but to know ahead of time who that person or people might be, and to have the chance to build a relationship with them. But this is just one of the elements that we need to ponder. Because all of these types of continuity need to be considered and explored and discussed amongst ourselves and with women so that we can continue to find out what really matters to them and then ensure that is what we are offering.

References

Freeman GK, Woloshynowych M, Baker R et al. Continuity of Care 2006: What Have We Learned Since 2000 and What are Policy Imperatives Now? Report for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). London: NCCSDO, 2007. http://www.hpm.org/Downloads/Bellagio/Articles/Continuity/138-final-report.pdf

Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004667.pub3/pdf

Wesson N, Carter N (2014). The search for continuity. AIMS Journal 26(3):14-16