Continuity of care

Site: Royal College of General Practitioners - Online Learning Environment
Course: Clinical toolkits
Book: Continuity of care
Printed by: Guest user
Date: Wednesday, 19 June 2024, 12:22 PM


For those looking to improve continuity of care for the benefit of your patients, GP colleagues and practice staff.

About the toolkit

Are you looking to improve continuity of care for the benefit of your patients, GP colleagues and practice staff?

Take a look at our Continuity of Care Toolkit which shares the learning and experiences from practices who have been improving their continuity over a two year period with support from the Health Foundation.

Based around 6 steps from setting out your ambition to implementation, the practices involved in bringing this resource Toolkit to you range from 35,000 to 45,000 patients, located in urban, rural, affluent or deprived areas. The result is a resource that can be tailored to your practice.

“[The toolkit] is an incredibly impressive suite of information, advice and tools for General Practice."
 Dr Tom Smith, Fallodon Medical Centre, Bristol

Download this Resource Toolkit to access a wealth of bespoke resources to start your continuity of care journey today!  

This resource Toolkit for GP Practices was developed by Jo Knight and Dr Hugh Reeve of Morecambe Bay Primary Care Collaborative and Julia Martineau and Dr Jacob Lee of One Care CIC as part of the Health Foundation's Improving Continuity of Care in General Practice Programme.

Download the toolkit

Download the complete Continuity of care toolkit (PDF file, 2,581 KB)

Once downloaded you can work through the toolkit at a pace to suit your practice.  Hyperlinks in the toolkit will help you to navigate the steps and resources within. The toolkit is divided into three main sections:

  • 6 Steps: The guided approach to improving continuity
  • Resources: Helpful tools and editable templates to support the steps
  • GP practice stories: Examples of what others have done

Please share your continuity improvement journey with the RCGP to add to the GP Practice Stories online by emailing

Templates and resources

Continuity focus groups

The documents will help you to run and analyse continuity of care focus groups.

Waiting room chat

Practices have found chatting with patients in the waiting room can be insightful, the download includes questions to ask.

Reception desk audit

A short audit that helps understand patient behavior when booking appointments.

Patient participation group

Designed with the support of Bristol patients, a slide deck and guide to kick start continuity of care conversations with your PPG.

Frequent Attenders

Some thought on ways of working with frequently attending patients (based on work with Bristol practices and GP experiences) and ideas on how to manage those patients that make the GPs heart sink.

How to map a process

The toolkit shares the common process to map for continuity and their rationale. The guide provides you with all you need to know about process mapping:

  • What it is
  • How to map the current process
  • How to analyse to identify improvements (editable tables in appendix)
  • How to create a future process map
  • Example of a GP Practice's appointment booking process (current and future state maps)

Also available to download is a template (an A3 Power Point slide) to record your map electronically - a panoramic photo can be just as good a record of your map.

EMIS / Vision and System One new patient registration process 

When process mapping there were some discrepancies between what was understood by practices and what happens in EMIS on patient registration that you might find useful too.

Continuity project proposal template

A Project proposal outlines what the practice is doing to share with others.

Pixar framework examples

The Pixar framework is a storyboard formula you can follow to share your continuity of care aims, hopes and plans.

Driver diagram

The driver diagram has identified the drivers which will affect accomplishing an aim to improve continuity of care and the interventions that affect the identified drivers for you to edit.

Measures explained

An explanation of the Continuity of Care key measures with worked examples.

One care usual GP tool

The Usual GP Tool uses EMIS / vision and system one searches to measures continuity of care at your practice.

Idea generation

Idea generation is explained within the toolkit, a table for 6 Thinking Hats for focussed discussion is shared as a download.

Following changes to update the Usual GP field or flagged patient cohorts, the download table will assist you to consider processes that will support maintenance/encouragement of continuity.

Valentine Report

The report from a fellow project site in the Health Foundation programme specifically mentioned in the toolkit.

Reception team guide to continuity of care

Some hints and tips from Reception Team colleagues.

Using EMIS to promote continuity and other GP systems

Download a guide to how EMIS can be used to promote continuity e.g. flags, prompts, templates, online booking restrictions, patient list reports.

Continuity communication materials

Communication materials to promote continuity of care to your patients.


There are 2 PDSA templates available to download. Download them both and see which works for you.

Continuity plan template

A template for your own practice plan. It includes an example from one of the practices.

After action review

The available download is a suggested set of ground rules.

GP Practice Stories

Hear from GP practices about their continuity of care journey. As these are collected, more will be added.