Abstract
Background Personal continuity of care, that is, a continuous relationship between the patient and the GP, is a core principle of general practice, enhancing trust, safety, and therapeutic engagement. The alignment between personal continuity, as experienced by patients, and the use of GP services remains uncertain.
Aim To assess how patient-reported preferences for seeing their own GP and patient-reported personal continuity were associated with their use of GPs.
Design & setting Survey conducted among patients in waiting rooms of 80 GP practices in Western Norway in 2021.
Method Data were collected from 2230 patients using a questionnaire, which obtained information on their preferences, personal continuity (Nijmegen Continuity Questionnaire), and actual GP use. Poisson regression models were used to assess associations between patient preferences, continuity, and GP use in today’s consultation.
Results Most patients (88.7%) found it very important or important to see their own GP for a known problem, compared to 74.9% for a new problem. Strong preferences increased the likelihood of seeing their own GP in the consultation by 30–40% compared to those who valued this as neutral or not important. Personal continuity scores in the upper quartiles were associated with longer patient–GP relationships and frequent consultations with one’s own GP, and were not significantly reduced with increasing number of visits to other GPs in the practice.
Conclusion This study indicates that patient-reported personal continuity can be high despite patients seeing other GPs, if there is also a sustained, frequent, long-term relationship with one’s own GP.
How this fits in
Personal continuity of care is a core principle of general practice, yet the relationship between patient-reported continuity and actual use of GPs in consultations remains underexplored. This study confirms that patients have a high preference for seeing their own GP. Importantly, our findings indicate that patient-reported personal continuity can be high despite patients seeing other GPs if there is also a sustained, frequent long-term relationship with one’s own GP. These findings underscore the importance of policies that foster long-term GP–patient relationships to promote trust, safety, and high quality care.
Background
A continuous relationship between the patient and the GP, called personal continuity, is recognised as an important part of clinical care.1,2 It is also considered a core value and a central organising principle stated by the World Organization of Family Doctors (Wonca).3 Personal continuity establishes a relationship and fosters trust, safety, and a deeper therapeutic engagement, all promoting more effective treatment.4 Both patients and GPs seem to agree on beneficial outcomes like increased person-centredness, confidence in decision making, patient satisfaction, and better quality of care,4,5 especially for vulnerable patients.6
Several claims- or registry-based population studies have estimated continuity of care as the proportion or density of consultations with the most frequently used GP, presented as a proxy for personal continuity. High continuity in such studies is more strongly associated with reduced use of specialised care, better disease outcomes, and lower mortality.7–9 However, previous research has demonstrated a lack of concordance between patient-reported personal continuity of care and continuity indices derived from registry data.10–12 This may reflect that a personal relationship is not only about the proportion of consultations with a preferred GP or a long-term patient-GP relationship, but also depends on the GP’s recognition and respect for the patient.13 If these relational aspects of continuity of care are essential, personal continuity is probably best measured by recording patients’ experiences. Therefore, it is of interest to further study how the patient’s experienced personal continuity is linked to the consultation pattern and the duration of the patient-GP relationship.
For both policymakers and patients, continuity of care may be competing with a desire for high accessibility to services, and the high demand for quick access may result in fewer contacts with a preferred GP and decreased continuity.14,15 Measures to increase accessibility, such as team-based services involving multiple care providers in GP practices, as well as more GPs working part-time, are changes that challenge personal continuity16,17 and may reduce the possibility of establishing a personal relationship with the GP.
The value of personal relationships motivated the implementation of the patient list system in Norway in 2001, based on research.18 The GPs are primarily self-employed and work in group practices, typically with two to four other GPs. However, each GP maintains a personal list with an average of 1100 patients. Since the start of the list patient system, approximately 70% of all consultations have been with the regular GP.19 This may be a result of regulatory limitations that limit access to other GPs or be based on patient preferences. It also raises questions as to whether a patient’s preference to see their personal GP is related to which GP the patient actually consults with.
In this study, we aimed to examine how patients’ preferences for seeing their own GP and their reported experience of personal continuity were associated with patient characteristics, GP practice factors, and actual use of GP services.
Method
This was an observational study based on a survey among patients recruited in waiting rooms in 80 GP practices in Western Norway in 2021.
Setting
Norway established a patient list system in 2001.20 The GPs have a contract with the municipality and are obliged to prioritise patients on their list. More than 99.5% of the population has chosen a named GP. Most GPs work in group practices with three to five colleagues and a staff of health secretaries, seldom other professional groups. In many GP practices, interns work for a 6-month period as the first part of specialisation for any medical field, and locums for varying periods. GPs are self-employed and reimbursed by a combination of capitation and fee-for-service, except for a minority that is employed by municipalities. In a recent survey, 44.5% of patients reported waiting 2 days or more for an urgent appointment, and 45.6% waited 8 days or more for a regular appointment with their GP.21 If their own GP is unavailable, patients most often see another GP or a locum in the same practice.
Data collection
In the final year of medical school at the University of Bergen, Norway, all students have a 6-week clinical placement in general practices. Research in general practice is a topic in the curriculum. In this study, 139 students in 80 different practices were involved, with placement periods during 2021. Each student is instructed to give an information letter and a 1-page questionnaire to 20 consecutive patients. Patients ≥18 years and able to answer a paper-based survey in Norwegian were included. The patients completed the questionnaire while waiting for their consultation and returned it in a sealed envelope to a receptionist. The patients provided implicit informed consent by completing the questionnaire. All information in the questionnaires was collected anonymously. The questionnaire was constructed for this study by the author group. It contains questions on demographics, use of GPs and an 8-item section from the Nijmegen Continuity Questionnaire (NCQ) regarding personal continuity.
The NCQ was developed by Dutch researchers based on elements from other assessment tools to capture the patient’s perspective on continuity of care,22,23 and has been translated into Norwegian and validated.24 In our study, we used only the eight items related to the GP, summarised in two subscales: ‘Personal continuity — the GP knows me‘ and ‘Personal continuity — the GP shows commitment’. The eight statements were answered using a 5-point Likert scale from strongly agree (highest) to strongly disagree (lowest) and an option for an ‘I do not know‘ response, treated as missing in the analyses. We estimated a mean score for each of the two subscales if ≤1 item was missing from the actual subscale, otherwise the score was set to missing.
Outcome variables
We used the following five variables (a-e) as outcomes:
The importance of seeing one’s own GP with a (a) new or (b) known problem, after dichotomisation with ‘very important or important’ as the outcome, compared to neutral or not important or not at all important.
Seeing one’s own GP in today’s consultation (c), compared to seeing another GP.
High patient-reported personal continuity, defined as a score in the upper quartile in the NCQ scales (d) ‘the GP knows me’ or (e) ‘the GP shows commitment’.
Explanatory variables
Patients’ gender (dichotomous), age (18–24, 25–39, 40–59, and ≥60 years), educational level (completed basic, upper secondary, or higher education), self-reported health (very good, good, not so good, bad), number of consultations in the last 12 months with own GP (0, 1–2, 3–4, and ≥5) and other GPs (0, 1–2, 3–4, and ≥5), time registered with the current own GP (0–2, 3–5, 6–10, and >10 years), the number of GPs in the practice (1–2, 3–4, 5−6, ≥7), if the practice had an intern (yes/no) were used in different combinations in regression models. For the analyses of seeing one’s own GP today, waiting time (≤1 day, 2–3 days, 4–7 days, 8–14 days, >14 days) and importance of seeing one’s own GP (very important/important versus other responses) were added as explanatory variables.
Statistical analyses
We used multivariable Poisson regression models with robust standard errors to estimate the associations between outcome variables and explanatory variables, presented as relative risk (RR) with 95% confidence interval (CI). We selected the explanatory variables for each model based on clinical reasoning and unadjusted association analyses. Additionally, we tested for trends for an increase or decrease across categories of the explanatory variables using them as continuous variables in similar regression models, reporting significance in columns marked ‘P for trend‘. We present the fully adjusted models in the tables. Responders were excluded from the regression models if they had missing values in any of the variables used in the model. The significance level was set at P<0.05. Stata (SE version 17) was used for statistical analyses.
Results
The analyses are based on responses from 2230 patients; the response rate was 83%. The mean age was 50.6 (SD 18.7) years, and 60.2% of patients were women (Table 1).
When surveyed, 77.4% of the patients were waiting for a consultation with their own GP (Table 2). Notably, 56% of appointments with waiting time ≤1 day were with the patient’s own GP, increasing to 90% when the time since the appointment was planned exceeded 14 days (Figure 1).
The figure is a six-panel horizontal bar chart showing the percentage distribution of GP contact type by waiting-time category. The panels are arranged in two rows and three columns, labelled ≤1 day, 2–3 days, 4–7 days, 8–14 days, >14 days, and Total. Each panel compares three categories on the vertical axis: Own GP, Other GP, and Locum/Intern. The horizontal axis shows percentage values from 0 to 100%.Across all waiting-time categories, Own GP accounts for the largest proportion of contacts. The proportion for Own GP generally increases as waiting time lengthens, from approximately 55% for waits of ≤1 day to approximately 90% for waits of >14 days.Approximate values by panel are: ≤1 day: Own GP about 55%, Other GP about 17%, Locum/Intern about 25%.2–3 days: Own GP about 70%, Other GP about 10%, Locum/Intern about 18%.4–7 days: Own GP about 78%, Other GP about 6%, Locum/Intern about 17%.8–14 days: Own GP about 86%, Other GP about 6%, Locum/Intern about 9%.>14 days: Own GP about 90%, Other GP about 4%, Locum/Intern about 6%.Total: Own GP about 78%, Other GP about 8%, Locum/Intern about 15%.Overall, the chart shows that patients were most commonly seen by their own GP in every waiting-time category, while contacts with another GP or a locum/intern represented smaller proportions throughout.
A large majority of patients (74.9%) found it very important or important to see their own GP if the reason for the encounter was a new problem, with an even higher proportion (88.7%) when the consultation was for a known problem (Figure 2).
The figure is a grouped vertical bar chart comparing percentage ratings of importance for known problems and new problems. The y-axis is labelled % and ranges from 0 to 60. The x-axis contains five response categories: Very important, Important, Neutral, Not important, and Not at all important. The legend shows two series: Known problem in dark blue and New problem in light blue. Approximate values are:Overall, both known and new problems were most commonly rated as very important or important. Known problems had a higher proportion of very important ratings, while new problems had higher proportions of neutral, not important, and not at all important ratings.
Male patients had a somewhat lower preference for seeing their own GP (Table 3). There was a significant trend towards a higher preference for one’s own GP with increasing age. There was a clear trend for increased preference for seeing one’s own GP with lower self-rated health.
Patients who considered it very important or important to see their own GP were 30–40% more likely to see their own GP in today’s consultation, and there was a clear dose–response relationship between time since appointment was planned and the likelihood of seeing their own GP (Supplementary Table S1).
The responses to the single items of the NCQ are presented in Supplementary Table S2. The mean score for ‘The GP knows me’-subscale was 3.9 (SD 0.85), the upper quartile had a score above 4.6. The respective scores on the ‘GP shows commitment’-subscale were 3.9 (SD 0.85) and 4.7. The likelihood of high scores on both subscales increased significantly with increasing number of consultations in the past 12 months and longer relationship with the same GP, most clearly for ‘the GP knows me’ (Table 4). The number of consultations with other GPs, as an indicator of possible discontinuity, showed no association with patient-reported personal continuity.
Discussion
Summary
Most patients surveyed in Norwegian GPs’ waiting rooms had a very clear preference for seeing their own GP. It was slightly more important for female patients, older people, and patients with medium to lower self-rated health. When surveyed, 77% of the patients had an actual appointment with their own GP, and this proportion was also high when the appointment was made the same day. The likelihood of seeing their own GP was 30-40% higher when the patient gave this a high priority. High patient-reported personal continuity was associated with longer relationship with own GP and more consultations with own GP in the past 12 months, and this association was not diminished by occasionally seeing other GPs.
Strengths and limitations
A strength of this study is the large sample size, with patients recruited from many different GP practices on random days, and the high response rate. As the questions referred to the same-day consultation, recall bias was minimised. The patients did not know in advance what sort of questions the form contained, which reduced selection bias. Some selection bias may be anticipated, as patients who frequently visit the practice will be overrepresented in the waiting rooms. Further, patients who were perceived as being able and willing to participate may have been asked preferably. Thus, the oldest and most disadvantaged patients may be underrepresented. The questionnaire was in the Norwegian language, and immigrants were likely underrepresented.
Also, the survey was conducted in 2021, during the COVID-19 pandemic. This may have affected patient selection, with some restrictions on access for those with airway infection in the first part of the year, while consultation rates for persons with chronic diseases were less affected in analyses including the first quarter of 2021,25 and probably not much biased by the pandemic in the last half of 2021. Generalisability to other patients in general practice is regarded as high, with the limitations mentioned above.
Comparison with existing literature
Seventy-seven per cent of the patients confirmed an appointment with their own GP, which is slightly higher compared to findings in Norwegian register-based studies19 and higher compared to other countries.26 The strong preference for seeing one’s own GP across all strata indicates that the high personal continuity shown in registry studies in Norwegian general practice is driven by patient preferences and not solely by a system that prevents access to other GPs. This patient preference may be related to the well-established list system that, over the past 20 years, has increased awareness of the benefits of achieving continuity of care. However, a similar preference for one’s own GP is also found in Sweden, without a list patient system.27 There was a somewhat higher preference for seeing one’s own GP among women, older people, and patients with lower self-reported health, as also reported by others.27,28
Waiting times were relatively short for a large share of patients, while nearly one-quarter of consultations could be appointed as ‘urgent’, but no data on the degree of urgency were available. Even for consultations arranged with short waiting times, more than half were with the patient’s own GP, indicating that their personal doctor is usually highly accessible, which was found to be challenging in other studies.29 We found that both longer waiting time and a strong preference for seeing one’s own GP were predictors for actually seeing one’s own GP when surveyed. This indicates that patients prioritise between seeing any GP and waiting for own GP, probably related to the kind of problem,14 but we cannot elaborate on this in our data. However, there is probably a large share of planned follow-up visits among those with longer waiting times.
A cross-country study showed that patients prefer practices with fewer GPs.30 However, in the Norwegian setting, where the majority of patients are connected to practices with 1–5 GPs, we found no trends related to patient-reported continuity or actually seeing one’s own GP, regardless of practice size. Having an intern in the practice reduced the likelihood of seeing one’s own GP without affecting patient-reported continuity.
The absolute score on the ‘GP knows me’ scale is similar to prior Dutch and Norwegian studies.23,24 We found somewhat higher scores on the ‘GP shows commitment’ scale compared to a study among Norwegian patients referred to rehabilitation centres, 3.8 versus 3.5.24 We argue that a NCQ subscale score in the upper quartile is a valid indicator of ‘good’ personal continuity, representing a score above 4.6. The number of contacts with own GP and the length of the patient–GP relationship were very clear predictors for good personal continuity. Seeing other GPs occasionally did not reduce the experienced personal continuity. The value of repeated contacts with the same GP was explored by Ridd et al,31 linking the depth of patient-GP relationship to the number of meetings. On average, 50% of patients reported a ‘deep’ relationship with their GP after eight consultations. These findings align with our findings that repeated consultations and knowledge over time are predictors for patients to feel that they have a GP who knows them.
The key components of personal continuity of care are not yet fully understood. However, a conceptual article by Sideway-Lee et al in 20214 summarised the evidence regarding important factors which contribute to continuity of care as a measure of quality of care. These elements include, among others, the GP’s accumulated knowledge of the patient as an individual, in addition to understanding the medical facts. The GP’s sense of responsibility, trust, and empathy are also important. In a qualitative synthesis of studies on perspectives on the relational continuity of care, Nowak et al5 found that patients’ and GPs’ perspectives were congruent and emphasised the same factors as valuable. These studies emphasise the importance of measuring personal continuity as experienced by patients as a quality indicator. To obtain high personal continuity, both healthcare policy and organisational models should underpin stability in GP services.
Implications for practice
The present study indicates that it is possible to achieve both reasonable access and high personal continuity of care, as experienced by patients. Seeing other GPs occasionally did not reduce the experienced personal continuity, as long as patients regularly visited their own GP. We are likely to observe the same trend if other professionals supplement the GP service. Developing general practice with new care models and team-based approaches must ensure that patients experience continuity with their own GP to promote trust, safety, and therapeutic engagement through regular contacts over time.
Notes
Funding
Not applicable.
Ethical approval
This study was approved by the Regional Committee for Medical and Health Research Ethics, Region West (REC West) with reference number 202991 (date 15.12.2020).
Provenance
Freely submitted; externally peer reviewed.
Data
Data are available from the corresponding author on reasonable request.
Competing interests
The authors declare that no competing interests exist.
- Received May 26, 2025.
- Revision received September 6, 2025.
- Accepted October 2, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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