This study has used in-depth interview data to systematically explore the views of GPs and patients of the value of personal continuity and access to care. The study successfully recruited a heterogeneous sample of GPs, and of patients with experience of consulting with a range of problems and degrees of urgency. The proportion of patients saying they had a personal GP was comparable to large surveys, consistent with recruitment via the participating GP not preferentially selecting for patients that they knew very well (78% here vs 75%) . One potential limitation is that the patients recruited had only a limited range of conditions. In particular, the study did not actively recruit patients with chronic diseases such as asthma where the need for urgent access is likely to be common, or patients with mental health problems where personal continuity may be particularly important. However, most of the patients in the study had had occasions where urgent access had been important to them, and several had consulted their GP with family problems, anxiety and depression. Patients with other conditions are also likely to balance when to be seen against who to see, although the choices they make in doing this will vary depending on the particular problems they are consulting with. A second potential limitation is that the study was limited to one UK region. However, sampling ensured a range of practice size and deprivation, and included practices from small towns and villages in Lothian as well as Edinburgh city. Survey research involving family practitioners in the UK, Holland and the US identifies personal continuity as an important feature of their clinical practice, although what patients value is less certain . We therefore believe the results to be applicable elsewhere in the UK, although their generalisability to countries where healthcare organisation is radically different is less certain .
From the patients' perspective personal continuity and access to care were inextricably intertwined. In general, patients all valued rapid access. However, access to an appointment with a GP was a means to an end – help with the management of particular problems in a clinical consultation. Four of the patients interviewed considered that any GP could deal with their current and foreseeable problems, and only valued rapid access to an appointment. The rest identified previous, current or foreseeable problems where seeing a known and trusted GP familiar with their past history was important. What patients therefore wanted was 'access to appropriate care' , where what was appropriate depended on the problem to be dealt with. For chronic, complex and psychological problems this was usually consultation with a GP with whom the patient had an ongoing relationship, because it made the process of consultation easier, and allowed greater involvement in decision making. For minor or episodic problems, or where the problem was perceived as very urgent, then any GP was likely to be appropriate.
The GPs agreed that personal continuity mattered under broadly the same circumstances, although they focused on its value in improving the diagnosis and management of problems in the face-to-face consultation. In the GP interviews, there was little unprompted discussion of access to care or the negotiation of appointments, which was therefore presented as much less central to their work. A key finding is that patients and GPs appeared to have little explicit knowledge about the other's perceptions of personal continuity and access. GPs' beliefs about what patients valued appeared based on their consultation pattern, which could be misleading since it was contingent on both patient preferences and other circumstances such as the problems they had had, and the way that appointment systems were organised.
General practice research and training have placed great emphasis on the consultation, as the place where the core values of personal continuity and holistic care are played out. The GPs interviewed had internalised this, but the emphasis on appropriate care in the consultation was at least partly at the expense of paying inadequate attention to access to that consultation.
Equally though, current policy focuses almost exclusively on rapid access to consultation without considering or measuring effects on the appropriateness of care in the consultation. Although Advanced Access documentation emphasises that patients should be able to book appointments with the clinician of their choice, the measures used to judge successful implementation, and the targets set for primary care organisations focus almost exclusively on 'entry access' or the speed with which patients get into the system [11, 10]. There is some evidence that pressure to achieve these targets reduces personal continuity, and therefore leads to less appropriate care in the consultation for those with more complex problems [24, 10, 12], although the extent and implications of this will remain uncertain until external evaluation of Advanced Access is complete .
The evidence presented here supports changes to everyday practice and current policy in relation to access arrangements to primary care. However, the patients' perspective would be better accommodated if both GPs and policy targets addressed 'access to appropriate care' (or in-system access), rather than focusing on personal continuity (GPs) or rapid access (policy) . All patients in this study wished rapid access under some circumstances. However, for ongoing and complex problems with less immediate urgency, then access to appropriate care for most patients meant being able to see 'their' GP who knew them as an individual, and knew their medical history. From this perspective, demand management strategies focused on improving speed of access including triage and direction of patients to the first available provider increases professional control over the definition of what care is 'appropriate' and reduces patients' ability to choose the service that they consider appropriate for the problem they wish to discuss.