Continuity of Care: a fundamental or a luxury we can no longer afford?

As I reflect on my journey as a family physician, the concept of continuity of care stands out as one of the cornerstones of my practice.

For over 40 years, I’ve dedicated myself to building relationships with my patients in South Africa’s public healthcare system.

In conversations with fellow family physician Professor Steve Reid, we’ve explored the many dimensions of continuity, revealing both its complexities and its profound importance.

What follows is an edited reflection of that conversation.

The Puzzle That Is Never Complete

Hoffie: When I started studying family medicine, continuity of care was always a core principle…seeing the same patient over time, building a relationship.

Steve: Fundamental.

Hoffie: I often think of it like a puzzle. Every encounter adds a few pieces. The picture becomes clearer over time—but it’s never complete.

For me (Hoffie), this idea of continuity has always been deeply relational. It’s about something that unfolds over time—slowly, imperfectly, but meaningfully.

There is also something in this image that resonates beyond clinical work. It speaks to a way of being with patients—one that values curiosity over closure, and relationship over resolution.

Steve: What you’re describing is interpersonal continuity. But the literature also talks about informational continuity—through notes—and managerial continuity—through systems and teams. In those models, the interpersonal element becomes secondary.

Hoffie: Yes… and those are important. But what feels fundamental to me is that interpersonal continuity.

This tension—between relational continuity and system-based continuity—sits at the heart of the discussion, especially in the South African public sector. This distinction also raises a deeper question:

Is continuity something we manage—or something we experience?

A Triangle of Care

Steve: You can’t see all the patients… so continuity has to become a team-based thing.

Hoffie: Yes, in the clinic where I work, patients are first seen by the nurse practitioners. I see those referred to me. But over time, you still get to know some patients.

Steve: So there’s almost a triangle—patient, nurse, and doctor. Continuity exists across all those relationships.

Hoffie: And often the nurse is the real continuity… especially when they live in the community and know the patient’s context.

In this sense, continuity is less about ownership and more about connectedness—between people, roles, and perspectives.

Creating Continuity in Fragments

Hoffie: Even if I only see a patient every six months, there’s something that builds. And when they come back from hospital or a specialist, that continuity deepens.

Steve: But the system itself doesn’t prioritise it. Patients don’t know who they’ll see.

Hoffie: That’s why we’ve tried to create teams in the clinic—to improve that continuity.

There is something quietly important here. Continuity may not be given—but it can be cultivated. Even within these constraints, something relational still emerges.

A Personal Investment

Hoffie: When I see a patient for the first time, I invest. I ask about their life, their family, their context. And then… I want to see them again.

Steve: Almost a sense of possessiveness?

Hoffie: Yes… perhaps that’s the word. I feel disappointed when they see someone else—not because the care was wrong, but because the relationship is interrupted.

This speaks to a subtle shift—from seeing the consultation as a task, to experiencing it as the beginning of a relationship.

And with that comes attachment, expectation… and it raises an uncomfortable question.

Steve: Is that reciprocated? Do patients value it in the same way?

Hoffie: My experience is that many do. They say, ‘I hoped to see you.’ But perhaps that’s also what I want to hear.

What Do Patients Value?

Steve: The literature suggests patients often prioritise efficiency—being seen quickly—over seeing the same doctor.

Hoffie: Yes, I’ve seen that too. But in practice, some patients clearly value the relationship.

Steve: So maybe it’s not universal. Some want quick solutions. Others want connection.

Continuity, it seems, is not equally valued by all—but for some, it matters deeply. Perhaps it’s not something patients demand upfront, but something they come to value once they have experienced it.

Continuity and Practitioner Fulfilment

Steve: There’s very little literature on what continuity does for the practitioner.

Hoffie: For me, it’s central. Early in my career, the satisfaction came from making diagnoses or doing procedures. But over time, that became routine. What gives meaning now is the relationship.

Steve: Patients give something back. That reciprocity—that’s a major factor in preventing burnout.

Hoffie: Yes… in a busy clinic, a patient might simply say, ‘Doctor, you look tired—have you eaten?’ That connection matters.

This reciprocity is not easily measured, but it is deeply felt. In a system that can feel mechanical and overwhelming, these moments of recognition are sustaining. It shifts the consultation from a one-directional act of care to a relational exchange.

The Risk of Getting Too Close

Steve: But there’s a downside. Clinicians are scared of becoming too involved—of being emotionally drained.

Hoffie: Yes… and I’ve wondered whether the real challenge is not the involvement itself, but how we hold it.

Steve: Because it brings responsibility. Uncertainty. Vulnerability. Some people prefer to keep things contained—just do the job.

Hoffie: And yet, when you know a patient well, you become more careful. More thorough. You see when your plan isn’t working. That can be uncomfortable—but also valuable.

Continuity asks something of us. It is not neutral work. In one encounter, a patient’s spouse expressed anger about a previous clinical event.

Hoffie: My immediate response was to defend myself. But then I realised—this was about her fear and distress. And I needed to be with that, rather than protect myself from it.

This kind of moment lies at the heart of both continuity and reflective practice.

It requires the capacity to pause, to notice, and to choose how to respond.

From Fixing to Serving

Steve: Over time, the relationship changes. You don’t have to be the all-knowing doctor. You can be more real, more vulnerable.

Hoffie: Yes… it becomes less about fixing and more about serving. More equal.

Steve: And that’s not comfortable for everyone.

This shift—from authority to relationship—may be one of the deeper transformations continuity brings.

Can Continuity Be Taught?

Steve: We know continuity can be learned—we’ve experienced it. But can it be taught?

Hoffie: I think it has to be experienced. You can’t just teach it conceptually.

Steve: And that’s the problem. Training is fragmented. Students rarely see patients over time.

Hoffie: Yet when they do—even briefly—it changes something. They start to see the person behind the diagnosis.

Perhaps the challenge is not teaching continuity directly, but creating the conditions where it can be lived.

This points to something broader:

Continuity is not just a structural feature of care. It is also a way of seeing—and a way of being.

Full Circle

Hoffie: I feel as if I’ve come full circle. I still find myself seeking continuity—creating it where I can.

Steve: So for you, it remains fundamental?

Hoffie: For me, yes. Not because the system demands it—but because it gives meaning to the work.

An Invitation

We ended our conversation not with conclusions, but with questions:

Steve: If continuity is fundamental, we’ll prioritise it. If it’s a ‘nice to have’, it will fall away.

Hoffie: So perhaps the question is—what is it for each of us?

We invite you to reflect:

• What is your experience of continuity of care?

• Does it enhance your sense of meaning—or contribute to fatigue?

• Do your patients value seeing the same doctor?

• What in your setting supports—or undermines—continuity?

• And ultimately: is continuity fundamental—or has it become a luxury?