Falling through gaps : primary care patients accounts of breakdowns in experienced continuity of care

Background: Experienced continuity is important for good quality primary care, but may be challenging to achieve. Little is known about how discontinuities or gaps in care may arise, how they impact on patients’ experiences, and how best to understand them so that they can be avoided or managed. Objectives: Using the theoretical framework of candidacy, we aim to explore patients’ experiences of discontinuities in care, and to gain insight into how gaps come to be bridged and why they might remain unresolved. Methods: A secondary analysis was undertaken of interview data from a large study into continuity in primary care, involving a diverse sample of 50 patients, recruited from 15 general practices, one walk-in centre, and community settings in Leicestershire, UK. Analysis was conducted using a constant comparative approach. Results: Experiences of gaps in care were common, arising from failures in communication and coordination of care. Although some gaps were easily bridged, many patients described ‘falling through gaps’ because of difficulties establishing their candidacy for ongoing care when gaps occurred. These patients commonly had complex, chronic conditions and multi-morbidity. Bridging gaps required resources; relationship continuity was a valuable resource for preventing and repairing gaps in care. When gaps were not bridged, distress and dysfunctional use of health services followed. Conclusion: This study demonstrates that some patients with complex chronic conditions and multi-morbidity may be unable to get the continuity they need, and highlights the potential for relationship continuity to help prevent vulnerable patients falling through gaps in care.