An Observational Study of How Clinicians, Patients and the Health Care System Create the Experience of Joined Up, Continuous Primary Care in the Absence of Relational Continuity

Background: There is an international trend towards the at-scale provision of primary care services, with such services often provided in different settings by a clinician unfamiliar to the patient. It is often assumed that, in the absence of relational continuity, any competent clinician can deliver joined up, continuous care if they have access to clinical notes. Aim: We use case study data of care delivered away from a patient’s regular practice, by a different organisation and set of staff. We studied this “extreme” example of a system where joined up, continuous care will be more difficult, to better understand the factors which affect the potential for providing such care. Design and Setting: Case studies of two initiatives to improve access to primary care. Data collected included observations, interviews, and documentation. Method: Case studies used an inductive approach. Cross-case comparison took place using a constant-comparison approach. Data were coded. A model of factors affecting continuity was constructed. Results: The potential for joined up, continuous care appears dependent upon patient, staff and system factors. This includes diverse elements such as the attitude of clinicians to care co-ordination to the ability of an organisation to retain to staff. Discussion: Healthcare systems increasingly rely on the assumption that any competent clinician can deliver joined up, continuous care if they have access to clinical notes. This appears not to be the case. We present a model of factors affecting the patient experience of continuity. The model needs validating in in-hours general practice and other settings.