Memorandum by the Royal College of General
Practitioners (PS 49)
1. The College welcomes the opportunity
to respond to the Parliamentary Health Committee's Inquiry into
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education, training, research,
and clinical standards. Founded in 1952, the RCGP has over 34,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
3. We welcome this wide ranging Inquiry
into the important issue of patient safety in the healthcare system.
The RCGP has a strong commitment to improving the quality and
safety of care to patients and raising standards in medical practice.
4. We support the work of the National Patient
Safety Agency in raising safety standards. It should work with
PCTs to develop reporting systems that are appropriate and workable
for general practice. We believe that good systems of communication
between primary and secondary care and within clinical teams and
the development of communication and reporting systems that are
appropriate for the setting are key to improving both care delivery
and patient safety.
5. General Practice is well placed to implement
patient safety techniques as practices are generally smaller and
more autonomous than hospitals and practice teams have considerable
freedom in agreeing and implementing improvements.
The College supports patient safety through
much of its work, recent work includes:
The MRCGP examination: Patient Safety
and reduction of risk are embedded within the curriculum and there
are several specific curriculum statements on patient safety
Clinical Leadership is key to good
governance that can ensure safety: The RCGP leadership programme
launched in 2006 is a 1 year robust academic programme designed
to improve GP leadership roles in commissioning, clinical governance
and GP education.
GP Practices working together: The
Colleges recently published "Primary Care Federations: putting
patients first" document sets out a vision for practices
working together to offer better patient services and enhance
clinical governance and education functions that are key to ensuring
The College aims to ensure quality
across the general practice profession by delivering a recertification
scheme that will enhance and encourage the professional development
of GPs, maintain high standards in clinical general practice and
promote excellence, in the service and the safety of patients.
Working with the Department of Health
to develop a system for Primary Medical Care Provider Accreditation,
this is currently being piloted on a voluntary basis
Please find RCGP comments and evidence set out
against the terms of reference of this Inquiry below (NB Inquiry
Terms of Reference in Italics)
What the risks to patient safety are and to what
extent they are avoidable:
Role of human error and poor clinical
Systems Approach and Human Error
6. Rarely is there a single, isolated cause
of errorattempts to prevent errors need to address safety,
learning and improvement within systems as a whole. In other safety
critical industries there is recognition that errors and incidents
occur within a system and that there is generally a sequence of
events that occur before resulting in an incident or accident.
The systems approach in patient safety starts from the premise
that human performance and human error are two sides of the same
coinhumans are fallible, will make mistakes and patients
can be harmed as a result, even in the best-run organisations.
Ultimately, we cannot change human nature, but we can change the
systems in which we work so that errors are less likely to happen.
Organisations with strong safety cultures proactively look for
those things that could go wrong within systemshazardsand
attempt to build in barriersdefencesto minimize
the likelihood that these things will happen.
7. In contrast to the systems approach is
the person-centred approach, whereby the accidents of an individual
are identified as the cause of an incident and that individual
takes the blame for the harm that occurs. Such an approach invariably
damages the lives and careers of those, generally well-intentioned,
staff who find themselves performing the actat the end
of a long chain of errorsthat results in harm to a patient.
Without changes to the system in which the error occurs, the same
event can potentially happen again and again. It is unfortunate
that some NHS Boards follow this approach which results in a blame
culture that is counter productive to improving systems and patient
8. Taking a systems approach in looking
at errors does not mean that malicious, criminal or frankly negligent
individuals should escape the consequences of their actions. Rather,
there is a recognition that sometimes individuals find themselves
operating in poor systems where there are "accidents wait
to happen", and that in those circumstances it is more appropriate
to re-design the system than to inappropriately discipline the
How far clinical practice can be risk-free; the
definitions of "avoidable" risk; whether the "precautionary
principle" can be applied to healthcare.
9. Whilst all steps must be taken through
continuous system improvement to minimise risk it should be acknowledged
that some degree of risk is unavoidable. The risks that result
from illness, its consequences and complications are unpredictable
and unavoidable. Some level of risk is present in the diagnosis
of illness; available resources and technology for diagnosis and
treatment constrain how avoidable the risks arising from a medical
10. However risks that result directly from
the operation of the healthcare system itself can be categorised
as avoidable. It has been estimated that as many as 70% of adverse
incidents are preventable.
Reducing risk by improving communication
11. Communication between primary and secondary
care is important in ensuring that the system operates effectively.
This is a two way process and GPs must effectively communicate
relevant information upon referral to hospital specialists and
they must also understand and act upon that information and feedback
information about interventions to GPs. Unfortunately cases of
incomplete information transfer between primary and secondary
care do occur and can compromise patient safety.
12. Integrated working between primary and
social care is important to ensure a joined-up and holistic approach
is taken to the delivery of care in the community
and to ensuring patient safety. These aims are set out in a recent
joint statement between the RCGP and the Royal College of Physicians.
The role of public perceptions of risk in determining
13. The media has a significant impact in
the way that the public perceives risk and the public's misperceptions
of risks are often the result of this. For example MRSA and C
Difficile are both problematic issues for the NHS to tackle, but
the perception of the risk posed by them is inflated by the coverage
that they receive within the media.
What the current effectiveness is of the following
in ensuring patient safety
a. Local and regional NHS bodies, and other
organisations providing NHS services (including primary and community
care, and mental health services)
How far the boards of NHS bodies have established
a safety culture
14. A safety culture can only be fostered
when there is accountability and when healthcare professionals
are able to disclose mistakes so that process can be examined
and improved upon. Unfortunately some NHS bodies still foster
a "blame culture" which creates fear of incident reporting
and detracts from a safety culture and sharing of learning and
15. A safety culture can be characterised
as one in which every person in the organisation recognises their
responsibility for patient safety and works to improve the care
that they deliverthere is also a recognition that healthcare
is not without risks and that errors and incidents will occur.
The emphasis in general practice should be on minimising these
and on ensuring that when things do go wrong, the practice can
identify this and take appropriate action. Further the organisation
must have communications founded on mutual trust, by shared perceptions
of the importance of safety, and by confidence in the efficacy
of preventive measures.
16. PCTs must work with the NPSA to improve
the system of incidence reporting for general practice. Current
reporting systems have been developed for hospital settings where
staff are more closely managed than in primary care.
b. Systems for incident reporting, risk management
and safety improvement
Whether adequate measurement and assessment is
undertaken and acted upon
17. Significant Event analysis is an important
risk management tool that can be used to identify problems and
allows learning to take place in a positive way. It must be used
in this way and not as a tool to allocate blame.
Clinical teams can under report near misses
and errors for a number of reasons
(i) Unaware of the communication channels
(ii) Reporting systems have not been adequately
(iii) Perceived legal risk in their engaging
in this process, that could result in an adverse outcome
(iv) Perception that reports are stored and
(v) Professional shame at reporting errors
(vi) Lack of a contractual incentive
18. Discrepancies in reporting figures emerge
because performance of vastly different organisations is attempting
to be compared. A system of reporting that is supported by the
NPSA and PCTs should be developed that is appropriate to general
practice and primary care. We do not believe that it would be
appropriate or right to set incident reporting targets or make
reporting compulsory, rather a safety culture and an approach
that can extract learning and achieve system improvement should
The impact of the changing public-private mix
19. It is important that the same high standards
of care and patient safety are maintained across the health system
irrespective of who the provider is.
c. National policy
The appropriateness of the objectives set out
in national policy statements, including Safety First and High
Quality Care for All, and what progress has been made in meeting
20. We welcome Safety First in attempting
to place patient safety at the heart of the way that NHS works.
There is a lot of work done to ensure that it is implemented.
Whether past spending on patient safety has been
sufficient and cost effective, and what future spending should
The appropriateness of national targets
21. Measurement is an important and high
profile part of modern healthcare systems because it can facilitate
greater accountability and help to improve quality and patient
safety. Some aspects of general practice can be measured with
greater reliability and validity than others, meaning there is
a risk that some areas are overlooked. Unless measurements are
identified correctly, their impact can be damaging, particularly
as they divert governance activity away from other areas. As MTAS
(Medical Training Application Service) demonstrates, we should
always question the assumption that a central agenda is correct,
and welcome the views of those who question the indicators used
by the current system.
22. Use of quality indicators is most powerful
when used as a mechanism for improving systems rather than judging
performance or apportioning blame, as is outlined in a policy
statement on quality indicators issued by the RCGP.
d. The National Patient Safety Agency and
other bodies, including:
23. The National Patient Safety Agency is
an organisation which does a great deal of work in setting standards
that help raise levels of patient safety in the care delivered
in the healthcare system.
24. We hope that the NPSA will design reporting
systems that are more appropriate for a general practice setting.
Seven Steps to Safety in Primary Care
25. For example the RCGP recommends the
NPSA publication "Seven Steps to Patient Safety in Primary
Care" as a valuable framework for practices working together
to offer enhances delivery of patient care (see below Primary
Care Federations). The "Seven steps" are intended as
guidance to NHS organisations to ensure that care provided is
as safe as possible and that, should things go wrong, appropriate
action is taken. Following the seven steps should also assist
organisations in complying with their clinical governance, risk
management and controls assurance targets.
26. The Seven Steps are 1. Build a safety
culture that is open and fair, 2. Lead and support your staff,
3. Integrated risk management, 4. Promote reporting and learning,
5. Patient Involvement, 6. Learn and Share Lessons, 7. Solutions
to reduce harm.
Healthcare Commission / Care Quality Commission
27. The Care Quality Commission should focus
greater attention in its work to general practice and the way
services are offered in primary care where the majority of patient
contacts take place. For example the Healthcare Commission's Annual
Health check 2008/09 document was written regrettably largely
from the perspective of secondary care and PCOs.
28. It is unclear at present what form of
regulation the Care Quality Commission will implement. If it is
based on minimum standards through registration little will change.
However a rapid raising of expected standards, enforced on all
services, could cause disruption and the diversion of investment,
leaving little for the rest of the service.
29. A model such as the Primary Care Medical
Provider Accreditation (PCMPA), which the RCGP is currently piloting
with the Department of Health, is effective because it sets minimum
standards but uses developmental criteria to achieve improvement.
It also works in conjunction with clinical summative criteria
(Quality and Outcomes Framework) to raise standards in areas where
evidence demonstrates it is needed. This model is accepted by
NHS litigation Authority
e. Education for health professionals
RCGP Curriculum (MRCGP)
30. Patient Safety is a specific curriculum
statement (3.2) within the section relating to personal and professional
responsibilities. The rationale for this statement points to the
need for GPs to understand their personal responsibility for safety
as a core part of medical professionalism. General practices,
as the sites where most GPs work can also have a major impact
on safety in the design and implementation of systems of care.
The statement describes the learning outcomes for safety in general
practice training and these include basic tools and techniques
for patient safety that should be applied in the context of general
practice. Within the statement are references to key texts, tools
and techniques that will equip GPs with the knowledge, skills
and attitudes to practice safely and protect their patients from
National Patient Safety Agency's
"Being Open" programme to support better communication
National Patient Safety Agency's
"Safe Foundations" facilitates education in patient
safety to doctors in the Foundation years.
31. The development of diagnostic training
tools and better informatics to support GPs in diagnosis are areas
that can have a real benefit in reducing diagnostic errors in
32. Some College members are involved in
a soon to be published report entitled "Patient safety in
health care professional education curricula: examining the learning
experience". This is a collaboration of five institutions
led by Newcastle University and funded by the Department of Health
(Patient Safety Research Programme) to undertake into education
for patient safety.
It is premature to release emerging findings here but once published
it will be of real relevance to this section of the Inquiry.
What the NHS should do next regarding patient
Whether the measures taken to improve
patient safety are supported by adequate evidence regarding their
clinical effectiveness and cost effectiveness
How to determine best practice and
ensure it is spread throughout the entire NHS
33. The NHS should have systems that support
good clinical leadership, this is vital to ensuring that best
practice is spread across the NHS. Leaders must foster a professional
culture within which errors can be shared and learned from rather
than one where individuals hide mistakes in fear of the consequences
of disclosing them.
34. The RCGP leadership programme launched
in 2006 is a 1 year robust academic programme designed to improve
GP leadership roles in commissioning, clinical governance and
Primary Care Federations
35. The College's recently published "Primary
Care Federations: putting patients first"
sets out the concept of GP practices working together as federations.
The RCGP believes that the development of Federations where appropriate
should be supported by the NHS and the Department of Health as
a workable solution to delivering better patient care in the community.
36. Federations would improve the quality
of patient care and patient safety by ensuring good governance
across practices. This governance function would include support
for effective annual appraisals and revalidation for medical members
and other staff.
37. The RCGP recommends that Federations
should look at the framework set out by the National Patient Safety
Agency, "Seven Steps to Patient Safety in Primary Care".
By their nature, Federations will be looking at new and innovative
ways to provide care and ways of working, including the provision
of specialist services and diagnostic facilities outside of traditional
hospital settings. These services must be run so as to maximise
quality of care and health outcomes. Incorporating the principles
set out in "Seven Steps" will allow Federations to develop
their services and working practices to build a local health community
that will be as good and safe as design and planning can allow.
What should be measured and assessed; and what
data should be published
38. Diagnostic error is an area that has
not so far received much attention. GPs play a key role as gatekeeper
to specialist and other services in the healthcare system and
as such diagnostic errors have impacts on onward patient experience.
Areas that could be further developed in this area to allow diagnostic
error to be better understood are:
(i) Training tools for diagnostic skills
(ii) Development and evaluation of better
informatics tools to support GPs in diagnosis
What incentives there should be to
improve patient safety
How patients and the public can be
involved in ensuring that services are safe
39. Public communication and engagement
in the delivery and development of services, with the aim of reassuring
patients and improving systems and safety, is important. The RCGP
Primary Care Federations model of care delivery in the community
would have the following in place to ensure this:
A written public constitution detailing
the Federation's membership, responsibilities, management arrangements,
decision making processes, vision and values
A public communication strategy that
explains how the Federation will communicate effectively with
A public engagement strategy
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