Select Committee on Health Written Evidence

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 Patient Safety.

  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[274].

  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[275]

    —  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 patient safety.

    —  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 judgement

    —  Systems failures

Systems Approach and Human Error[276]

  6.  Rarely is there a single, isolated cause of error—attempts 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 coin—humans 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 systems—hazards—and attempt to build in barriers—defences—to 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 act—at the end of a long chain of errors—that 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 safety.

  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 professional.

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 problem are..

  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[277].

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[278].

  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[279] and to ensuring patient safety. These aims are set out in a recent joint statement between the RCGP and the Royal College of Physicians.[280]

The role of public perceptions of risk in determining NHS policy.

  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 system improvement.

Safety Culture

  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 deliver—there 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[281].

  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 designed.

    (iii)  Perceived legal risk in their engaging in this process, that could result in an adverse outcome

    (iv)  Perception that reports are stored and not used

    (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 be fostered.

The impact of the changing public-private mix in provision

  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 them.

  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 be

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[282].

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[283]

  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[284].

  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 the profession.

NHS litigation Authority

  No comment.

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 avoidable harm.

Education Resources

    —  National Patient Safety Agency's "Being Open" programme to support better communication with patients.

    —  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 primary care.

  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[285]. 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 safety

    —  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

Clinical Leadership

  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 GP education

Primary Care Federations

  35.  The College's recently published "Primary Care Federations: putting patients first"[286] 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

Diagnostic Errors

  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[287]. 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 the public

    —  A public engagement strategy

September 2008

274   Baker M-Patient safety in general practice InnovAiT. 2008; 1: 431-437 Back

275   RCGP Curriculum Map Domain 3.2 Patient Safety. RCGP Website: Back

276   Baker M-Patient safety in general practice InnovAiT. 2008; 1: 431-437 Back

277   Ibid Back

278   Davies P "The great NHS Communication breakdown" BMJ 2008 2008;337:a664 Back

279   RCGP submission to Lord Darzi's invitation to submit policy ideas (January 2008): Section 5.8.1 RCGP website: Back

280   "Making the best use of doctors' skills"-a balanced partnership-a Joint Statement from the Royal College of General Practitioners and the Royal College of Physicians on how specialists and generalists can work together for the benefit of patients in the NHS", April 2006 Back

281   National Patient Safety Agency. Seven Steps to Patient Safety. NPSA, London, 2004. Back

282   Baker M, Marshall M, Wilson T Quality Indicators-Royal College of General Practitioners Policy Statement January 2002 Back

283   National Patient Safety Agency. Seven Steps to Patient Safety. NPSA, London, 2004. Back

284   RCGP submission to the Healthcare Commission consultation on developing the Annual Health Check in 2008/09 (March 2008) RCGP website: Back

285   Information on "Patient safety In health care professional education curricula: examining the learning experience" project retrieved from Newcastle University Patient Safety website: Back

286   Royal College of General Practitioners: "Primary Care Federations: putting patients first" (June 2008). RCGP website: Back

287   Olga Kostopolou, Jurriaan Oudhoff, Radhika Nath, Brendan Delaney, Craig W. Munro, Clare Harries, Roger Holde: "Predictors of Diagnostic Accuracy and Safe Management in Difficult Diagnostic Problems in Family Medicine" (2008): Society for Medical Decision Making. Back

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