Patient Safety - Health Committee Contents

Examination of Witnesses (Question 580-599)



  Q580  Stephen Hesford: So it becomes not exactly scientific but it has a representative nature?

  Professor Esmail: Yes, and I think the point is it has the effect of actually getting you to improve things, and that is very important. It means that when you find out, for example, that a patient had a blood test done and it was not followed up, you invariably go and look at your systems and what are our systems of follow-up. When a patient comes for a blood test what reminders do we have, what sort of prompts do we have to make sure that someone follows up on that result. So it tells us to do things like that, and I think we can hugely improve systems in primary care through those sorts of techniques. We also have techniques like significant event audit. We have a system whereby we ask people to make a record of something that goes badly wrong. It is a significant event, it is not something minor; something that they feel is really big. They will make a record of it and we will discuss it as a team, and, as a result of our discussion, we will say, "Gosh, this is not very good in what happens. It highlights a flaw here. It shows we do not do this very well", and we then actually get someone, or a team of people, to go and make the changes and we hope that it does not happen again, but if the problem arises again, we have a record of what happened before, we can follow the audit trail to see what happened. Those sorts of things can be very important and should not be negated.

  Q581  Dr Taylor: Going on with significant event audits, do you only look at those four weeks at a time?

  Professor Esmail: No, that is an ongoing programme. We just talked about reporting. We have a computerised base system. For those four weeks we want them to report everything that goes wrong, from their perception, and we will get everyone to do that—nurses, reception staff, the people who work in the admin office—so everyone knows that that is the four weeks we try to collect information on. That is the purpose; it gives us an idea of how big a problem it is. Significant event audit goes on throughout the year, because I may find out last week something happened. If I got a very poor discharge of someone from hospital, I did not know something that should be happening, then I should log that so that when we come to discuss it we know. How can we actually contact the hospital to make sure that this does not happen again? Can we make sure that it is followed through? Does that audit loop get closed? Can we make sure that we have something in place that we know it is not continuing to happen? That is what significant event audit achieves, and that has to happen all the time.

  Q582  Dr Taylor: Could you give us some other examples of what are significant events?

  Professor Esmail: I will give you an example of a patient of mine who was discharged from hospital with a diagnosis of cancer, which I was never told about, and nor was she. Eventually we were able to find out. We kept insisting: "Why have we not had a proper discharge letter?", and we then discovered this happened. That was a terrible case really, and what happened on that is that I discussed this. We discussed it as a team. We wrote a letter to the hospital. We asked them to investigate it. We expected a response back again. We hope we have a system in place so that that should no longer be the case, and things are improving on that. That is an example of significant event audit.

  Q583  Dr Taylor: That is really something happening in secondary care though. What about significant events in primary care?

  Professor Esmail: A common problem is someone has a blood test done and is found to have anaemia and we do not follow it up. We look at it, we see that the haemoglobin is low and it is just put down as probably due to iron deficiency anaemia, but actually it might be something more significant. We might have to do more investigations to see is there a cancer underlying that, are those investigations followed up, who is going to carry them out, and so on. It is becoming particularly important in primary care: continuity is a real problem. You might have one doctor seeing the patient and then someone else having to follow it up three or four weeks later, and if the record keeping is not good or the audit trail is not good, that might get missed. That is a very common example, when we have a result which might signify something more serious but is not followed up.

  Q584  Dr Taylor: Has incorporating SEAs into the QOF made any difference?

  Professor Esmail: I do not think it has yet. The reason is because the way that people do significant event audit in general practice varies hugely from practice to practice, and we need to have a standard way of doing it, we need to have a standard way of collecting information, we need to have a standard way of making sure that information is shared, and all that the QOF does is say, "Do you do it?", yes or no, and that is it.

  Q585  Dr Taylor: So you can get the money if you say, "Yes", even if you do not do it?

  Professor Esmail: That is lying, and that should not be the case. The point is you can do it, but are we learning from it. That is the critical question. Also important is: are we sharing the information? I might have a problem in my practice. I work in a primary care trust where there are 50 other GPs, and what I have found is a problem may also be very relevant to others. Are there mechanisms whereby we can share that sort of learning? That does not happen consistently—even the mechanism of recording them, for example. The Royal College of General Practitioners has just launched a significant event audit tool kit which suggests a format for collecting information, for reporting on it and so on, and that is only recent, but that has been the problem. So the QOF merely asks you: "Do you do it?", yes or no, but really the question is: "How do you do it, what do we learn from it and how can we make sure it does not happen again?"

  Q586  Dr Taylor: Even though it has been going for some few years, you have only just got a tool kit of how to do it?

  Professor Esmail: Yes. No, a tool kit for standardising it.

  Q587  Dr Taylor: Which is what it has to be?

  Professor Esmail: What it has to be, yes. Actually significant event audit pre-dated QOF. GPs were doing it in some areas of the country ten years back, because they saw it as an important way of driving improvement. So when someone dies unexpectedly many good practices were reviewing that information and saying, "Why did they die unexpectedly? What was going on here?", and they look at the period of care. So that was very, very important. We do it with every cancer death, and we do it, not because of some terminal cancer stuff, but we actually look at the quality of care. Was there a good follow-up? Were people informed correctly what should happen when they died? All this information is very important. We do that routinely, for example, for every cancer death. We do a review of it.

  Q588  Dr Taylor: Does the tool kit standardise what is significant?

  Professor Esmail: Yes, it will have. The point about significant event, we tend to leave it to the practitioners and the reporters to determine it. You cannot say that is irrelevant, because from a patient's point of view it might be very important, so we tend to leave that open: either the patient raises it and we say, "Gosh, that should not have happened", or the practitioner raises it. You cannot predefine a significant event. I think it has to be determined a lot by the circumstances and the context it occurs in.

  Q589  Sandra Gidley: I must admit, I am somewhat horrified that the evidence is that GPs will not report the lower level stuff if they have to do it for more than three or four weeks, because one would have hoped that there would have been sufficient interest in improving things for patients that this would become endemic, embedded good practice.

  Professor Esmail: It is not that they will not. The National Learning and Reporting system, as you probably know, if you look at the reports from primary care it is point 5% per cent, and most of those from general practice, so it does not even include community pharmacy, it does not include district nursing and areas like that. Is it because they do not want to or is it because they have been asked the wrong question and asked to report the wrong thing? I think that if you look at a practice like ours, when probably about 500 or 600 patients are seen every day—we have 18,000 registered patients—the volume of work is immense. The reality is that you are so caught up in the day-to-day running of things that to have a system without doing a lot more work and without the culture changing, where every incident is reported. We even have to ask ourselves, "If you report everything what is going to happen to it?", and we do not have the capacity to even analyse everything that comes in.

  Q590  Sandra Gidley: I am sure there was that attitude in hospitals once, but they seem to have managed it in hospitals. I do not buy into this, that primary care so is rushed that they cannot do things that are good practice elsewhere?

  Professor Esmail: All right. I understand what you are saying and I realise that it comes across that we do not want to or we do not care. I am just saying that this is based on a research project of ours, and that is what we found and we have had to react to it. We found this was not just the case in Britain, we found it was the case in Australia, in the Netherlands, in Canada, in America. This was a universal problem. I think we have to ask ourselves: how can we sustain that level of reporting? One of problems is this. A lot of things that happen in primary care, whilst they should not happen, have no consequence, and that is another problem, which is why things like significant event audit have got a catechism in general practice which has been very powerful: because when something terrible goes wrong it really concentrates the mind.

  Q591  Sandra Gidley: That is fine, but the lower level events and the near-misses can often educate about a potential problem as much as a significant event?

  Professor Esmail: Yes, and that is why we have said if we can do it for a month at a time and vary that over a period of years, we will build up a very, very important profile, and we can sustain that and have good quality data and we can then work on that, and that is very important as well. I think that sort of model might work better in primary care than in hospital, where you have better structures and organisations, and so on, to do that.

  Q592  Sandra Gidley: I am not convinced, but I think we are going to go round and round in circles. Let us get to some specifics. Is there a problem with prescribing and medicines management in primary care?

  Professor Esmail: The research data shows that there is a lot of interaction. This has come about from all sorts of work where patients are admitted to hospital, for examples. Many admissions are due to drug interaction, so again we understand there is a problem there. I think at one level we have quite good safeguards in primary care. We have been computerised for a long, long time and our computer systems are constantly improving. For example, we get warned now if you prescribe something and there is interaction with another drug. That is quite sophisticated and has been around for a long, long time. We know that there are problems with the system still, but they are constantly being improved and I think people are aware of that, so at that level we are moving towards electronic prescribing. Virtually no-one writes handwritten prescriptions because there are transcription errors, for example.

  Q593  Sandra Gidley: They are not allowed to; that is why they do not.

  Professor Esmail: Yes, but the point is that that is an error that rarely exists now. Sometimes when you go on home visits you have to write handwritten prescriptions, so that still happens, but that has become minimal now, so those areas have gone. We, for example, recognise the problem and we employ a pharmacist. In fact the research shows that the solutions are not necessarily in the technology but in the people, and because so much prescribing goes on in general practice, it is so important, we have actually employed a pharmacist who works alongside the doctors and helps us towards identifying problems where things are not going right, develops systems so that things happen properly, and in our case I would say that has made the most impact. We have good computerised systems and I think that that has helped tremendously, and where the problems arise probably are when people go into hospital, because there is not good exchange of information that goes across that, and, secondly, when people are discharged from hospital. I think when general practice handles the prescribing, on the whole, it works pretty well and I think that pharmacists play an increasingly important role in helping us reduce error in that area.

  Q594  Sandra Gidley: Is there a problem with variable quality of diagnosis in primary care?

  Professor Esmail: We have always known about. I would not say variable quality. The research was based really on our small studies which we did, where we got people to report things and find out what went wrong, but also by looking at the litigation databases, for example, and what had people complained about, and what was surprising, what stood out very clearly in primary care, was that 50% of the cases in the litigation databases we looked at were because of delayed diagnosis. What happens is that someone has a condition and it is picked up quite late. Let us take a simple example of a bowel cancer. The problem is, of course, that they present sometimes with very non-specific symptoms, it may take three or four months before the diagnosis becomes known and they get referred at that point. So we know that delayed diagnosis is a big problem, it stands out, it really hits you in the face, and of course the reason for this, when we do work around diagnosis in general practice, is that things that come to general practice in primary care are very undifferentiated; people do not come with a glaring symptom. If someone came to me saying, "I am bleeding rectally", that hits me in the face and says, "Yes, we need to examine and understand why that is happening", particularly if you are in a particular age group, but what happens is they come in and say, "I have not been feeling right for a while and I am not quite right here and I have got a bit of pain in my stomach." You investigate, you look at this, and it is a rolling process and when you have completed the process, you say, "Gosh, this is a cancer", and yet you can see they presented three or four months down the line, and from the patient's perspective they say, "I have had this for three or four months", but, of course, if I just referred everyone to hospital with those non-specific symptoms, we would bankrupt the system; it just could not sustain itself. So there is always that balance of trying to say when is it serious, when are the problems arising and how can we investigate as much in primary care before we refer people on? There are many examples like that: headaches which people talk about. We know that headaches are a sign of brain tumours, yet if we scanned everyone with a headache we just could not sustain that; our system cannot allow that.

  Q595  Sandra Gidley: Is there not some evidence that there is a huge difference in the way individual GPs would react to those sets of symptoms, which is why the referral centres were introduced?

  Professor Esmail: That is right, and they have made a huge difference, I think, in making early diagnosis available, but we have not actually done the research to see whether it has reduced that.

  Q596  Sandra Gidley: Some would say that it has gone the other way and when GPs have wanted to refer, if they are seen to be referring more than the people down the road, they are asked to look again. Who is to say who is right?

  Professor Esmail: We do not have the research evidence on that—that is what I am trying to say. We have put in these innovations. It is too early for us to even understand whether it has had an impact on things like delayed diagnosis, but what you say is absolutely right: we know there is huge variability. Of course the thing that struck me when I was looking at the research in this area is sometimes you have what I call `barn door cases' and you just cannot understand why it is that people miss them. You look at the case and you read the medical legal summary and you think, as an outsider, that is an obvious case of a heart attack, and yet it was missed by the doctor, and then you ask yourself: "Is it because they did not know?", and you think that may be the case, but it is highly unlikely, it is something that you learn really early on, so what else was going on there? I think that when we begin to understand this we begin to realise the complexities around the situation. For example, the patient had had a long history of chest pain which has never amounted to much and has been diagnosed as having indigestion, but on this occasion it was because of myocardial infarction, for example, and it can be very difficult to distinguish. These sorts of things become much more complex. So we are beginning to realise that when we look at diagnosis it is as dependent on the patient as it is on the clinician as it is on the context of where you are and when you were, and so on, and it becomes very, very difficult.

  Q597  Sandra Gidley: You are describing something that is more of an art than a science by the sound of it. Is there a role for automated decision support systems that would mean you have better outcomes?

  Professor Esmail: I think they can help, definitely, in some areas. The problem is that because things are so dependent upon the context, we do not have good enough systems that can tell us about it. For example, if I get a prompt with someone who comes in with rectal bleeding and the prompt simply says, "Think about cancer", if it is a 20 year old, that is not helpful, but if it is a 50 year old, it is. Somehow you need to have a system which can not only look at it by age, for example, which is a simple example, but, more importantly, might able to look at it by things like ethnicity, might be able to look at it by other factors that they have, other co-morbid conditions, diseases and so on, and can give that information. That is the holy grail we all look for, and I think we are a long way away from that because it is actually very, very complicated. I think the NHS is littered with examples where someone has come along and said, "This will do it" and people have invested huge amounts of money into it and it has not delivered it. I think, yes, we should try and achieve that, but it is far more important probably to try and get doctors to work together, to understand these things, to feed back relevant information, for example, to look at cancer referrals, see what is happening about that. We can do a lot around training and improvement before trying to say: let us put all the money into trying to find a technological solution which I am not entirely certain will work.

  Q598  Dr Naysmith: Professor Esmail, I want to ask you a question in a minute or two about the role of commissioners and also about the role of registering of GPs and so on. First of all, I would like to ask you: why is it there is still such a large amount of over prescribing of antibiotics by GPs? Dr Holmes went on at some length about the importance of not allowing the emergence of resistant bacteria, but GPs still do it, and we know they still do it, so why?

  Professor Esmail: I would question whether. I think, for example, it is very common now; it is part of the commissioning process. We get feedback on the antibiotics prescribed for conditions and we have targets, in effect, and we use those internally. If we see that we are over prescribing, for example, if we look at our diagnosis of upper respiratory infections and we say, "Why is the prescription writing very high?", we look at that and say "Gosh, what is going on?", and we even look at it by doctor then and, as part of our review, we take it up with each other and say, "What is happening here?" So I would question that. I think there are many improvements that have happened. It is always given as example that GPs over prescribe. Looking at it from my part, I get people home, discharged from hospital and I think, "Gosh, they have been given a whole paraphernalia of drugs which I do even go near."

  Dr Naysmith: No-one would dare over prescribe in Dr Holmes' hospital; they would not dream of doing it.

  Q599  Dr Stoate: It is our job to stop it all, is it not!

  Professor Esmail: That is right, yes

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