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Independents' Day

GPs in the dock over safety data 'black hole'

As the Government considers whether to make patient safety incident reporting mandatory, By Nigel Praities looks into why the current voluntary reporting process has come under threat.

By Nigel Praities

As the Government considers whether to make patient safety incident reporting mandatory, By Nigel Praities looks into why the current voluntary reporting process has come under threat.

It's part of the fabric of being a doctor: the Hippocratic oath and its key principle of first doing no harm.

But GPs are coming under pressure to prove that they are applying the principle to their own clinical practice.

The low rate of reported patient safety incidents in general practice had been taken as a sign that everything was well, but GPs are now in the dock over what some experts claim is a ‘black hole' of safety information

A looming parliamentary report is expected to call for a crackdown of lax standards of reporting and clinical governance, and as Pulse reveals this week, ministers are quietly considering how to make patient safety reporting mandatory for GPs.

Under the current system, GPs are expected to volunteer information about incidents where patient safety has been put at risk.

They are incentivised through the QOF to record serious events or deaths in significant event audits several times a year. And GPs are supposed to voluntarily report less serious events – such as unexpected hospital admissions or delayed diagnoses – to the National Patient Safety Agency or to PCTs.

41226185It's this system that has come under increasing attack, as a string of experts triggered ‘horror' among MPs on the Commons health committee during their ongoing investigation into patient safety in the NHS.

Dr Olga Kostopoulou, a researcher in the Medical Decision Making Research Group, at Birmingham University, told MPs that GPs were often too busy to focus on safety concerns.

‘It is a very difficult job and sometimes it is not done well. We know it is not done well because patients complain. More than 60% of claims against GPs are about diagnostic errors,' she says.

On the surface the figures certainly do not look good. A National Audit Office report in 2007 reported only 4% of GPs routinely report patient safety incidents.

And latest figures from the NPSA show safety incidents reported by GPs made up only 0.2% of the total in 2007/08, down from 0.4% in 2006 and compared with 74% from hospitals.

These miniscule rates come despite 95% of all NHS contacts taking place in primary care and 300 million general practice appointments per year.

The NPSA concludes there is a ‘different reporting culture' in general practice, with GPs only likely to report incidents that result in severe harm or death.

Professor Aneez Esmail, professor of general practice at the University of Manchester, says even cases that can have ‘serious consequences' are not always reported, because of a lack of any mechanism to allow it to happen.

‘Research I and colleagues have done shows there are issues, in some cases very serious issues.

‘GPs are very good at reporting major misdiagnoses, but not incidents such as a patient not getting an appointment for a chest infection that turned out to be very serious. There is no mechanism of picking that up.

‘Errors of omission are also very common, where a patient should be on aspirin because they have heart disease – and these have quite serious consequences down the line,' he says.

Professor Esmail estimates the rate of safety incidents in primary care could be as many as 80 per 100,000 consultations, with most studies showing the most common errors are from delayed or missed diagnoses or treatment.

‘Significant event audits do work, but while that it is a good mechanism for identifying what happens, we don't have a very good follow-through. We identify the problem, but don't make any change so it doesn't happen again.'

That may change with the onset of revalidation, which will require GPs to review a number of adverse events – the RCGP says five, the NHS Revalidation Support Team wants 10 – over a five-year cycle.

But elsewhere, there are also concerns about yellow card data. The MHRA describes GP reporting of yellow cards as the ‘backbone' of the scheme – but warns numbers are in decline.

‘While GPs remain the profession with the highest reporting rate we have noticed a continued fall and are investigating to ensure this can be reversed,' says a spokesperson.

The rising concern over the reporting of patient safety incidents has filtered through to various NHS advisory bodies, with a raft of new initiatives planned for this year to address the problem.

The NPSA will pilot an improved electronic reporting form at surgeries in the south-west and wants a new ‘single central definition' for when serious incidents should be reported.

And the NHS Institute for Innovation and Improvement – more usually associated with moves to drive up efficiency - is working on a ‘global trigger tool' that combs through practice records for instances where patient safety have been threatened.

The tool will be launched in November this year and the Department of Health is looking very carefully at the results of a pilot in 42 practices in England that has just finished.

Trigger tools are used widely in hospitals to pick up errors, but not in primary care. The idea is to pick up small signs – such as unscheduled admissions to hospital, hyperkalemia or a fall – and then scrutinise practice records for any mistakes made.

The NHS Institute says it is capable of picking up 70 to 80% of adverse events in patient records and would provide figures on how often mistakes were being made in individual practices.

PCTs are also working on local schemes to improve patient safety.

NHS Hammersmith and Fulham has introduced indicators in its QOF-plus incentive scheme to improve incident reporting. NHS Hull says it is tightening up the reporting of incidents at its anticoagulation service, after discovering GPs were not reporting issues with admissions and discharge.

NHS Somerset is introducing a pilot programme where practices will receive funding to sign up to a quality and safety framework and a clinical audit programme. Practices will be required to identify vulnerable patients, ensure continuity of care and have formal discussions about drug errors and significant events in practices.

Dr Berge Balian, a GP in Crewkerne and a lead on the scheme at Somerset LMC, dismisses suggests of a data ‘black hole' but says the scheme could address areas were potential gaps.

‘It will act as a learning tool to inform the PCT about the sorts of drug errors that might be happening and what can done to prevent them. Most of them will be minor, but they might have the potential to become major in the future,' he explains.

But while local clinically-led schemes are largely welcomed, the prospect of imposed mandatory national reporting has alarmed GPs.

The new health and social care regulator – the Care Quality Commission – says it is developing a notification system for patient safety incidents with the NPSA and says statutory notifications of patient safety incidence will be ‘important evidence' for identifying bad GPs.

Professor Tony Avery, a GP in Beeston, Nottingham, and head of primary care at the University of Nottingham, said there is justification for mandatory reporting of serious events, but not for all patient safety incidents.

‘We are working towards a blame culture, rather than trying to build a safety culture.

‘GPs are being criticised for not reporting to the NPSA, yet as a GP myself I have hardly seen anything on this. I would strongly suggest that they try and improve reporting to voluntary system before pushing ahead with mandatory reporting.

I don't think we are the problem,' he says.

Dr Balian echoes this view: ‘If they want to report every minor incident in primary care, then the amount of time it will take to record that will be disproportionate to the benefit.

‘If someone is prescribed 36 tablets when they should have had 28, it is not a significant incident, whereas someone being sent out on warfarin and not being checked for 10 days is.'

GP patient safety reporting, in numbers

94% have reporting systems in place
34% have never reported an incident
32% routinely report incidents to PCTs
4% routinely report incidents to the NPSA
0.2% proportion of incidents reported by GPs to the NPSA
Sources: National Audit Office 2007, Improving quality and safety; NPSA 2009, Reporting and Learning System data

What errors commonly occur in general practice?

508 Medication
258 Documentation, including records or identification
239 Consent, communication, confidentiality
185 Access, admissions, transfer, discharge (including missing patients)
146 Patient accident
146 Treatment, procedure
135 Clinical assessment, including diagnosis, scans tests or assessments
102 Other
69 Implementation of care and ongoing monitoring/review

Source: NPSA 2009, Reporting and Learning System data, February 2009


What is a patient safety incident?

Any unintended or unexpected incident which could or did lead to harm for one or more patients receiving NHS care.

How do GPs currently report patient safety incidents?

Practices receive QOF points by doing a minimum of 12 significant event reviews in the past three years. These include serious events such as deaths on the practice premises, suicides or medication errors. GPs can also submit anonymous reports of patient safety incidents voluntarily via the NPSA website.

Does reporting need to improve?

MPs, the NPSA and academic experts say it does, as GPs report a tiny percentage of incidents despite conducting the majority of patient facing work in the NHS. Pulse has discovered the Department of Health is looking at mandatory reporting as an option for improving reporting rates.

How would mandatory reporting work?

This has yet to be decided by the DH, but possibly through the Care Quality Commission's registration and monitoring processes. The CQC says it is developing a notification system for patient safety incidents with the NPSA and expects making reporting a statutory requirement for all NHS providers, including GPs.

What other options are there?

The NHS Institute is working on a ‘global trigger tool' that could be used within practices to identify vulnerable patients and spot problems. This would enable GPs to track where problems arise, put them right and track them for improvement.

GPs are good at reporting serious incidents but not those with the potential to cause harm in the longer term GPs are good at reporting serious incidents but not those with the potential to cause harm in the longer term GP patient safety reporting in numbers

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