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Analysis: Do GPs have the teeth to act as hospital watchdogs?

As the NHS absorbs the implications of the Mid Staffs report, Caroline Price asks how GPs can monitor hospitals if their complaints are not acted upon

The inquiry led by Robert Francis QC into the horror story that was the Mid Staffordshire scandal sent shockwaves through the medical profession as well as the rest of society. Doctors have been criticised for not being ready enough to question the system when things go wrong. Mr Francis himself singled out local GPs for only raising ‘substantive’ complaints once the investigation had already been set up.

And with GPs now in the commissioning driving seat, the onus appears to increasingly be on general practice to stop the next Mid Staffs before it happens. But are GPs really in a position to police quality across the wider NHS?

A Pulse survey of 343 GPs suggests even when the profession does raise concerns about the quality or safety of hospital care, they are too often ignored. Some 40% of the GPs who responded had raised concerns about care with their local hospital in the past 12 months alone.

But of those who had raised concerns, almost a third (31%) said their information was not listened to or, where appropriate, acted on, while a similar number (30%) said they do not know if their complaint was acted upon.

Pie GP complaints

Among the issues the GPs reported were medication delays, discharge errors and high rates of readmissions after premature discharge.

Patient ‘shouted at’
One GP from Birmingham, who says their patient was shouted at and then refused admission to A&E at their local foundation trust, despite needing urgent care, says: ‘It turned out the patient was in terminal renal failure and our registrar had every right to send him in.

‘The patient eventually went to another hospital and ended up in intensive care.

‘The consultant sent a letter back saying it would be investigated in the hospital and it should not happen again but we have heard nothing since – it was just to protect themselves.’

GP testimonies

‘Sometimes you don’t get [discharge information] at all, sometimes after a few weeks. And not enough information is given, especially from A&E. We learned that A&E discharges were done by receptionists on night duties.

‘The main [problem in the past 12 months] was the quality of discharge letters from A&E, which we have raised officially to no satisfactory outcome.’
GP from north-west England

‘The registrar on call sent the patient away – he shouted at him. It turned out the patient was in terminal renal failure and our registrar had every right to send him in. The patient eventually went to another hospital and ended up in intensive care.’
GP in Birmingham

‘[Complaints] are just not responded to, or I’m told I’ll get a response within a certain time and then it is either half-baked or doesn’t really answer the query.’
GP from north-west London

Dr Mary Hawking, who recently retired after over 30 years as a GP in Bedfordshire, said she had raised many concerns stemming from the poor quality of discharge from hospitals.

She says: ‘The problem is, you send off a complaint and it gets completely lost. I’ve tried various tactics, sending it to the chief executive [of the trust], to the PCT, trying to get the official channels involved and nothing at all happens.’

A duty of candour
Problems of this kind are not new. Last year, Pulse revealed a similar high level of concern among GPs about standards of care at local hospitals, with one GP in seven claiming that one or more of the departments at their local hospital was ‘dangerously substandard’.

But the Francis Inquiry has concentrated minds on the role of GPs in ensuring quality of hospital care. One of its central recommendations was that GPs should play an active role in monitoring hospital care and have systems to identify ‘patterns of concern’.

At the time of the publication of the report, Prime Minister David Cameron backed the recommendation, calling for GPs to be ‘more enquiring’ about what happens to their patients in hospital.

Ministers have said that they want all providers to have a ‘duty of candour’ over their mistakes but have not clarified how this will apply to practices.

The Government is introducing chief inspectors for hospitals and care homes – and considering the equivalent for primary care – but it is not clear how this will prevent the ‘next Mid Staffs’ that is predicted by some commentators.

Dr Grant Ingrams, a GP in Coventry, says: ‘There is still a question over what duty is going to be placed on GPs. If it is to notify whoever we believe is the appropriate person each and every time we find a problem and to actively monitor patients when they are in hospital, we can’t do it. We don’t have the resources.’

A spokesperson for NHS England says it ‘strongly supports’ the recommendation that GPs should take a greater role in monitoring the quality of their patients’ hospital care.

She says: ‘The introduction of clinical commissioning groups provides an unprecedented opportunity for GPs and GP practices to work together more collaboratively and systematically in sharing intelligence about quality of care for their patients.’

RCGP chair Professor Clare Gerada says there must be better systems for GPs to ‘feed back patient concerns about hospital care’, but she draws the line at the profession having formal responsibility for what goes on in secondary care.

She says: ‘Patients and their GPs need to be confident that they will receive good and safe care in hospital. [But] we do need to be clear about where the boundaries lie in terms of the GP’s role here.

‘GPs should not ultimately be responsible for the standards of care in hospitals but it is important that any concerns GPs have are raised, to help hospitals improve patient care.’

The GPC agrees, saying CCGs should assume the responsibility for collecting data and making it easier for practices to raise concerns.

Dr Chaand Nagpaul, GPC negotiator, says: ‘Individual practices should certainly be able to relay feedback, but we need to be realistic about the extent to which GP practices can provide information about hospitals – we can’t assume GPs hold all the keys to assessing hospital performance.

‘I think this a role for CCGs – they should be facilitating the processes to allow practices to raise concerns as part of their commissioning function.

‘In my area we have a “service alert” form. The GP practice sends that to the CCG so even for a single event, if many practices notice the same problem it helps to identify trends and take action on service issues.’

CCGs take action
There are signs that CCGs are getting the message. The CCGs that have taken over the Staffordshire area say they are looking closely at how they can monitor their providers more closely.

Andrew Donald, chief officer for Stafford and Surrounds and Cannock Chase CCGs, says: ‘We’re Mid Staffs, we have to be exemplars for the new system.’

He adds: ‘We have a fairly structured way of getting feedback. There’s an information sheet that we ask people to complete and send through, and if there’s a problem with an acute trust there’s a GP advice line that directs into Mid Staffs. This has been well established for three years now.

‘We’re also asking GPs to get their patients to keep diaries to write about their experiences as they go through the system. We have had discussions on Francis – about GPs not abdicating responsibility for their patients once they have left the surgery. It’s about saying, “how do we follow patients through?”.

‘The idea of having patient diaries could be a good way of doing that – creating opportunities for patients to give feedback as they’re going through the process.’

Dr Michael Dixon, interim president of NHS Clinical Commissioners, says CCGs will be ‘morally obliged’ to act on the concerns of GPs.

He adds: ‘I think CCGs will want to put resource towards this, because this is part of improving and redesigning services. This will not only involve totting up the problems but also the solutions as well – which probably pay for the job in terms of saving resources for the future.

‘I think there may be short-term benefits – if patients receive atrocious care I can see CCGs not paying the bill, putting a service on hold or on probation.

‘What we’re stymied by at the moment is the complete paralysis of the past, where if a patient had a bad deal, all the payments had been made in the past through payment by results. This is exactly the sort of re-engineering that CCGs are going to need to do; if you get
a shoddy service, you don’t pay for it.’

One complicating factor for GPs in this new era of openness could be the CCGs themselves, however. Last month a Pulse investigation revealed that hundreds of GPs have been obliged to sign up to ‘gagging clauses’ under their CCG constitutions.

While GPs have historically been free to speak publicly and to the media about their local NHS, from 1 April more than 200 practices across five CCGs – NHS Newbury and District, NHS Sutton, NHS Dorset, NHS Thurrock and NHS Windsor, Ascot and Maidenhead – have been prevented from making any ‘public statement’ about CCG matters without prior written approval. Members of the governing bodies of five further CCGs are bound by similar clauses.

Such clauses do not remove GPs’ ability to blow the whistle on specific concerns about patient safety, and CCG leaders have defended the move, insisting it is simply to ensure a ‘consistent view’ on local services.

But critics have attacked the clauses as unacceptable, with the GPC warning that ‘in the post-Francis world, practices should not be restrained or put under any pressure with regards to not voicing concerns’.

A key plank of the reforms was to shift power and influence into GPs’ hands, but it seems GPs will need to keep fighting on all fronts to make sure their voices are heard.

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