Patient safety in primary care

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Dr Nikita Kanani, NHS England and NHS Improvement’s Medical Director of Primary Care, describes the changes that will underpin safety improvement in primary care.

Primary care is the first point of contact for most patients seeking healthcare: it saw 307 million patients in the year ending 31 January 2019. It encompasses 7,500 practices, 11,500 pharmacies, 7,000 optometrists and 8,500 dentists. On average a GP has 42 patient contacts a day, a number that increases year on year. NHS dentists saw 22.1 million adults and 6.9 million children in the 24 months to July 2018.

High quality patient care at every contact is the aim of the primary care team. Work led by the University of Nottingham’s Division of Primary Care has found that the vast majority of people receive safe care. However, reports from around the world indicate that errors occur in 2% to 3% of primary care encounters and one in 25 of those involve serious harm to a patient. The Nottingham-led study identifies the most common problems are difficulties making the right diagnosis, delays in referring patients to hospitals and prescribing errors.

New ways of working

The NHS Long Term Plan describes the development of new ways of working in primary and community care that can increase the focus on safety. The development of integrated care pathways with patients moving seamlessly between primary, community and secondary care services is an opportunity for local systems to develop sensitive clinical governance with clear lines of accountability and safer care. New ways of working for healthcare professionals offer further opportunities. As an example, ‘extensivists’ — GPs or physicians working primarily in the community but able to follow their patients into hospital  reduce admissions and length of stay. Another is the Digital Minor Illness Referral Service which directs appropriate patients to community pharmacies instead of GPs or A&E. 

Dental work historically done in secondary care, such as minor oral surgery, is increasingly being commissioned in a primary and community care setting. As this develops we will need to apply secondary care safety initiatives to this new setting.  

The new primary care networks (PCNs) bring the opportunity to promote a safety culture and focus on continuous quality improvement and patient safety in primary care. The role of the PCN clinical director will be developed though leadership programmes to ensure they have the expertise to facilitate this. Once PCNs are established there will be potential to support the new safety initiatives signalled in this strategy, and indeed establish new initiatives designed with the sector. There is also significant potential for PCNs to learn from each other and to establish new ways of sharing data which could shine a light on areas for improvement across primary, community and secondary care.

Insight

Only a tiny fraction of the two million patient safety incidents reported to the NRLS come from primary care. By making it easier to access reporting systems and by providing a more responsive and interactive reporting experience, the replacement for the NRLS (see later) will support primary care practitioners to use digital incident management functionality.

We know there are issues relating to the dissemination and implementation of Patient Safety Alerts in primary care. We will work with PCNs to explore how they can engage primary care providers in alert implementation. The National Patient Safety Alerting Committee (NaPSAC, see later) will also have a role in ensuring primary care receives alerts and takes identified actions. 

The medical examiner system (see later) is due to be rolled out for all deaths in primary care from March 2021 and will provide an additional structure for insight.

Improvement

Patient safety improvement work and engagement with primary care has been variable across the national Patient Safety Collaborative (PSC) programme, with most work focusing on the acute setting. We must now translate the most appropriate secondary care safety initiatives into primary care, adopting and spreading evidence-based interventions or testing those that lack evidence. 

The General Practice Development Programme seeks to spread innovation and build capacity for improvement through funding, training and coaching across 10 high impact actions, including by developing quality improvement expertise. This initiative is an opportunity to spread learning, safety actions and frameworks.

Medicines safety is a key area for primary care safety. The Medicines Safety Improvement Programme (see later) will support medicines safety across systems. The system-wide medicines safety assurance model is being developed in response to the WHO global patient safety challenge. It seeks to provide organisations with a self-assessment assurance framework to reduce the risk of harm by supporting local best practice through a whole-system approach to medicines harm reduction. PINCER, a pharmacist-led intervention for reducing errors in primary care prescribing, is being implemented through Academic Health Science Networks.

Digital

Digital strategies offer several mechanisms to address issues that contribute to patient safety in primary care; better administration to reduce delays in referrals; developing more effective ways of managing patients with multimorbidity and improving continuity of care; better communication between healthcare professionals and patients, and between primary and secondary care. Integration and connection of GPs and community pharmacies through electronic prescribing will reduce the risks of harm from medication errors, particularly as increasingly complex care is delivered in the community and prescribing is managed by more than one team. PCNs and ICSs also offer the opportunity for the summary care record to be accessed digitally across primary care providers. Our aim will be to deliver digital access that improves safety and reduces incidents such as those associated with drug interactions.  

Multiple IT system designs are in place to support patient safety; for example, systems that flag adverse drug interactions or promote safe prescribing associated with a patient’s medical history. Despite these, errors occur. Better design could make these IT systems more effective. 

The GP IT Futures Digital Care Services Framework will embed patient safety architecture in primary medical care systems and is intrinsically linked with the 2019 to 2021 GP IT operating model (to be published shortly). The operating model will provide the assurances and framework for digital enablers to be embedded in general practice and CCGs, with details of the infrastructure needed to ensure implementation of the digital strategy in the NHS Long Term Plan for primary care. The ‘keeping general practice safe’ component of the operating model outlines the requirements for digital changes, such as video consultations and patient access to medical records, to be delivered safely and securely. New digital technology such as artificial intelligence will help identify patients whose medical data shows worrying trends.


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