How safe are patients in primary care?

Improving patient safety is one of the key aims of the government’s NHS Next Stage Review.

Until now, most of the focus has been on the acute sector where untoward incidents are generally reported and the outcome of any safety failings are well documented – and often accompanied by media coverage. But what about primary care?

‘The spotlight has been on the acute sector,’ admits Ann Close, national clinical adviser for the Care Quality Commission – the successor to the Healthcare Commission, which officially began its tenure earlier this month.

‘There probably has not been quite as much focus on primary care. But we are getting right to it and we are trying to build up a fuller picture,’ she said.

Such efforts would appear to be both welcome and necessary.

Anne Duffy, chief executive officer of the Community and District Nursing Association, said that based on her own data observations she believed that an analysis of Healthcare Commission reports would reveal an increase in the number of drug errors and other mishaps involving community nurses over the last four to five years.

She described community nurses as being ‘vulnerable’ on patient safety issues, explaining that while technological developments had allowed more advanced care in the community, they had inevitably increased the margin for clinical error within these settings.

As examples, she cited long-term care developments such as community nurses increasingly administering blood transfusions in a patient’s own home and being required to operate equipment such as hoists that enabled patients with disabilities to live in the community.

For shorter-term patients, she pointed out that the move towards earlier hospital discharge was increasing the burden on community nursing in terms of caseload numbers and high-risk care.

‘It all comes down to the pressure of time and how stretched they are. If you have high patient numbers and less staff there are going to be short-cuts and accidents. It is up to individual trusts to carry out risk assessment,’ said Ms Duffy.

Moreover, when high-risk situations arose, she highlighted the particular difficulties facing lone workers. A nurse in an acute setting could call on acolleagues for advice and support, while a nurse working on their own in the community may have to make life-altering decisions under pressure and alone, she said.

The situation in some general practice settings may be even more problematic. Lynn Young, RCN primary health care adviser, said that practice nursing was not currently as well regulated as community nursing.

‘In community nursing you are part of the NHS, there is a nursing hierarchy and the infrastructure to support provision of safe practice,’ she said. ‘There is nurse leadership, appraisal, monitoring and peer review with access to a training department and clinical leadership.’

But she added: ‘I get worried about the lone nurse working in a small practice. It is fine in well-developed practices but I have concerns about new practice nurses going into practices where there are no senior PNs to give support. PCTs may employ a practice nurse lead but this is not mandatory.’

Stakeholders therefore suggest there is cause for concern – but how serious is the situation?

If one takes the latest National Patient Safety Agency figures at face value, the answer would be ‘not very’. Between October 2007 and September 2008, there were 268,997 patient safety incidents across all healthcare settings in the NHS, of which only 1,998 occurred in general practice. This comprises just 0.7% of all reported patient safety incidents.

However, a legitimate question might be whether this is a true reflection of practice or a symptom of insufficient reporting.

Suzette Woodward, the NPSA’s nursing lead for patient safety and director of implementation of the Patient Safety First campaign, said variation in reporting of patient safety incidents varied vastly, with higher reporting from community nurses and mental health staff than clinicians in general practice settings.

More accurate monitoring and measurement of the true situation was needed, she suggested.

‘More needs to be done to understand the actual problem rather than the anecdotal one,’ she told Nursing Times.

‘The risks appear to be in relation to timely access from primary care to secondary care, with the potential for lost referrals, the potential for lost results, prescribing errors and the potential for misdiagnosis,’ she said.

In addition, she would like more PCTs sign up to the Patient Safety First campaign – launched by a group of NHS clinicians in June 2008 and sponsored by the NPSA, the Health Foundation and the NHS Institute for Innovation and Improvement.

So far only half of all PCTs have signed up to the campaign’s aims – the central one being ‘to make the safety of patients everyone’s highest priority’ – compared with 87% of acute trusts.

Dr Robert Varnam, a GP working in the Safer Care team at the NHS Institute for Innovation and Improvement, acknowledged that relatively little research had been carried out on patient safety in primary care. But he said this would change.

As part of Patient Safety First, Dr Varnam said the NHS institution was developing ‘Global Trigger Tools’ for primary care – a case note review tool that enables clinicians to understand the main causes of harm in their setting – which would provide a set of patient safety risk indicators.

The institute is not alone in its efforts – there appears to be a real impetus to make primary and community care safer, and find demonstrable ways of measuring risk.

Since last summer, when Lord Darzi set his NHS Next Stage Review into motion, action has been taken to ensure measures and checks include all aspects of health care, including those areas that have traditionally been hidden – the lone community worker administering care behind closed doors and the practice nurse working in relative isolation.

Some of the changes will build on existing protocols. PCT providers, for example, already have a number of governance processes in situ and recruitment checks – to ensure that nurses are registered with the NMC and fit for practice – are mandatory for all nurses.

Audits are also already in place – some nationally and some locally to check policies against guidelines. But Ms Close said that as the CQC was tasked to look at safety across health and social care boundaries, even more would be done to ensure an equal focus of attention on the acute and primary sectors.

Indeed, one of the commission’s first statements said: ‘Until now, hygiene inspections have targeted predominantly the acute sector, where more infections tend to occur’ and went on to pledge in future to ‘pay particular attention in monitoring and inspecting non-acute services’.

In addition, the CQC’s new NHS registration system applies to PCTs and mental health care trusts, ambulance trusts and Blood and Transplant, as well as acute trusts.

By April 2011, the commission will begin registering GPs and plans to introduce a risk profiling system to help build a comprehensive picture of the quality of general practice.

While many processes are similar to those already used in acute care, the Department of Health is also exploring safety solutions specific to the primary care setting.

The NPSA’s National Reporting and Learning System, for example, which captures all patient safety incidents reported from NHS organisations in England and Wales, is set to include specific analysis of non-acute settings.

A DH spokesperson said: ‘Currently data received into the RLS is analysed regularly by the NPSA.

‘We are currently refining our systems to ensure that a sample of incidents are looked at on a monthly basis. This will include all deaths and examples of severe harm plus a sample of lower-grade harms.

‘We intend to undertake analysis in the following settings – community hospitals; community nursing; general medical practice; general dental practice and community pharmacy,’ he added.

Additionally, existing NPSA guidance, which on the face of it appears to be aimed at the acute sector, will become relevant to primary care as more complex therapies are undertaken in this area.

An example of where this has already happened is the Rapid Response Report on oral chemotherapy, which came about due to more chemotherapy being administered in the community.

However, the Department of Health acknowledges that how successful the transition of such guidance is will only become apparent with experience.

‘Different models of employment and contracting in primary care do pose specific challenges in the implementation of national guidance, which are different to those encountered in the acute sector,’ a the spokesman said.

‘As a result the NPSA is working closely with royal colleges, other professional bodies, organisations and patients to ensure that primary care is as safe as possible for patients,’ he added.

Additionally, Dr Bruce Warner, head of primary care at the NPSA, said efforts were being made to make the incident reporting procedure in primary care settings easier for frontline healthcare staff.

‘The NPSA is currently revising the electronic form used to report incidents from general practice to make it more relevant, as we believe this is an area where reporting could be improved,’ he said.

The drive to improve patient safety systems in primary care will be given a further impetus by government plans to transfer more and more services from the acute sector to the community.

The challenge presented by this transfer of services was documented in Transforming Community Services, published by the Department of Health in January 2009. By October PCT provider services will have to assure themselves and their SHAs that they have the best governance arrangements in place to sustain high quality community services.

These steps have gladdened the RCN’s Ms Young. ‘The drive is to develop far better and far more community services and there are mechanisms coming through to facilitate best practice and to deal with poor practice before it happens,’ she said.

However, she said that a drive for excellent clinical leadership must be at the heart of any policy changes, if improvements were to be realised.

‘We have some very strong community organisations but others one is not entirely satisfied with and there is a dearth of clinical leadership. This applies in acute care as well. In a poor hospital you get poor practice and no system or proper clinical governance – just look at Mid Staffordshire,’ she said.

‘You have a clinical governance framework and that is national but you still get these issues if the clinical leadership is poor. If I could dictate anything I would put more energy into developing clinical leadership,’ she added.

Fortunately, good clinical leadership in non-acute settings has been specifically name-checked in NHS policy documents.

The NPSA’s framework for the NHS – Seven Steps to Patient Safety – lists visible leadership as one of its key steps. A version of Seven Steps is currently being developed for general practice.

Ms Woodward said: ‘The central focus for primary care is the leadership intervention. This promotes the use of tools like the global trigger tool, leadership walk-rounds, getting leaders to demonstrate their visible personal and corporate responsibility for patient safety. It is highly relevant for all primary care areas.’

Action plans appear, therefore, to be under way on a range of fronts to support patient safety in community and general practice settings. These will hopefully lead to nurses in these settings feeling better supported as well as boosting patient confidence in this sector of care.

Baroness Young, chair of the CQC, has described primary care as the one element of the health care system to date with ‘least information for patients and least assurance on the quality of the services’.

What is apparent is that this situation cannot be allowed to continue, not if the government is to remain true to its new quality healthcare agenda and its commitment to the wholescale improvement of NHS services.

* Find out from Suzette Woodward why gudiance is only the first step in ensuring safety, p27

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