Louise Gorman:

Hello, and welcome to Voices for Safety, a podcast from the NIHR Greater Manchester Patient Safety Research Collaboration, or GM PSRC. I’m your host, Louise Gorman, the Public and Community Involvement and Engagement Manager for GM PSRC. I’m very excited to introduce to you our brand-new podcast, where we’ll explore the latest issues and breakthroughs in patient safety research.

Today’s episode is extra special. Besides being our very first episode, kicking off our journey together, it also marks this year’s World Patient Safety Day, celebrated on September 17th, 2024.

World Patient Safety Day is an initiative established by the World Health Organization to raise awareness and emphasise the importance of patient safety globally. But what exactly is patient safety, and why does it matter?

To help us unpack this critical area of health, I’ll be joined today by Professor Darren Ashcroft, Director of GM PSRC, and Neil Walbran, Chief Executive Officer of Healthwatch Manchester. Together, we’ll explore what patient safety truly means and why it should be a priority for everyone.

Then, later in the show, we’ll dive into this year’s World Patient Safety Day theme: improving diagnosis for patient safety. I’ll be joined by Tom Blakeman, a GP and Professor of Primary Care at the University of Manchester, Umesh Chauhan, a Professor of Primary Care and GP Partner from the University of Central Lancashire, and Tony Avery, Professor of Primary Care, a GP, and also the National Clinical Director for Prescribing from the University of Nottingham.

Anyway, enough from me. Let’s get on with the show!

[Music]

So, Darren and Neil, welcome to Voices for Safety. It’s really great to have you here. So, what is patient safety?

Darren Ashcroft:

From my perspective, patient safety is really a discipline where we look to identify where risks, errors, and harm occur to patients. The research arm of that focuses on how we address those issues.

Neil Walbran:

From our perspective, as Healthwatch, it’s about members of the public having the right to feel safe entering any health and care system and knowing that their safety is a priority for the people treating and caring for them.

Louise Gorman:

Is patient safety a local issue?

Darren Ashcroft:

It’s very much a global issue. But within the NHS, we regularly see news reports of problems that occur within our health and care systems. We’ve conducted research that starts to identify and quantify how often some of these errors occur, so we have a good measure of how often adverse or preventable events happen within our health system. A lot of our research focuses on how we address some of those problems, co-develop interventions with patients and practitioners, and try to get them embedded into our NHS to improve safety overall for everyone.

The WHO have established a special interest group around safety, and they’ve had three international campaigns to date. The most recent one was around improving medication safety and reducing harm from medicines.

As part of the global initiatives, governments in different countries are often asked to challenge and test the systems they operate. For instance, in the UK, we brought together groups of experts to consider the recommendations from the WHO, which led to some recommendations that were implemented. In fact, one of our interventions from the Greater Manchester Patient Safety Research Collaboration was rolled out nationally to try and reduce harm from medicines in primary care, and we’re in the middle of evaluating what the impact of that intervention is at the moment.

Louise Gorman:

So, locally then, to what extent is patient safety an issue for our NHS?

Neil Walbran:

I think it’s a massive issue. It’s an ongoing issue, and it always will be. Whether you’re somebody who requires medicines use review from your pharmacy because you’re being prescribed 35 different medications and experiencing contraindications, or somebody in full-time care who needs turning and your pressure sores are treated, to someone who is unable to understand the letter they’ve received from the hospital and doesn’t know where to go for their appointment. The more you think about it, the more it unravels. Patient safety runs right through—it’s the golden thread that runs through all our health and care services.

When a patient goes into hospital, when we… Any of us are a patient at any time in our lives, when we go into hospital, we become more vulnerable. Now, if you add to that somebody with a protected characteristic, say someone with a learning disability who goes into hospital, they’re even more vulnerable in that situation. Those things have to be taken into account.

Louise Gorman:

So, who are the key groups we want to highlight as being important for improving patient safety, both on the health service side and on the public side?

Darren Ashcroft:

I personally think it’s everybody’s business, really, around safety. Clearly, healthcare professionals—doctors, nurses, pharmacists, and other allied health professionals—have an important role because they’re often on the front-line delivering health and care services. But patients themselves, when they’re actively engaged in their own care, can be excellent advocates for improving safety by identifying when things go wrong or reporting when things just don’t feel right in a particular situation.

Within healthcare organisations, I think it covers all levels. You know, the leaders and managers have responsibilities for the policies and procedures set around safety and for monitoring how effective those are. But beyond that, we’ve got regulators responsible for monitoring safety and protecting public safety, and educators, too, who educate the workforce that will work in our health and care services in the future. So, I think it really is everyone’s business.

Louise Gorman:

Absolutely.

Neil Walbran:

Yeah. Definitely. I mean, it’s the people that work in the healthcare system that need the ability—the freedom—to speak up. Freedom to Speak Up Guardians are an example of a step towards creating better patient safety. But out there in the real world, outside health and care, it’s the citizens who speak up, who decide, “This isn’t good enough,” whether they’re from those communities or just as a family. fa springs to mind—that’s fairly recent now, and it’s being rolled out across all our hospitals. That’s because those parents decided that simply wasn’t good enough the way their daughter was treated and how she died. So, yes, I would say from the citizens’ perspective, it’s those champions who speak up.

Louise Gorman:

So, Neil, I think this is a really good point. Can you tell us a little bit about what Healthwatch Manchester actually is?

Neil Walbran:

Okay, well, Healthwatch was set up in 2013 through national legislation brought about by the Health and Social Care Act in 2012. In each local authority area in England, there is a Healthwatch by law. We are independent, not-for-profit organisations with a board of directors or trustees and a small staff team, usually. It’s our job to inform and signpost people to health and care services, to speak up for people, and to direct them to their rights as citizens, patients, and users of health and care services.

We also collect the views, opinions, and experiences of people around health and care, and use those in our reviews and reports to influence health and care services and improve them by having conversations with the planners and commissioners of those services.

So, we are Healthwatch Manchester. We are also part of the Greater Manchester Healthwatch network, which includes all ten local Healthwatch organisations in Greater Manchester. We meet regularly, and we have people in post to support us, commissioned through the Greater Manchester Integrated Care Board (ICB).

What we do locally is inform and signpost people to health and care services. This could be anyone phoning or emailing us, asking, “Where can I get an NHS dentist?”—which happens almost every day at the moment and has been for a few years—or someone asking, “Where can I make a complaint? I feel like I’ve been treated very badly.” We also do outreach, engaging with people to find out their views, experiences, and opinions of health and care services. If we see anything concerning, we act on that by doing an interview or a review of that service.

I can give you an example of that recently, if you like.

Louise Gorman:

Yes, please.

Neil Walbran:

A woman was on her way to work when somebody collapsed at the bus stop. They dialled 999, and the ambulance service told them to go to a defibrillator site. They went there, but there was no defibrillator. They called up the ambulance website and tried to find another defibrillator, but there wasn’t one there either. After 15 minutes, they returned to the person who, luckily, was being resuscitated and survived. But they came to Healthwatch in an absolute state, saying this had happened.

So, we’ve just completed our review of defibrillator sites—are they there? They say they are there, but are they actually there? It’s not looking good. 40% of the time, they’re not there, nobody knows anything about them, or they’re not in a condition to be used. We’re taking that report nationally. There doesn’t appear to be any regulation around the information on defibrillators. Anyone can pick one up, but if they decide not to have it anymore, there’s no obligation on them to inform anyone or say, “We’re not using this defibrillator anymore, we’re not providing it”.

We don’t think this is good enough. We’re going to call for regulation around this information so that this never happens again. It’s not like, “Oh, try again next time.” There is no next time in this situation—someone will die.

Louise Gorman:

So, helping to identify those areas where patient safety errors or unsafe practice can occur.

Neil Walbran:

Yes.

Louise Gorman:

As well as helping to find out exactly what’s going on in those areas and trying to figure it out.

Neil Walbran:

And learning from them.

Louise Gorman:

And learning from them, exactly. And, I suppose, sharing that learning as well.

That links nicely to Darren. Would you be able to explain to us what the Patient Safety Research Collaborations (PSRCs) are?

Darren Ashcroft:

The Patient Safety Research Collaborations, or PSRCs for short, are an initiative funded by our national research funding scheme, the National Institute for Health and Care Research (NIHR). They’ve awarded just over £25 million over a five-year period and funded six PSRCs to conduct research to address patient safety problems and, in particular, to start reducing inequalities in safety. That’s the main focus of the PSRCs.

Within Greater Manchester, we’re a collaboration that brings together safety scientists across the Universities of Manchester, Nottingham, and Leicester to tackle some of these problems. We have four main research themes. One is around improving medication safety—medication is the most common intervention used in healthcare, and it does a lot of good, but from time to time, medicines can also cause problems. We’re trying to address some of that hazardous prescribing or misalignment of medicines to the wrong patient or at the wrong time.

We have another theme focused on developing safer health and care systems. Many innovations come into our health service, and while they’re intended to bring a lot of benefits, sometimes there are unintended consequences. It’s important that we evaluate these systems and understand not only the effects but also some of the adverse consequences so we can develop better systems going forward.

We have a theme around enhancing cultures of safety. Often, when we look at major incidents within healthcare, the underlying culture within those organisations is flagged as a key factor in why things go wrong. So, we’ve got a team focused specifically on trying to understand and improve organisational culture.

And finally, we have a theme focused on mental health, particularly around preventing self-harm and suicide. Unfortunately, too many people die through suicide, and rates of self-harm have increased in recent years, especially in particular groups of patients. We’re developing initiatives to try to address some of these issues and reduce the inequalities that occur within our society as well.

Louise Gorman:

And how does Greater Manchester PSRC relate to other PSRCs in England?

Darren Ashcroft:

We were very fortunate that, through the national funding body, we were awarded a project fund that allowed us to create a network. So, we have a network called SafetyNet that brings the six PSRCs together around some common themes. We take responsibility for different areas of those activities, and we’ve established a number of working groups across that network, allowing us to bring expertise from across the country together around key areas of work.

Louise Gorman:

How do you see our own PSRC in Greater Manchester working with organisations such as Healthwatch to improve patient safety?

Darren Ashcroft:

It’s hugely important, and across our own PSRC—and likewise for the other PSRCs—public involvement, along with the involvement of charities and other organisations, feeds in at various levels across the infrastructure. As Neil has highlighted, we’re really fortunate that he is a member of our Strategic Advisory Group, along with many other organisations. That plays a key role because they are seeing lots of problems in the system, which allows us to hear about their experiences and think about what some of our research priorities should be going forward.

Within our governance board, we have patient and public representation, so they’re holding us to account in terms of what we say we will do and whether we meet those goals in due course, which is appropriate. But also, when we get down into our themes and individual projects, all of those projects have public involvement anchored into them as well. It’s really important because, if our focus is on co-developing interventions, we need to work closely with patients and practitioners who are going to use these interventions in the future to make sure we’re developing interventions that are likely to be adopted, are sustainable, and have evidence of impact going forward.

Neil Walbran:

Well, it’s great to be able to add the patient and public voice to the mix as well. From my perspective, it’s all about building responsivity into the system in terms of taking that patient voice and making it heard. That’s how I see the role of Healthwatch at the PSRC.

Yes, and how important is research in the whole topic of patient safety?

Darren Ashcroft:

Through research, we can often identify some of those problems and quantify the impact and size of the problem. We can use research to develop solutions to address some of those problems. But also, as I mentioned earlier, many things are rolled out into systems with the intention of doing good, but sometimes there are unintended consequences. So, we can also evaluate some of the innovations that happen in our health and social care systems, making sure they land on the right tracks, deliver what they were hoped to deliver, and, hopefully, result in better care, not worse care.

Louise Gorman:

Thank you, Darren and Neil, for talking to us today about what patient safety means.

This World Patient Safety Day focuses on improving diagnosis, but patient safety incidents and avoidable harm don’t just happen in hospitals. Primary care is often the first point of contact for most patients seeking healthcare. But what do we mean when we say primary care?

Primary care is described as the front door of the NHS. It is made up of around 7,500 practices, 11,500 pharmacies, 7,000 optometrists, and 8,500 dentists. High-quality patient care at every contact is the aim of every healthcare team. There are approximately 340 million consultations in the UK each year in general practice, and on average, a GP has 42 patient contacts a day.

Although the vast majority of these consultations pass without incident, the sheer volume of contacts can significantly increase the likelihood of patient safety incidents occurring. A review by the Health Foundation in 2014 estimates that patient safety incidents may occur in around 2 to 3% of all family practice consultations, and one in 25 of those involves serious harm to the patient. This means that there are several million patients potentially at risk of avoidable harm each year.

A paper published in 2021 by Professor Tony Avery and colleagues concludes that diagnostic error accounts for the most avoidable significant harm seen in primary care. So, I’m utterly thrilled today to welcome Professor Tony Avery, Professor Tom Blakeman, and Professor Umesh Chauhan to the show. All three are general practitioners, amongst their many other roles. Would you like to introduce yourselves?

Tony Avery:

Yeah, hi, I’m Tony Avery, a GP in Nottingham. I’m Professor of Primary Healthcare at the University of Nottingham, and I’m also the National Clinical Director for Prescribing for NHS England.

Louise Gorman:

Welcome, Tony. And Tom?

Tom Blakeman:

Hi, nice to be here this morning. I’m Tom Blakeman, a GP, and I work in Harehills, inner-city Leeds. And I have a transpennine experience in that I’ve been a researcher at the University of Manchester for over 20 years as well.

Louise Gorman:

Wonderful, thank you for joining us. Umesh, it’s lovely to have you here as well.

Umesh Chauhan:

Thank you. So, I’m Umesh Chauhan. I’m a GP in East Lancashire in Brierfield. I’m also Professor of Primary Care at the University of Central Lancashire and the Quality Place-Based Lead for Lancashire and South Cumbria.

Louise Gorman:

Wonderful, well, thank you all for being here this morning. I wondered if you could tell our listeners what diagnosis means and, importantly, what a diagnostic error is.

Tony Avery:

A diagnosis identifies a patient’s health problem and is the key to making sure that people get the treatment they need. Now, in general practice, we don’t always come to a clear diagnosis at the end of one consultation, and it may not be necessary to have a clear diagnosis. But the most important thing is to have a good idea of what is going on for the patient and what you need to do, particularly in order to either identify or exclude a serious illness. So, I think that’s the important thing: having that approach to really thinking about what is going on for the patient and what needs to happen next.

A diagnostic error occurs if you either don’t manage to get the right diagnosis or the right idea of where you need to be going with things, and fail to do that in a timely way. This can then result in an incorrect diagnosis or approach, which can waste time and potentially be harmful, delaying or actually missing the diagnosis. The key risk is that what is really causing the problem for the patient doesn’t get picked up, and a patient may be harmed as a result. A particular example is cancer, one of the areas where we want to be identifying cancers as soon as possible. Although we’re doing much better than we were, there can still be delays in diagnosis, which obviously has an impact on patients.

I think it’s really important to get the right balance, and that’s where organisations like NICE (National Institute for Health and Care Excellence) and the National Screening Committee are helpful in advising us on the sorts of tests and approaches that are useful for picking things up. The approach we have to the two-week wait system for picking up cancers, I think, is helpful. You’ve got a clear set of criteria, and if people fit the criteria, we can refer them for further investigations.

The challenge, I think, is with people who don’t quite fit those criteria. There’s a risk they slip through the net or end up on a prolonged waiting list to be seen. I think it’s with that group that you’ve got to be particularly on your toes. As a GP, you might think, “I know they don’t quite fit the criteria, but I’m still worried about this person.” It’s making sure that, in general practice, we talk about safety netting, making sure those people don’t just drop off and don’t get reviewed.

Making sure you have some systems in place to follow up with that patient—not just keep following up, following up, following up and doing nothing, which can waste weeks and sometimes months—but to get to a point where you say, “Hold on, we’re going to bail out on this; we need to get another view on this.”

Louise Gorman:

Absolutely. So, the complexity of the patient and what they’re presenting with—the signs and symptoms—are very difficult for you in general practice to make decisions, I suppose, quickly and cleanly. Particularly when you have, from the initial statistics, 340 million consultations in general practice alone in the UK, it is absolutely staggering to me. An average of 42 patient contacts a day for GPs makes it clear how challenging that is on so many levels, especially when you have that complexity for each individual that you’re seeing as well.

Tony Avery:

It is phenomenal what we manage as GPs from just what you have said. That was one of the things that came out from our major study on avoidable harm in Primary Care. To reassure people, when we looked at over 100,000 consultations across the country, we found that 97%, 97 out of 100 consultations were done well. We didn’t identify any significant patient safety issues. It was only in the 3%, but of course, when you multiply that by all the consultations, we did detect problems. Often, it was where GPs are having to deal, as you say, with highly complex problems presenting with multiple issues at the same time, and in the context of extreme demand. This requires tremendous ability to sift out what’s important and, most importantly, to do the necessary follow-up and safety netting.

Tom Blakeman:

I agree with Tony’s points. In a way, how a diagnosis helps in the ongoing planning of care is crucial. Identifying the problem and how diagnosis helps with that, having systems and care planning in place to see things through, is really important. Going back to the diagnosis, we need to ensure that they are helpful and don’t add to the complexity. How are they useful in planning care for somebody, and how do we minimise noise around making a diagnosis?

New diagnostic entities have come into place over the years. For instance, chronic kidney disease is a relatively new classification, a new diagnosis in the systems of care, which has been around for 22 years—which is nothing in the history of medicine. How we introduce it in a way that’s helpful and helps frame care for people. We need to ensure that it is understandable and doesn’t create extra noise and additional work. That requires careful consideration.

Umesh Chauhan:

I’m just conscious that the terms we’re using at the moment are very medicalised. A person, a patient, will present with a complaint or problem, and what we label it as is a diagnosis—what we think the cause of the complaint or problem is. In the context of working with people with learning disabilities, issues such as diagnostic overshadowing can arise. A person may present with something we don’t fully understand, and we put a label on it, saying this is the problem and this is how we’re going to manage it. This often leads to issues where it causes more harm than good to the person.

 

Inherently, I think it’s important for us to understand where we can avoid harm and where we’re causing more harm than good. Much of our work focuses on avoiding things that can be avoided and not causing unnecessary harm.

Tony Avery:

I think that’s a really good point, Umesh, because one of the biggest dangers, I think, is actually coming too early at a firm diagnosis. Once that’s done, once you’ve stated, “these upper abdominal pain symptoms are due to reflux or acid coming back into the esophagus or gullet”, or another example, it can lead both you and those following you to assume that the symptoms are only due to that issue. You need to ensure that your diagnosis is well formulated and that you keep an open mind as things develop, and thinking “perhaps that wasn’t quite right, perhaps it’s something else”.

Louise Gorman:

I think, for me, the point that Umesh was picking up on well is that how we talk about and define a diagnosis can potentially have consequences for patients, caregivers, practitioners, as well as the health system. It’s not just about the patient; it’s also about how that information is communicated and understood, affecting how you proceed both in medical diagnosis terms and in how the person and their caregivers interpret the information.

Tom Blakeman:

The risk often arises when you treat a working diagnosis established elsewhere in the system, by another GP or in A&E, at base value. Sometimes this can be a problem. It’s those points when you think that when you’ve seen somebody, and there’s something about preparing in advance of consultations, but also when you’re seeing somebody and you’re thinking “this doesn’t quite add up”. Using your clinical acumen and time and listening to somebody. And, so, that’s the moment to slow things down a little bit.

Tony Avery:

The most important thing from our study and experience is the value of rigorous training we have. It takes at least 10 years to train to be a GP, and experience continues to develop beyond that. But, starting out with that thing that we have had reinforced to us so much; starting with listening, really listening to what the person is telling us. Performing an appropriate examination and investigations, formulating an idea of what might be going on without fixating too early on a specific diagnosis, and ensuring appropriate follow-up with the safety netting.

Umesh Chauhan:

Tony and Tom will probably reflect on their training. One of the simple rules that I was taught is that if you’ve seen the person for the third time, or within the system for the same problem, you need to think again because, clearly, you can’t assume that whatever the diagnosis was, was the right diagnosis if the symptoms haven’t gone away. So, there has to be triggers in order to support you to think about this. Part of it is about our training, but also the system. There need to be ways to make you think: have I got the right diagnosis here? Have I gone down the right route? Should I be thinking of something else here?

Tom Blakeman:

In practice, my experience over the last 20 years—being in the same practice for over 20 years—is that uncertainty is inherent in everyday practice. Meeting people, listening, and thinking things through are crucial. I think listening is absolutely the key aspect of care. And with that, when you’re uncertain, having a safe environment to share those uncertainties with colleagues is vital. Corridor conversations, clinical meetings, team meetings, multidisciplinary meetings—you learn from them. You learn from the reception staff, clinical admin, the advanced clinical practitioner in the practice, and the social prescribing link worker, who has an insight into the person. This is where you begin to generate safe practice. This is what I’ve learned in my experience, in how to thrive, and how everybody begins to thrive, in general practice.

Louise Gorman:

Is that heavily relied on having a good culture to work in?

Tom Blakeman:

I think so, that doesn’t just come on its own. It requires active work. It requires leadership to get to that point, and it requires resourcing as well. You have to create spaces for people to meet and actively engage. You have to create a shift. In our practice, we’re trying a shift now (and I don’t think we’ll go back) to 15-minute appointments. There is agreement in the practice that this is the best way for us to begin providing care.

Tony Avery:

One of the key things is actually—we talk about the 10-minute consultation, the 15-minute consultation—it’s having that flexibility as a GP. It’s recognising that for some people coming to see you… So, I saw a gentleman with abdominal pain last Thursday who had what we call an obstruction—his bowels weren’t working. That probably took me about 40 minutes to get sorted, right from the point of actually getting him admitted to hospital. But then, we’ll perhaps make up the time with a relatively simple medication query that, on the phone, may take only five minutes.

The key thing is that the 10 or 15-minute consultation is only part of what goes into a typical general practice surgery, and it’s having some flexibility around that.

Tom Blakeman:

There is something about ownership of the space, and the spaces that exist in general practice, and that includes people—patients—having a sense of ownership of the space, and that space being, you know, maybe the consultation itself. And knowing when, as Tony’s example shows, when to speed things up and when to slow thinking down a little bit, and having the flexibility and ownership to do that. Because, there are moments when you really have to slow down and listen, and be listened to—to be understood and to understand—and then there are moments when you really have to speed things up. That’s the beauty of general practice. I mean, it’s amazing, really. You meet so many people, but it’s about creating spaces where you have ownership of the work you’re doing, as a GP, as a patient, or as a carer. As we all experience in our lives, having a sense that this is part of, you know, my everyday life—that I can come to this practice, and I can feel that I can say what I need to say, and begin to, you know, share whatever thoughts or difficulties you’re experiencing as a person.

 

Louise Gorman:

Well, there’s a couple of things going on in my head there. Tom, does that come with training? Does it come with experience? Because I can imagine that’s a very interpersonal skill that you need to have or develop in general practice, which probably feeds into the 8–10 years of training to be a GP.

Tom Blakeman:

Just one immediate thought that comes to mind—and it links back to a patient safety lens—I think there have been various reports over the years, and you referred to the Health Foundation one, I think, that was mentioned earlier. But the Francis Inquiry, the Berwick Report, and how you begin to strengthen systems of care and people ownership within, are really important.

The Berwick Report—there are key points on page two or three of that report. Patient safety issues exist in the system and always will, and NHS staff and patients aren’t to blame. In the vast majority of cases, it’s system issues that need to be strengthened. And then you can take the point: how do you begin to think about strengthening systems of care? Do you look at just significant events and where things have gone wrong, or do you look at people’s everyday work? By understanding those, you begin to say, “well, things made sense at that point, but this is how we can strengthen it?” And by creating spaces where you can reflect on how we went about something that went well, and how we achieved safe care—as well as moments when things didn’t go quite as well—you begin to create an environment where you feel safe to talk about things.

That doesn’t just happen. In our practice, it’s taken 20 years to get to a point where you feel very safe to bring things up, because you’ve built trust. You understand that’s how we frame things, and we’re looking after each other. So, I think patient well-being and staff well-being—staff well-being is absolutely paramount to the success of patient well-being. And I think there’s a recognition of that, and that requires resourcing.

Umesh Chauhan:

I just want to say, I know Tom mentioned chronic kidney disease earlier in our conversation, and that’s a really interesting condition or diagnosis in the sense that, you know, when I look at our register, even two or three years ago, the prevalence—the number of people with chronic disease labelled as having chronic kidney disease—was around 2%. Through quality improvement work, we brought it up to just over 4%. But the biggest challenge we had was actually trying to explain to patients what that means in terms of their life, the complications it can lead to, and how we can try to avoid those.

There are also issues around prescribing non-anti-inflammatories and what that might mean for them, or, when they go into hospital, what that might mean. It’s quite a challenge because it’s a very new condition for people to understand. I think there are lots of challenges around how we communicate that as a condition people understand, especially when largely it’s asymptomatic—you don’t know you have it until it becomes a real problem. Communicating that is a real issue for me.

Tom Blakeman:

Sorry, I mean without getting drawn down into chronic kidney disease, there is something about how to navigate that challenge of how to frame things better and how to place certain diagnoses in clinical context and in the context of people’s lives. There are perhaps better ways to frame things than coming in with a medical term like chronic kidney disease. You may want to frame things more around kidney health, for example, and then begin a conversation that is less frightening and less problematic. It places the issue in the context of maintaining someone’s vascular health, general health, and also safety in medicines.

So, there are perhaps better ways of framing things than the historical approaches, which have created a challenge. When you’re not clear on how to frame it, you might avoid having the conversation in the first place, and avoiding it isn’t a biopsychosocial approach. The medicine really matters. If we talk about medication, it’s a really important part of a biopsychosocial approach to improving people’s lives.

Louise Gorman:

How do we begin to overcome that challenge? Is it a factor of just more training?

Tom Blakeman:

Two quick responses to that would be: I think multidisciplinary engagement is key in how you think about things. It’s not just a secondary care issue or a primary care issue, or a patient issue. Multidisciplinary, in the sense of having patient voices and expertise in understanding and driving how you might improve talking about things, is fundamental. It’s central. In the history of medicine, it’s relatively early that we’ve fully recognised the importance of people’s voices in the design and strengthening of systems of care.

Louise Gorman:

Alongside that, research carried out by one of our colleagues, Sudeh Cheraghi-Sohi, concluded that estimating diagnostic error is, as we said, challenging for many reasons. But, because we’re a research organisation, how we measure diagnostic error can be very complex. How do you think having good measurement instruments plays into the idea of improving diagnosis?

Tony Avery:

Yeah, having good instruments is helpful, but because of the complexity of it, we’re probably not going to get a perfect instrument. I think, for example, when we did our study of avoidable harm in primary care, I thought, “Well, if the end result was plus or minus 50% of what we found, would that make a lot of difference?” The most important thing, I think, is actually what we have found from it. What are the different types of errors, the different categories of error? Which parts of the care process have the most effect, and most importantly, what are likely to be the most important solutions?

So, while there’s still room for doing more, I think the work that Sudeh has done, and the work we’ve done on our avoidable harm project, and of course work done by others around the country and around the world, has probably given us enough to say we’ve got a pretty good idea of what the problem is. I think focusing our research around the solutions is going to be one of the most important things for us to be doing.

Tom Blakeman:

There’s something about the solutions not being transactional in nature. I mean, there’s a risk that we can be showing on paper that we’re improving care through metrics, achieving incentives for hospitals or primary care to improve processes of care, and that’s important. But it’s also important that the way we go about it is relational, relationship-based, and person-centred, as opposed to just looking good on paper. There’s a real risk that we can seem to be doing the right thing but miss the point in the process.

Tony Avery:

Yes, and in terms of solutions, one of the things we’ve not touched upon so far is the importance of continuity of care. We found that in 14% of the significant harms we identified, there was a problem related to continuity of care. It can cut both ways—it can be a risk that, as a single practitioner, you might go down the wrong route and keep seeing the same person again and again. But, as Umesh made the point about, after seeing the person three times, you need to be thinking again.

Overall, numerous research studies, including systematic reviews, demonstrate a strong association between having continuity of care and better outcomes, including reduced death rates for patients. Of course, we’re in a difficult position for that in general practice, but we do need to be identifying those patients where continuity of care is likely to make a difference. We may not be able to provide it for everyone, but we need to recognise that for some people, particularly those with complex problems, having someone follow through with them makes the most difference. I’d like to make a particular shout-out for that and its importance.

Umesh Chauhan:

At least in my reflection, in terms of what’s happening in primary care at the practice level, what I’m getting good at is coordinating continuity of care. There’s so much information coming in from different healthcare professionals, and what I need to ensure is that the person is getting the right care, at the right time, by the right person. Continuity matters in the context of knowing that if the person isn’t in a position to inform healthcare professionals about where they’re at in terms of their care—and this is really important for vulnerable people, for example, those with dementia or learning disabilities—someone needs to take control of what’s happening to them in some capacity. If it isn’t a carer, then there needs to be a healthcare professional who takes responsibility for coordinating that person’s care across different healthcare systems. More importantly, the focus is on providing care within the person’s home, rather than thinking about primary care as being the place where most care happens. We have so many patients now who are housebound or living in environments that require us to provide care at home. This coordination of care is a key element of how we do that now.

Tom Blakeman:

Yeah, I agree with this. In our practice, we have a housebound team. Recently, I was chatting with a nurse colleague, and we talked about how there’s an aspect of holding people—that you take responsibility for holding people, individually as a practitioner and as a team. In doing so, you begin to understand somebody in their context, identify key issues at that moment, make a plan with that person, and see it through. In pressurised systems like the NHS, where we look at the policy and recognise that the NHS is under strain due to workforce pressures, there’s a risk when making quick decisions, especially with uncertainty. The risk is that you push the problem to someone else, devolve it, dilute it, or defer it, and in doing so, fail to handle it properly. It’s the handling and holding of people with complex health and care needs that’s crucial, as Tony said.

Tony Avery:

Another potential solution is technology. I don’t want to overplay this, but there are ways in which our computer systems can help us. You need to get the balance right. If doctors and other professionals are being over-alerted all the time, that’s not helpful. But there are some tools that can be helpful. For example, I had a patient last week where I put an entry into the computer system. It recognised that this patient had a history of cancer and flagged up to say this symptom could be related to their cancer. Now, I think I was on top of that anyway, but I found that to be a helpful intervention.

Another thing that can help reduce diagnostic delay, though it’s not quite diagnostic, is when you plan to refer a patient to hospital, and for some reason, it doesn’t happen. Perhaps the message gets lost in the system. We have systems now that can flag this up, asking, “Do I need to tell the secretary about this?” It keeps someone else in the loop when I’m planning to refer someone to hospital. So, while I don’t think technology is a panacea, it can help us in some ways with reducing diagnostic error or delay.

Tom Blakeman:

In terms of technology, it can enhance continuity. When confident in a diagnosis, coding it properly in the records helps down the road. For example, if someone had acute kidney injury years ago, you can be aware of that in decision-making during a home visit five years later. Technology is really important. In Leeds, I can look into hospital records if someone is admitted and see what’s happening. You can get a sense of when they might be discharged and what happened. And that generates learning. You begin to have an understanding of a person’s story in hospital, rather than just sending them in and waiting for them to come out as if it’s a black hole they got into.

Umesh Chauhan:

One thing worth reflecting on is that we’re all academics, and as academics and GPs, there are certain things we need to think about. One challenge for us has been around creating measures we can look at. Increasingly, we’re training people to be co-researchers, so people with lived experience who can help us develop and design studies that reflect their experiences. This has been a real challenge, but also where we’re really developing our understanding and creating better research studies, because we’re involving people, rather than just being academics and clinicians, we’re actually involving people with lived experience to tell us what we should be looking at and how we should be looking at, and actually analysing the data, and disseminating when it comes to findings. So that’s a really important element of creating measures that are important and how we can disseminate the findings once we come to realising the fruits of our labours.

[Music]

Louise Gorman:

Unfortunately, that’s all we have time for today. I want to extend my thanks to Neil, Darren, Tom, Umesh, and Tony for their insightful discussion on what patient safety is, what patient safety means, and improving diagnosis for patient safety in primary care. Thanks for listening and see you in the next episode of Voices for Safety.

[Music]

You’ve been listening to Voices for Safety, the podcast that explores the forefront of patient safety research, brought to you by the NIHR Greater Manchester Patient Safety Research Collaboration. If you enjoyed today’s discussion and want to stay updated on the latest in patient safety, be sure to follow us for upcoming episodes. You can also find us on X (formerly Twitter) at GM_PSRC, and on our website, http://www.psrc-gm.nihr.ac.uk. Join us as we continue to cover insights and innovations that make healthcare safer for everyone. Thanks for listening, and we’ll catch you in the next episode.

 

ENDS