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Primary care patient safety strategy

This narrative supports the launch of the Primary care patient safety strategy and is for any healthcare setting and can be used whole, or edited into bitesized pieces of information.  It can also be summarised as part of a covering letter.

Narrative

  The Primary care patient safety strategy has been co-designed by staff and lay patient safety partners.  It is based on the NHS Patient Safety Strategy (2019), which was the first national strategy for improving patient safety and very much included a specific emphasis on primary care. Here, we recognise that implementaiton within primary care needs different approaches.

Primary care – general practice, community pharmacy, optometry and dental services – delivers 90% of NHS interactions, face to face, by phone or online. The overwhelming majority (97%) of primary care interactions are safe, but with between 20,000 and 30,000 incidents of avoidable significant harm identified in general practice in England per year , there is opportunity to continue to improve patient safety in primary care. While incidents are recorded, we also know that incident data may be an underrepresentation of harm, as incident recording systems are not as well developed in primary care when compared to secondary care. Less than 1% of the 2.2 million incidents recorded nationally each year are from primary care, despite this being where most patient interactions take place.  We also know that 21% of all new claims to NHS Resolution are from general practice (as reported in the new CNSGP and ELSP claims notified in 2023/24 ), with a GP indemnity expenditure of £149m per annum. 

This strategy is about setting the ambition and vision for patient safety in primary care to encourage discussion and exploration across all primary care platforms.  This is not about implementing everything on day one in all sectors, it is about providing ideas and opportunities that can shared. This strategy draws together best practice. It is not a contractual requirement on primary care providers, or ICBs. NHS England will continuously review its effectiveness and how we can best implement the strategy to improve patient safety. 

Given the capacity pressures in primary care and integrated care boards, this strategy seeks to build on existing safety culture and utilise opportunities to learn and redefine the steps involved.  It is intended that the timeframes for the implementation of the local commitments are flexible to allow for piloting different approaches. This strategy is for all areas of primary care, though with some pilots starting first in general practice [GP] to enable the successes and learning to be taken across into community pharmacy, optometry and dental services [POD].  

This is about step by step implementation bearing in mind that GP, community pharmacy, optometry and dental services are at very different stages and have different contractual and regulatory requirements. This is not a sprint, it's a marathon.

This has to be achieved within the current resource, so this will take time.  The strategy seeks to build on existing safety culture and utilise opportunities to learn and redefine the steps involved.  Most areas need testing and piloting in primary care before full implementation, so the delivery timeframe is iterative starting with pilot introductions of some projects.  For example, the first step towards PSIRF implementation is a funded pilot approach for a small number of General Practices supported by the Health Innovation Network.  There is no intention to make PSIRF a requirement for General practice at the end of 12 months.

In summary:

  • Safety culture: opportunities to participate in the NHS staff survey [pilots in GP]
  • Safety systems: opportunities to complete patient safety syllabus training [GP&POD]
  • Insight: register with the new incident recording (LFPSE) [GP&POD] and start to implement the PSIRF incident response systems [initial pilots in GP]
  • Involvement: identify patient safety leads [GP&POD] and lay patient safety partners [initial pilots in GP]
  • Improvement: review and test ideas for patient safety improvements in diagnosis, medication, referrals, optometry and dental services [GP&POD]

This strategy focuses on:

  1. Developing a supportive, learning environment and just culture in primary care, with sharing across the system so that the services can continually improve.
  2. Ensuring that the safety and wellbeing of patients and staff is central, and that our approach to managing safety is systematic and based on safety science and systems thinking.
  3. Involving patients in the identification and co-design of primary care patient safety ambitions, opportunities and improvements.

There are no additional resources for this strategy, as this will build on the existing infrastructure within primary care. However, investment has been made in the provision of free patient safety training, modernising and streamlining the national incident recording system from NRLS to the Learn from patient safety events (LFPSE) service and appointing a trained patient safety specialist in each ICB who provides patient safety guidance and support to the system.  Additional resources and case studies will be shared as they become available on Patient Safety in Primary Care - FutureNHS Collaboration Platform .

Improving patient safety may feel like a challenging task in an already stretched environment; however, there are some significant benefits to these relatively small changes that are intended to reduce rather than increase the workload while improving patient safety.

Benefits to patients and families

  • Improved patient safety will lead to more efficient, effective care and mean fewer patients are harmed, and should lead to fewer complaints.
  • Provision of free online patient safety training (including primary care-specific modules) to lay patient representatives such as members of Patient participation groups (PPGs) will enable them to be more active participants in the patient safety agenda supporting their GP practices.
  • Fewer harmed patients should lead to increased patient confidence in primary care clinicians and staff. This should result in increased engagement with primary care services by all groups of people, including those with protected characteristics.
  • Patients involved in co-designing their primary care services will be able to influence the inclusion of patient safety improvements that matter the most to them.
  • Increased national recording of safety events, especially those which are new or unusual, will lead to improved patient safety alerts and solutions targeted directly at primary care patients.
  • Patients and families will have reassurance that if after 3 consultations a patient’s condition remains unresolved, or their symptoms are escalating and/or they have no substantiated diagnosis, their case should be elevated for review and a new assessment made: ‘ 3 strikes and we rethink ’.

Benefits to staff

  • Free, online patient safety training (including primary care-specific modules) for all staff, should lead to empowerment to speak up, improved understanding of human factors, improved safety culture, more psychological safety, multi-disciplinary working and decreased blame from incidents.
  • One national system (LFPSE) to record patient safety incidents, leading to familiarity of how to record and access information in different organisations.  Also leading to decreased duplication such that incident records and learning can be used for multiple purposes such as revalidation, annual appraisals, continual professional development (CPD), significant event audit/ analysis (SEA), quality improvement and audit evidence. 
  • Recording safety events is seen as a positive process by professional regulators demonstrating transparency, openness and reflection ?ie a positive patient safety culture.
  • One system: Patient safety incident response framework (PSIRF) which is a learning tool to enable learning from patient safety incidents (linked to LFPSE).  This leads to more opportunities for quality improvement within and between organisations and a move to an emphasis on systems.  As a result there will be a shift from a blame to a just (no-blame) culture. There is commissioned support via the South London Health Innovation Network to work directly with general practices in each region to develop PSIRF pilots via their Patient Safety Collaboratives, to test the application of PSIRF principles and develop case studies for wider sharing.
  • Support from dedicated, trained patient safety staff within organisations and from ICBs (via Patient safety specialists).
  • When the system is under pressure, it is even more important that staff know that there are safety nets in place (implemented from previous learning) to help them deliver safe patient care.
  • Local PSIRF plans will include learning from complaints, which should lead to improvements that also reduce complaints which should free up time and reduce staff and patient stress.
  • Participating actively in improving their organisation should lead to  greater alignment and belonging for the staff. This should enhance job satisfaction and workforce retention.

Benefits to organisations

  • Using LFPSE will mean the practice can record incidents that occur in other organisations as well as their own to increase sharing of learning and risk management across the system.  It will also mean that practices can notify CQC and MHRA at the same time, without having to access another reporting system for example to report the death of a service user or suspected side effects to medicines (yellow cards) .
  • Improved patient safety communication and learning between organisations via identified and trained patient safety specialists (in Trusts and ICBs) and identified and trained patient safety leads in primary care.
  • Recording safety events and sharing learning can contribute towards a positive CQC rating, for the “safe” and “well-led” domains, as recording events is seen as a positive process by CQC?.
  • Decrease in the financial costs of incident-related treatments, estimated at more than £100 million per year across the whole of primary care.
  • Decrease in litigation and claims costs (from a 2023/24 expenditure of £149m for GP indemnity). 
  • Enhanced opportunity to improve services with an evidence-based methodology.
  • Embedding continuous improvement should ensure enhanced efficiency of processes and use of resources.

Benefits to systems

  • Recording safety events and sharing learning will lead  to a systems approach to problem-solving and feedback of good practice approaches for identified patient safety themes and trends. This will offer opportunities to improve patient pathways, in terms efficiency and outcomes.
  • Using LFPSE will lead to the identification of previously unknown national safety issues and therefore the development of new systems and solutions to improve safety both specifically within primary care as well as across the interfaces with other service providers.  
  • Recording safety events and sharing learning will enable better oversight of how demand and capacity impacts on patient safety.
  • The alignment of PSIRF plans in GP alongside the established PSIRF plans from secondary care providers will deliver opportunities to embed NHS Impact and its components of system-wide continuous improvement.

Regulatory and contractual requirements

  • Organisations that provide NHS-funded care under the NHS Standard Contract but are not NHS trusts or foundation trusts (eg independent provider organisations, and NHS Standard contract commissioned primary care services) were required to adopt PSIRF for all aspects of NHS-funded care from 1 st April 2024.
  • Appraisal, leading to revalidation includes the six types of GMC-directed supporting information that licensed doctors must collect and reflect on, including significant events.
  • All doctors, nurses, AHPs, optometrists, pharmacists and dentists have a duty via their relevant Councils [General Medical Council (GMC), General Dental Council (GDC), General Pharmaceutical Council (GPhC), General Optical Council (GOC), Nursing And Midwifery Council (NMC)] to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organisations in which they work. They must also encourage and support a culture in which staff can raise concerns (such as recording safety events) openly and safely.
  • The primary care commissioning assurance framework identifies the responsibilities being exercised by ICBs that have delegated responsibility for the contract management and assurance of providers/contractors.
  • All GP and dental  practices in England have a CQC regulatory requirement to report patient safety incidents. GP mythbuster 24: Recording patient safety events with the Learn from patient safety events (LFPSE) service - Care Quality Commission
  • All doctors are required by GMC to follow Good medical practice (sections 75, 76) and this includes following the procedure where they work for reporting adverse incidents and near misses. Maintaining and improving standards of care professional standards - GMC  
  • Community pharmacies have been required by contract to record incidents on the national incident system since 2005 and as such have benefitted from improved safety alerts and solutions.

Challenges

  • Time – this will take some additional time initially, though the future benefits (experienced at Middlewood Partnership) indicate that less time will need to be spent managing complaints and fixing problems. Middlewood Partnership is one of the first primary care adopters of PSIRF and has shared a podcast to help explain PSIRF in General Practice .
  • Culture - sharing information about safety events and incidents beyond a single organisation will be new to many primary care colleagues and may feel difficult and uncomfortable.  It may be necessary to develop the capacity, or capability of leadership within primary care to support this.
  • Culture - Spending time to discuss and record incidents and safety events may appear to be in conflict with the business model of some primary care sectors.
  • Culture – this will need leadership and commitment from senior staff across the system to support moving towards an increasingly proactive approach that improves patient safety.

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