NHSE is asking GPs to report patient safety incidents to the national system
GP practices are now expected to report incidents nationwide as part of NHS England’s drive to improve patient safety in primary care.
The new policy, published last week, set out a series of reforms to be implemented across the board, while stressing that these are not ‘contractual requirements’ and that the times are ‘intentionally changing’.
By recording incidents, the policy states that GP practices are expected to link their local risk management practices to the Learning from Patient Safety Incidents (LFPSE) national NHS system.
NHS England said it wanted a ‘single, simple patient event recording form and process, with improved event quality (patient safety events), near misses (with sometimes called good fish), good practice events and risk recording’.
Another system used in secondary care – the Patient Safety Response Plan (PSIRF) – will also be implemented in general from this year, starting with airports.
PSIRF is ‘developing a response system’ to incidents to help healthcare professionals learn and improve patient safety.
NHSE said: ‘While there is no intention to scale up and transform the PSIRF directly from secondary care to primary care, we want to implement its principles of equity, flexibility and conditions to respond to the primary care response to incidents, depending on local arrangements.’
According to this policy, the ‘culture of reporting incidents’ is generally ‘underdeveloped’ compared to secondary care.
It highlighted that although more than a fifth of new claims to NHS Resolution are from practice, only 1% of the 2.2 million cases reported nationally each year are from primary care.
This is the first patient protection policy for primary care and is based on the NHSE’s observation that the NHS’s ‘wider policy from 2019’ requires a more specific definition for GP practices.
NHSE anticipates that further improvements will be implemented first in GP practices before being rolled out more widely to other primary care providers.
Other ‘wishes’ mentioned in the new policy:
- Improve communication between providers of primary care as well as secondary care, mental health, ambulance, social care, and community care – as incidents are more likely to occur in these transition areas’;
- Implementing IT systems in primary care that ‘automate patient safety issues such as sequencing patient referrals, security, diagnosis and clinical issues’;
- Develop IT that ‘supports clinical decisions at all times’, for example by including digital diagnostic decision guidance;
- Implementing a comprehensive employee survey to provide consistent data on employee experience;
- GP practices to identify patient safety systems among staff and ‘place patient safety partners’ in PPGs;
- The pilot approaches and shares best practices for improving patient safety around the topics of: diagnosis, medication, and referral.
NHS England also said it would ‘review the application’ to primary care of the approach used in the nuclear power industry to manage risk, called the ‘safety management system’.
The strategy said: ‘Given the pressures on primary care capacity and ICBs, the strategy seeks to continue to improve patient safety through existing systems and facilities as much as possible, instead and increase work.’
In July, the NHSE was told to review patient safety risks associated with online chat tools used by GPs after an investigation found that the use of such tools led to a risk and death in a small number of cases.
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