Putting patient safety reports at the heart of safe care in General Practice

As NHS England launches a new reporting e-form specifically developed for GP staff, Martyn Diaper, NHS England’s Head of Patient Safety (Primary Care), and a practising GP, explains the importance of reporting in patient safety.

Since the NHS’ national patient safety incident database – the National Reporting and Learning System (NRLS) – was launched over a decade ago, the number of reported incidents has continued to grow year-on-year.

We have seen the number of incident reports go from just a few thousand by the end of the NRLS’ first year in 2004, to now receiving around 1.5 million each year.

This is a good thing for patient safety and vital in our work to keep patients safe from avoidable harm.

It is of paramount importance that these incidents, whether they result in actual harm or not, are reported into the NRLS to give us an insight into what is happening at a national level. It means we can learn and take steps to prevent identified risks to the safety of patients across the country.

Despite general practice being by far the most common placed interaction patients have with the NHS, the number of patient safety incidents reported by GPs and practice staff is decidedly low.

In fact, we have seen a slight decline in recent years to the few thousand reports that we do receive each year, compared with the 1.5 million and rising coming from secondary care providers. This creates a real loss in opportunities to learn valuable patient safety lessons from the 360 million general practice consultations each year.

Given the sheer number of patients seen in general practice, it is inevitable that on very rare occasions things will go wrong. Whether this is because of human factors, faulty equipment, administrative errors, or system problems – these all have the potential to cause harm to patients and are largely preventable.

By staff reporting into a national system, it provides NHS England with a national overview and insight of incidents from across the country so risks can be identified and action can be taken to prevent them.

There are various ways we can do this, such as raising awareness of a particular risk by issuing a patient safety alert; by developing learning resources to help staff learn how to identify and react when faced by a particular risk or symptoms; by holding local workshops and events and, on occasions, by incentivising good practice.

I know as a GP myself that the safety of our patients is central to everything we do in general practice. From my own involvement with NHS England I am well aware of the NRLS and what it is used to achieve. However, I am in a tiny minority of GPs having this knowledge.

There is currently a distinct lack of awareness that practice staff have the opportunity to report to a national incident database; that reporting is vital to improving patient safety; and that reporting is by no means used to implicate any sort of blame. Finally, I am of course more than aware of the demands on the time and resources of the modern general practice team and the perceived burden that goes with introducing new requirements to their busy routines.

As one step to overcome these barriers, we have developed a new e-form, in collaboration with general practices, to make it quick and easy for practice staff to report incidents.

The form has been designed in such a way it takes only a matter of minutes to submit a report. Furthermore, these reports can also be linked to team based learning and also personal learning for CPD, Appraisal and Revalidation. Anyone working within a practice could be involved with, or witness a patient safety incident, therefore reports can be submitted by any member of the team, from GPs to administrative staff.

Practices can choose whether or not they want to include their practice code when submitting a report. Including this data enables us to share information with local NHS England sub regions and, if the practice opts to, with their CCG. However, a practice can also choose to report entirely anonymously.

We will still analyse the information submitted for themes and trends to generate national learning. This takes us back to the purpose of reporting, which is to learn from incidents to prevent similar events occurring. Therefore, person identifiable information is not essential.

We are keen to achieve a reflective volume of reports coming into the NRLS that matches the scale of care provided by general practice. We will continue to work together with practice staff, commissioners and patients to introduce a real culture of blame-free patient safety reporting and learning. Our aim is to match the upward trends we have seen in reporting from secondary care that has continued to grow over the past decade.

Dr Martyn Diaper

Dr Martyn Diaper is the Head of Patient Safety (Primary Care) and the chairman of the Primary Care Patient Safety Expert Group at NHS England.

Born and raised in Southampton, Martyn trained at St Thomas’s Hospital and worked in the UK and Australia before settling with his wife in Winchester, where he was a GP for nearly 20 years. During that time he gained an MBA with the Open University and worked with the NHS Institute for innovation and improvement as clinical lead for patient safety.

In 2011 he trained as a Patient Safety Officer in Boston MA at the Institute of Healthcare Improvement. Martyn worked as Clinical Director for South East Hampshire ISD at Southern Health from 2013 to 2014, and later became Southern Health medical director until July 2015.

He has also worked for NHS Improving Quality as clinical lead for patient safety and commissioner development in its delivery team.