Staying Safe

When Thomas Wakley launched The Lancet in 1823, medicine was as much a threat as a benefit to human health. Wakley was determined to replace quackery with an empirical approach to clinical practice, writing that ‘We hope the age of “mental delusion” has passed, and that mystery and concealment will no longer be encouraged.’

In many ways this represented the beginnings of evidence-based medicine. Almost 200 years on, the safety of patients still remains a major concern of medicine and its regulators. The GMC’s document on medical education, Tomorrow’s Doctors, includes a list of the responsibilities of medical schools, the first of which is ‘Protecting patients and taking appropriate steps to minimise any risk of harm …’ When Sir Liam Donaldson was England’s Chief Medical Officer he established a national patient safety programme and a comprehensive health protection service. In the same vein, his successor, Dame Sally Davies, has made warning the public and the profession about the dire consequences of escalating levels of antibiotic resistance a major health protection campaign. In this issue three articles provide examples of three important aspects of patient safety: diagnostic decision-making in the consultation; the safety culture of the individual practice; and the risks to patient safety caused by shortcomings in the health system.

Diagnostic errors, and the lessons that can be learned from them, are the subject of a fascinating report by Goyder and colleagues from England and US. Reflecting on cases in which diagnostic errors were either made or avoided, GPs generated a set of important learning points, with the problems of diagnosis based on pattern recognition, the search for disconfirming evidence, and the problems of dealing with a ‘sense of unease’ about an individual patient being particularly striking, with the implications for teaching and training clearly articulated.

Researchers in the Netherlands, have already reported a randomised trial of an intervention which showed that it is possible to develop a positive safety culture within general practice,¹ and in their follow-up qualitative study they use the theory of communities of practice to assist in understanding how their intervention worked. They emphasise the importance of being involved in a joint enterprise, of mutual engagement, and of what is described as a shared repertoire, by which they mean the shared experience within the practice of dealing with and resolving difficulties and problems. The half-day workshop used in these studies may be something worth considering more widely.

One in five patients experiences an adverse event within 3 weeks of being discharged from hospital. Carson-Stevens and colleagues have analysed almost 600 adverse incident reports and identified four main themes causing harm. These are errors in discharge communication, errors in referrals to community care, errors in medication, and lack of provision of ‘care adjuncts’, such as dressings. The primary–secondary care interface has long been the Achilles heel of safe, integrated patient care, and it is clear that any interventions of proven value need to be implemented systematically, rather than merely locally.

If this BJGP has a Christmas message, it comes from the study by Watt’s group, in Scotland, on the continuing pernicious effects of the inverse care law. Their analysis of almost 1000 Scottish practices confirms that the poorest people bear the heaviest burden of ill health, and that their GPs are faced with more consultations of increasing complexity. Funding formulae for general practice still fail to recognise the need for more resources to support clinical care, and to contribute to better recruitment and retention of the workforce. The sobering conclusion of this article is that far from being a solution to health inequalities, general practice remains part of the problem. Sadly, bland phrases such as ‘health inequalities’ and ‘levels of deprivation’ tend to obscure the reality behind them, which is that once again, at Christmas time, large numbers of people in the UK will still be having to choose between keeping warm and eating properly. That is a national disgrace.

• © British Journal of General Practice 2015