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Patient Safety: Blame the Doctor?

20 Aug

by Gavin Daker-White, Research Fellow, Multimorbidity theme, NIHR Greater Manchester PSTRC, University of Manchester

“Physician, heal thyself” (Luke, 4:23)

Part Two - Blame the system

This is the second of 3 blogs that discusses the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 studies grouped into 5 topic areas:

  1. Patients’ perspectives around safety (8 articles)
  2. Staff perspectives on safety (14 articles)
  3. Medication safety (10 articles)
  4. Organisational or management issues (7 articles)
  5. Care transitions between primary care and hospitals (9 articles)

 The findings of the review were seen to boil down to those that blamed patients for safety failures, those that blamed doctors and those which explained safety failures by shortfalls in clinical systems or the organisation of care. This blog looks at the role of health service staff in patient safety in primary care. ‘Staff’ includes doctors, nurses or other health workers. Two of the studies we included in our review were focused on the role of practice receptionists, who often have a key role in patient safety through communicating with patients and dealing with repeat prescriptions. Administrative staff are also key to patient safety in primary care.

As was noted in Part One of this series of blogs, an important component of “feeling safe” relates to trust in care providers and the quality of inter-personal communication during interactions with health service staff. In the group of 8 studies that were concerned with patients’ perceptions, 2 were concerned principally with the consequences of real harms experienced by study participants. The results highlighted the role of past experiences in health seeking behaviour and showed how apparently trivial insults could spiral into more serious harm within a breakdown in the clinical relationship. These issues could be ameliorated for some people by training (of both staff and patients) concerning effective communication in clinical encounters.

Fourteen of the 48 articles we reviewed were focused on staff perspectives on patient safety. These studies were located in several different countries (USA, UK , Netherlands, Canada, Denmark, Germany  and Australia) and thus the kinds of processes and factors identified can be considered broadly relevant in western medical contexts. For staff, the main issues in patient safety concerned the characteristics or behaviour of staff or patients, doctor-patient communication and professional roles and responsibilities. Again, the main value of the synthesis in this group of papers appeared to be throwing light on those instances where the findings of different studies contradicted each other. For health service staff, these instances related to clinical autonomy, responsibility and emotional engagement with patients. For example, listening to patients was considered important so as not to miss vital information but it might threaten safety if the information given was perceived as irrelevant or distracting from the main issues at hand.

One commonly identified feature of clinical work in primary care was a perceived unwillingness to follow protocols, with GPs preferring to variously follow gut instincts or “do their own thing” (Elder et al., 2006). However, for health service staff the bulk of their concerns related to systems issues and the organisation of care, which is the subject of the concluding blog in this series. For staff, an important aspect related to the need for effective teamwork to promote safety within a context where staff can be held personally responsible for their actions.

One issue put forward by GPs as contributing to safety failures reflected the stressful nature of the job and the kind of work/life balance apparently necessary to operate “safely”. So far as the particularities of clinical and diagnostic work are concerned the dangers of false assumptions and explanations arrived at too hurriedly were both identified as threats to patient safety. The dangers in instantaneous judgements, perhaps based on stereotypes of presenting patients, was also identified as an issue in the ten medication studies. As in the patient studies, effective communication was considered essential, but potentially problematic given competing agendas and pressures on time and resources. There were also problems for GPs in managing rare drugs prescribed by other specialists, perhaps for conditions that were at the limits of their competence to manage (Rahmner et al., 2010).

Taking all of the studies into account, staff had the potential to compromise safety in the following ways:

  • Communication mediated by receptionists
  • Deference on the part of patients can impact effective communication
  • Poorly performing GPs
  • Lack of face-to-face contact between health workers
  • Ad hoc approaches

 Other findings pointed to the ways in which staff can help promote safety:

  • Create a feeling of safety
  • Understand patients’ circumstances, clinical history and needs
  • Training in doctor-patient communication
  • Share knowledge and training with colleagues
  • Teamwork / promote a safety learning culture
  • Open, blame free and effective communication between staff

 On the face of it, the above findings suggest that engendering patient safety in primary care is something that takes time. However, time is often seen to be at a premium in primary care. Further, the relationship between some of the issues we have identified needs further investigation. For example, are some GPs “poorly performing” because of stress or burnout, or due to deficiencies in training or clinical practice? The main point to note is that effective communication between patients and health workers and between different health workers themselves appear as the most important factors. Often, it seems as though the time available for consultations or other communication in health services is challenged by the way that services are set up, organised or run. These considerations form the subject of next week’s blog, which will be the final post in this series.

References

Elder NC, Graham D, Brandt E, Dovey S, Phillips R, et al. (2006) The Testing Process in Family Medicine: Problems, Solutions and Barriers as Seen by Physicians and Their Staff: A study of the American Academy of Family Physicians’ National Research Network. Journal of Patient Safety 2: 25-32.

Rahmner PB, Gustafsson LL, Holmstrom I, Rosenqvist U, Tomson G (2010) Whose job is it anyway? Swedish general practitioners’ perception of their responsibility for the patient’s drug list. Ann Fam Med 8: 40-46.

Case management is not the be-all and end-all of ‘integrated care’

20 Jul

by Jonathan Stokes, PhD student in Multimorbidity theme

Jonny Stokes_July15 blog on paper

The major health burden in any rich country (and increasingly poorer countries as well) is long-term conditions, e.g. asthma, diabetes, heart disease.

As people live longer, they tend to accumulate multiple long-term conditions over their lifetime, known as multimorbidity. These patients often require care from many parts of the health and social care system, use multiple medications, and their care is generally more complex and expensive to manage. These pressures have been further exacerbated by the 2008 economic crisis and subsequent austerity measures.

Better ‘integrated care’ is a common response from policy-makers, to achieve better outcomes for patients, and in a more cost-effective manner. Integrated care is a complicated concept, and it can be delivered at multiple levels of the health system, in the ‘background’ (e.g. integrated health records, pooled funding), or at the point of ‘service delivery’ (at the point of contact with the patient).

Case management for ‘at risk’ patients in primary care is an extremely popular way of ‘integrating’ service delivery. It involves identifying patients at increased risk of emergency admissions to hospital, and assigning them a specific case manager or case management team to tailor and co-ordinate their care (with an individual assessment, care plan, and regular review).

In the NHS, case management of the top 2% of highest risk patients is part of the current GP contract. Under the ‘Unplanned admissions directed enhanced services (DES)’, practices receive extra payments for signing up to these services.

Despite probably being the main form of integrated care being implemented in the NHS and around the world (looking at the NHS specifically, we previously found a clear dominance of case management being implemented as the core aspect of ‘integrated care’ in Clinical Commissioning Groups), with the aim of cost-saving and achieving better outcomes for patients, the evidence for this intervention is unclear.

We conducted a systematic review of the evidence generated to date. We used a statistical technique, called ‘meta-analysis’, to put together the findings of all of the studies we found. This technique increases statistical power (increasing precision and our confidence in the findings), and provides an assessment of all the high quality evidence available globally. For that reason, it’s often referred to as the gold-standard form of evidence in medicine.

We looked at effectiveness across a number of outcomes: health (patients’ assessment of their health, as well as mortality), costs and cost-effectiveness (total costs of care, as well as the use of specific services such as GPs, social workers, and hospitals care), and patient satisfaction.

Exploring data across 36 studies, we found that case management of at-risk patients in primary care showed no significant effect on most of the outcomes we looked at. The exceptions were self-assessed health status (which may improve slightly in the short-term, but with few long term benefits), and patient satisfaction (which improved a small amount in both the short and longer term).

We found little evidence of effectiveness of a very popular method of delivering ‘integrated care’.

Managing those high-risk patients is also important, and while the intervention analysed showed limited benefit, there was no harm shown. Therefore, we also tried to pick out some key learning opportunities for policy-makers to try and improve the interventions delivered in the meantime (for example, we found there may be slight benefits of using a multidisciplinary team to case manage; slightly more effect in a country with low initial strength of primary care; and there may be benefits when a social worker is involved).

Policy-makers may need to broaden their thinking about methods to improve care for those with multiple conditions. As others have pointed out, targeting only the highest risk patients puts limits on what can be achieved.

As enthusiasm for integrated care grows through the Five Year Forward View and the Vanguard programme, methods of achieving service improvement at scale need urgent evaluation.

With limited effectiveness shown for the main aims of the case management intervention, particularly no effect in reducing hospital admissions and total cost of care, for policy-makers to incentivise practices to implement case management appears counter-productive to relieving system pressures.

The full article can be found on PLoS ONE, titled: ‘Effectiveness of case management for ‘at risk’ patients in primary care: A systematic review and meta-analysis’ (DOI: 10.1371/journal.pone.0132340).