What seems to be “the problem”? Locum doctors, liminality and concerns about performance. Gemma Stringer, Jane Ferguson, Kieran Walshe, Thomas Allen, Christos Grigoroglou, Evangelos Kontopantelis, Darren M. Ashcroft (Social Science & Medicine)

Locum doctor working and quality and safety: a qualitative study in English primary and secondary care. Jane Ferguson, Gemma Stringer, Kieran Walshe, Thomas Allen, Christos Grigoroglou, Darren M Ashcroft, Evangelos Kontopantelis (BMJ Quality & Safety)

The quality and safety of locum doctors: a narrative review. Jane Ferguson and Kieran Walshe (Journal of the Royal Society of Medicine)

Locum doctors – curse or blessing for hospitals? Caroline Ruiner, Birgit Apitzsch, Vera Hagemann, Sabine Salloch, Laura Marie Edinger-Schons, Maximiliane Wilkesmann ( International Journal of Employment Studies)

Locums: threat or opportunity. Richard Lilford (BMJ Quality & Safety)

Louise Gorman: The quality of health care really depends on the people delivering it. And that’s why it’s so important for organisations to invest in their medical staff — helping them grow professionally, keeping standards high, and stepping in when things go wrong.

But what happens when hospitals or practices bring in locum doctors?

Locum doctors are part of the team for a short time, but not fully integrated into an organisation. You’ll find them working in both hospitals and GP practices. They’re a vital part of making sure that the NHS can keep up with demand.

Locums help to cover for staff who are off sick, away on leave, or when there are unfulfilled roles. Some do it as a side gig alongside their permanent job, while others choose to work only as a locum.

Hello, welcome back to Voices for Safety, the podcast from the NIHR Greater Manchester Patient Safety Research Collaboration, where we discuss all things patient safety.

A study by Jane Ferguson and colleagues has pointed out that working as a locum doctor can be tough, and it can be isolating. That lack of connection with your team, in some cases, can increase the risk to safe practice.

So who better to welcome to this discussion than the researchers leading the way in patient safety and locum working?

Jane Ferguson: So, I’m Jane Ferguson. I’m Assistant Professor in the Health Services Management Centre at the University of Birmingham, and I’m interested in the healthcare workforce and quality and safety.

Kieran Walshe: I’m Kieran Walshe. I’m a Professor of Health Policy and Management at the University of Manchester, and for a long time, my research has revolved around quality and safety in health care, governance failures in care, and quite a bit of work around the regulation of health care organisations and of health care professionals like doctors.

Louise Gorman: Amazing. Thank you very much. To start the discussion, we’re talking about locum doctors today. Can you tell us, and tell our listeners, about what a locum is? Who is a locum, and why they possibly move into locum work?

Jane Ferguson: And so, the reasons why doctors work as locums. If we think about the early years — you’ve just qualified — quite a lot of the time people are coming out of university with massive debt, and so locum work can be a way of earning a bit more money than they might have ordinarily, paying off some of that massive student loan that people have got.

But also, we’ve noticed that doctors are less likely to go into those traditional career paths, and there’s difficulty getting into those roles as well. So locuming can be a way of testing things out — to try a bit of variety, see if you like to work in that kind of organisation, or if you like to work in that role, get a bit more experience under the belt.

And for people who are a bit further into their careers, it can be to do with things like you’ve had a young family and it’s just the more accessible way of working. Or you’re experiencing burnout. So again, it’s a way of avoiding burnout. So you can earn quite — you can probably earn, what people told us when we interviewed them, the same as a full-time job in maybe two or three days. And then further in, further along — towards retirement — it’s a way of people keeping their hands in. Sometimes people will retire and they’ll come back as a locum.

So it’s options for people all through the career path.

Kieran Walshe: And a lot of doctors actually don’t just work as a locum. They may be doing a substantive job in an NHS organisation or a GP practice — perhaps part-time, perhaps full-time — but also doing some locum shifts at the weekend or in their free days.

So they’ll be doing a bit of both.

And it’s also worth remembering that locum work is not assured. In fact, in general practice, in the last couple of years, we’ve seen the demand for locum GPs really drop, and a lot of people who were working as locums have struggled to find work.

Louise Gorman: That was going to be my next question actually — how does that look? Because I assume locum work looks very different from primary care — so GP practices — compared to hospitals and secondary care services.

Kieran Walshe: In hospitals, in NHS trusts, you’ll have agency locums who come from a locum agency. You’ll also have quite a lot of what are called bank doctors. They’ll be doctors who work within the organisation but are doing essentially some overtime, some extra work, and doing some locuming, and they’re on the bank.

In general practice, you tend to have far fewer agency locums. GP locums are often people who are known to the practice. They might be people who’ve worked there before, sometimes someone who’s a regular locum, someone who’s retired, as Jane was saying earlier, and has come back to work for a part of their time to keep their hand in.

But there’s rather less use of someone ordered from an agency who you’ve never met before when they turn up at the door.

Jane Ferguson: There’s something to be said there as well about people knowing the system in terms of where to avoid and where not to avoid. Being well-networked was something that we found in our research was important for finding these practices that were easier to work for, safer to work for.

But this also had implications for people who weren’t well-networked. They might be overseas trained or international medical graduates who didn’t know the systems in the same way, which put them at risk. That was a bit vulnerable for them. They might find themselves in these places because they didn’t know the system. They didn’t understand the local region in terms of where to avoid and where not to avoid.

Louise Gorman: That brings us nicely into the topic of this podcast, which is patient safety.

I wondered if we could talk a little bit about the quality of care that locums may provide. Do we have any real insight into the quality of care that locums can give?

Kieran Walshe: On the whole, the research says that if you’re being seen by a locum, you’re probably going to get about the same kind of quality of care as you’d get from a permanent doctor.

Where locums practise differently, it’s mostly to do with the way the organisation has used or deployed them. Whether or not they know all the systems and processes. Whether or not they have full access to arrangements for ordering tests, for issuing prescriptions, for putting things on the electronic record system. All those trivial but really important bits of administration.

The fact that locums are subject to a bit more by way of complaints and referrals to the GMC is probably a lot to do with how problems with the doctor are dealt with. If there are concerns about someone’s performance and they’re employed in the organisation, that’s the way they get dealt with — until it becomes really necessary to involve outside agencies.

But if it’s a locum who was here today and gone tomorrow, there can perhaps be far fewer informal ways of resolving concerns, and it may then end up in a more formal process like a complaint or a GMC referral.

So the research fundamentally says don’t worry too much if you’re seen by a locum.

Patients actually value some aspects of being seen by a locum. For example, the fresh pair of eyes they bring to their care.

But organisations need to up their game in the way they look after and use locums in clinical practice.

Louise Gorman: That’s interesting, isn’t it? That patients have a — potentially have a positive perception of locums?

Do you think that’s a reflection of how they generally feel with their treatment in the health service? Has that changed over time, do you know?

Jane Ferguson: I think patients generally don’t know that they’re being treated by a locum, unless you’ve got a long-term condition and you’re really familiar with your general practice. Then you probably know that your doctor’s a locum.

And if you’re in hospital, then you’ve got even less chance of knowing because that might be a one-off thing, unless you’re there on a long-term stay.

And so, when we ask people that question around, should patients know, or should you share that information — because there was some negativity with being a locum, and it carries some baggage with it, just that term — it was almost like, well, we don’t tell people because we don’t want them to second-guess or feel as though they’re getting less good treatment because they were a locum.

So patients didn’t always know, and it depends on what they were being seen for. If it was a one-off thing, then access is king and you just want to be seen.

But the people who had a long-term condition, they felt a bit of an eye-roll at having to start again, tell the story again of why you’re here, and just that person not having your history or not knowing what your previous medications were, or having to go through all that again.

So I think, yeah, it depends.

And that fresh set of eyes — some really good experiences came from having that second set of eyes on things, where people would talk about, well, the doctor knows me really well, they’ve seen me all the time, and they’re just like, “Oh, there’s this patient again.”

And they could be seen as a new person by this locum, who then might offer some different ways of treating them, which then went on to be life-changing for some of our participants who found it a really valuable experience.

Louise Gorman: In the literature, there’s that idea that when people have complex, multiple conditions and are quite complex patients, that can potentially present risks for patient safety when people are treated by locums.

So your research would suggest that actually maybe that’s not quite right

Kieran Walshe: It sort of gets to the nub of what you think continuity of care is. Because we all tend to think, rather lazily, it means seeing the same doctor every time.

But actually, in hospital, you often don’t see the same doctor any time. In your GP practice, that might be more common. But lots of patients told us they didn’t generally see the same doctor any time.

So continuity of care then becomes, if you like, informational continuity — knowing that the doctor who’s seen you has all the information that the other people who’ve seen you in the past will have.

And I think that’s, in that situation, a locum can be just as effective as a permanent doctor.

And we do think there was some evidence from locums that they practise quite defensively, because they know they’re not going to be there next time the patient comes in. So they can’t rely on keeping things in their memory or saying something informally.

So perhaps they make a bit more effort to document things, and to follow things up, and to safety-net things in the right way.

So certainly, I — speaking personally — I would have absolutely no problem going to see a locum.

In fact, I was talking to my mum last week, and she had just been to see the locum, and she and my brother had a very high opinion of the woman who saw them because she’d been so thorough.

Louise Gorman: That’s — that is really nice to know.

Is that more challenging when we talk about information and sharing that information — continuity of care?

Would there be challenges, do you think, for locums around — I’m thinking in hospital settings — not necessarily being present at handover the next day, not necessarily being able to have that continuity of information?

Do you think that’s handled by the defensive practice, or do you think that’s a challenge that is ever-present for locums?

Jane Ferguson:  I think that we had examples where that was handled through defensive practice, through locums being afraid to make decisions because they were scared of the consequences.

Because if you’re excluded in an organisation, or you’re seen as here today, gone tomorrow, then you’re not involved in things like the multidisciplinary team meeting.

You might not be there for handover. You might not be there for those important things that give you the whole picture of what’s going on.

Locums did talk — and the people who worked with locums both spoke — about practising defensively to avoid those situations.

Being afraid to get in there and make a decision that was necessary, which kind of perpetuated that negative view of locum.

But I think that can be remedied by people being there for a longer period or practising in fewer organisations.

People would say, to improve safety for themselves — and risk for themselves, as well as for other people — they would just work across two organisations and go to those places on repeat, where they could become more familiar with the staff and become better integrated.

I think the highest risk is probably with the very short-term locum in multiple organisations, where you’re always new.

One thing I’d say about this is we all know what it’s like to be new in a job — where you don’t know where things are, you don’t know anybody, you don’t know who to ask for things.

And so it’s that perpetual newness — that’s where the risk lies.

Kieran Walshe: The other side of the coin on that was that locums certainly felt — and we had quite good examples reported to us — that because they weren’t in the room, because they had left and moved on somewhere else, it’s quite easy for them to get blamed for anything that happened to be hanging around.

They were sometimes the place where blame was positioned quite unfairly.

They wouldn’t be in the room, and they might find out later on, quite accidentally, that there had been a problem — and they’d never had a voice in saying why they thought something had gone wrong, and so on.

So that issue of kind of blame is one that plays out in an interesting way for locums who are no longer in the organisation.

If there’s a complaint, there’s no way for them to be asked about the complaint and give their views, and so on and so forth.

At the same time, we did hear people talking about some locums who, when there was a problem, they were moved on or they moved on.

So there are two sides to that which you might come to.

Jane Ferguson:  Also, it’s got implications for the learning.

If you’re not there to hear about a mistake that you’ve made, and nobody contacts you to let you know about it, or you’re not involved in the complaint, then how are you supposed to learn from that mistake?

So I think with that perception of locums being not quite as good, that kind of inability to learn and practice, and continue professional development based on things that you’re learning about your practice — that is an issue.

Louise Gorman: NHS employers and NHS Improvement — they all have that guidance, don’t they, on locum working?

So what can be done? Do you think that can improve that sort of clinical governance and access to personal development and development for locum staff?

Jane Ferguson: Reading the guidance, I think when we looked at that guidance — obviously we looked at it really closely as part of this project — and we worked with NHS England, and we thought the guidance was really comprehensive.

There was nothing that by the end of the project we thought maybe we could add or change — it was comprehensive.

But what we did find when we surveyed organisations was that people weren’t really aware of that guidance, or if they were, I doubt many people had read it.

So I think engaging with it, reading it, and implementing some of the guidance in there would be a first step.

Kieran Walshe: I’d just add to what Jane said a couple of things.

One is some bits of the guidance are very clunky.

For example, what are you meant to do if you have a locum doctor working for your organisation about whom you have a concern?

Well, there’s some guidance about what you’re meant to do, and it involves reporting it to the locum agency responsible officer and so on.

In practice, it’s really hard to make it work, and the easiest thing to do is just to get rid of that locum — end their placement, or when their placement comes to an end, simply not renew it.

So you’ve got to have guidance that ordinary people can follow sensibly.

But also, second point, there isn’t a closing of the loop on the guidance, and guidance is only as good as the systems for assuring that somebody’s doing what they ought to do.

Organisations like the Care Quality Commission, who regulate health and care providers, are probably the best placed organisations to have, as part of their oversight — and they do have oversight of staffing arrangements, staffing levels and things like that — as part of their oversight to say, when we come to check that you’re following the guidance on looking after locums.

The big hole in that is that locum agencies are not regulated — not by the Care Quality Commission or indeed by anybody else.

If I wanted to set up a locum agency tomorrow, I could do it.

And that, we felt, was a real gap in the current arrangements because someone should be checking that locum agencies are doing what they should be doing to look after the quality they provide.

Louise Gorman: When it comes to locums, what is it like for them in terms of supervision on the ground and clinical supervision?

I noticed from your work that, for example, they may not have regular appraisals, bringing in the idea that the evidence they need to collect, the development they need to collect, and that proof for their revalidation shows their fitness to practise.

Is it every five years, revalidation for a doctor?

Do you have any insight into how locums feel about any clinical management they have?

Kieran Walshe: Yeah, I mean there’s an attitude to locums that tends to say, right, once you get here, get your coat off and get working on clinical practice.

And so locums don’t get the same opportunities to engage in CPD or to have training, or to be involved in things like mortality and morbidity meetings and so on that permanent doctors do.

They’re also expected to loo k after themselves, particularly for those processes you referred to — appraisal and revalidation.

Now locum agencies can run the appraisal system but actually, for them to appraise locum doctors effectively is quite difficult because they’re not working with them clinically.

They’re not seeing them in clinical practice.

They’re completely reliant on the information the locum provides and that their placements may provide, and they struggle to get feedback from placements.

So it’s a very imperfect system in that regard, and that does mean that locums may find it hard to revalidate, which is getting somebody who’s a designated responsible officer to sign off on their practice at the end of five years.

Those arrangements definitely could be improved.

If I had one summary recommendation from the research, it would be that we get healthcare organisations who use locums to treat them much more like other doctors who work in their organisation, and give the same sort of access to induction, support, engagement in meetings and things like that, and not just treat them as a pair of hands.

Louise Gorman: I’m assuming there is a difference between internal locum bank doctors and those who are external originally to the organisation.

Did you have any insight from your work whether there was a difference or perception of difference between those two working groups?

Jane Ferguson: Yeah, I think if you could boil this whole project down to one word, it would be familiarity.

If you’re based in an organisation and you’ve got your responsible officer there and you know you’re involved in things, it’s very different from just doing a shift or several weeks of shifts there.

Louise Gorman: Talking of culture, it makes me think of team dynamics.

Are there any challenges for locums around that sort of familiarity with the teams they’re working with?

Not only the systems we said, not only the policies and procedures of the local systems, but also with the team and team dynamics?

Jane Ferguson: Yeah, and I think the obvious difference there is pay, isn’t it?

And that causes issues with team dynamics in terms of resentment.

Also, not taking responsibility for the kind of collective endeavour in terms of the admin that needs to be done, the leadership, and maybe the training of other staff.

A lot of people said that locums have control over when they work, how they work and what they do, but those jobs all still need to be done.

There was a sense of resentment from permanent staff because that work was still left to happen, plus the perception that locums get paid significantly more.

So that caused friction in the team sometimes.

While I appreciate what Kieran said about organisations needing to treat locums much more like other staff and integrate them better, there is something preventing people from doing that because they think, why should I treat you just the same as everybody else when you don’t have to do all these other things?

It’s seen by permanent staff as having your cake and eating it, causing a rift in the team where locums might be excluded.

We had people say they didn’t feel welcome in the doctors’ mess, for example.

They didn’t feel they could just go into that space.

That exclusion and marginalisation is a strong theme we heard in this study, and in our previous study about revalidation.

All the locums we interviewed talked about this feeling of othering and professional isolation.

And as much as you want to say it should be inclusive, there are issues that people find hard to swallow — pay, not being responsible for all the work.

Kieran Walshe: You get relabelled when you work as a locum, because you might have been a senior consultant radiologist, but suddenly you’re just a locum.

Your locum identity is what people attach to you.

But organisations ought to push staff back on that because it’s not the locum’s fault they’re working as a locum — it’s the organisation that hired them.

And it’s a bit unfair to shoot the messenger and blame the locum for the fact that they’re there as a locum.

They’re filling a shift that would otherwise have been vacant.

That’s what would have been the reality for the other staff there.

But it’s understandable that people feel some resentment, and it’s kind of fed by the narrative about, “Oh, they’re all just milking it for the money, they’re earning thousands of pounds a day,” which isn’t true.

Louise Gorman: This is a really big, complex, hard question: what can organisations do to improve that dynamic between their permanent staff and their locum workers so locums feel a little less discriminated against and more integrated?

Jane Ferguson: They need to bring them in — that inclusivity.

If I were going to recommend to a locum what they should do, I’d suggest working in fewer organisations and working there for longer periods, so people get to know you and you’re not this nameless person.

When people get a sense that you’ll only be there for a weekend, they naturally don’t make the effort to get to know you.

But if they know you’ll be coming back regularly, that familiarity helps — you get to know the processes.

It’s like with anything new; it takes time to get your head around how to use the systems, where things are, what the keypad code is to get into a ward.

So, if I could recommend anything to locums or people working with locums, it’s just to get to know one another and recognise it’s a collective endeavour.

It’s about patient safety ultimately, isn’t it?

Working against that by excluding a group who are really important for patient safety, keeping them out of the loop, and not giving them the information they need is nonsensical.

That would be my recommendation: bring people in, make it more inclusive.

Kieran Walshe: I’d just add that organisations should make less use of locums.

If you’re using locums because your HR department takes 12 weeks to recruit a replacement, tighten up your recruitment processes.

Use bank staff rather than agency locums, because bank staff are familiar to the organisation.

Where you do use locums, use them for longer term.

The key thing is to eliminate the use of short-term, unfamiliar locums — like someone hired for a weekend because there’s nobody to cover A&E.

That’s probably the highest risk area, both for the locum and for patients, so better to avoid that.

Jane Ferguson: Before we move on, there’s something to be said about the balance of the number of locums in an organisation.

Locums have been described as the oil in the wheels — really important to fill gaps when people are off sick or when recruitment is hard.

People say the NHS would collapse without them, and that’s probably true.

But locums shouldn’t be the wheels themselves.

There shouldn’t be so many locums that they are the service, because those jobs, like we said earlier, still need to be done.

There still needs to be someone who takes ownership, leadership, and thinks about quality improvement — things locums generally don’t.

So locums are the oil in the wheels, not the service itself.

Louise Gorman:  Something that came to my mind when you were talking is whether it’s infinitely more challenging for locums whose first language isn’t English, or who come from another country, to work as locums.

Is that more challenging on top of the difference between internal bank locums and external locums unfamiliar to the hospital, and then on top of that we have this.

 

Jane Ferguson: It does layer with other identities.

Locums often experience marginalisation and exclusion, and if you come from another country and don’t know NHS systems, it’s got to be really hard to get your head around.

Then being excluded and treated differently layers on top of that other identities.

Kieran Walshe: I think there’s a big difference between people working as locums by choice — for work-life balance, lifestyle, income, other responsibilities — and those working as locums because they don’t have a choice.

Some people coming to the UK from abroad might be working as a resident medical officer in a private hospital or as a locum as their first job.

From all the research the GMC has led, we know those doctors particularly need support and help, and are perhaps least suited to working independently.

They really need the scaffolding of working in an organisation with others who can support them.

Louise Gorman: Talking of support, what support do you think locums really need from their point of view?

Jane Ferguson: Induction — having a really thorough induction.

We could have developed a comprehensive induction pack in this project, but often that’s already been done.

The issue is locums aren’t paid to do the induction, so it’s kind of they have to meet the organisation halfway and take time to do it in their own time, which many are reluctant to do.

So that sense of inclusion and a proper induction programme doesn’t always happen because it’s not paid for.

So, do organisations pay locums to do that?

And is it going to be acceptable to say, “We’re going to pay you to do that piece of work, to do the training we need you to do, to come to multidisciplinary team meetings”?

Quite often, locums are employed to serve clinical needs.

We need hands on deck to do this job, but they’re not paid for all the other peripheral things that are also really important for patient safety.

I think it’s going to cost. Locums need to be paid properly for induction and for attending team meetings that they might otherwise miss because they’re on the ward doing the job while everyone else is in the meeting.

So, it’ll cost more money ultimately, which is a bit of an issue given that one of the things we hear most about locums is the cost of it.

To make it safer and better integrate them will be more expensive.

Louise Gorman: If there’s one point, Kieran, for you — I know Jane has given her point about what’s most important to think about for patient safety with locum workers — but for you, what would be the most important take-home?

Kieran Walshe: I think it’s about doing things that get organisations involved to, as I said earlier, up their game.

That’s partly about following the rules and guidance that already exist.

It’s also about creating a framework for overseeing locum agencies that doesn’t exist at the moment.

So regulating locum agencies and making sure that organisations who use locums are doing what they need to do to ensure patients are safe.

It’s not rocket science.

Louise Gorman: Thank you for that. That’s a really nice point to end on, isn’t it? It’s not rocket science.

What about both of you — what drives you personally to work in patient safety?

What is it about safety and quality that really entices you to work in this field?

Jane Ferguson: I think that’s an easy one, isn’t it?

You only need to spend time reading patient stories or seeing reports in the press to light enough of a fire under you to do this work.

Kieran and I are just moving on to a project about unprofessional behaviour among staff and what that means.

Knowing the effects of unprofessional behaviour on people, and how harmful it can be to their mental and physical wellbeing — that’s what gets me up in the morning.

Kieran Walshe: This is where I’m going to sound ancient, but I’ve worked in the NHS for nearly 40 years.

I started as an NHS manager.

Looking back, you realise how far we’ve come.

When I was an NHS manager, clinical practice was a secret garden.

What doctors did was no one else’s concern but that of other doctors.

We’ve travelled a long way in opening up that secret garden — getting much greater transparency and accountability, as well as better support and engagement, and lots of good things for doctors.

I’ve never wanted to be a doctor. I don’t know how I’d cope with the responsibility of the decisions they make.

I have huge respect for that.

But I think we are now doing a much better job of training, developing, and supporting doctors to be safe in practice.

And that is really satisfying.

Louise Gorman: Amazing!

Jane and Kieran, thank you so much for taking time out of your busy day to talk to us about the challenges of locum working — for locum doctors, organisations, and healthcare teams.

Listeners, thank you for taking time out of your busy day to listen to our podcast today.

If you want to find the papers and show notes, you can go to our website as always: www.psrc-gm.nihr.ac.uk/news/podcast

You’ve been listening to Voices for Safety, the podcast that explores the forefront of patient safety research, brought to you by the NIHR Greater Manchester Patient Safety Research Collaboration.

If you enjoyed today’s discussion and want to stay updated on the latest in patient safety, be sure to follow us for upcoming episodes.

You can also find us on X, Bluesky, LinkedIn, and on our website: www.psrc-gm.nihr.ac.uk.

Join us as we continue to uncover insights and innovations that make healthcare safer for everyone.

Thank you all for listening, and we’ll catch you in the next episode.

 

• ⁠MOMENTS – Nurturing safety culture through everyday practices – As discussed in the podcast, MOMENTS is a framework of resources aimed at nurturing a culture of safety within healthcare. You might want to explore their findings and tools for improving safety culture in practical settings.
• ⁠NHS Patient Safety Strategy – The NHS provides detailed guidelines and strategies to help improve patient safety. Understanding these frameworks can be valuable for contextualising the research findings discussed in the podcast.
• NHS People Promise – Explore the NHS People Promise, which emphasises the importance of a positive workplace culture, transparency, and giving all staff a voice. Understanding this can further guide you in discussing how employee empowerment impacts patient safety.⁠
• Enhancing Cultures of Safety research theme – This research theme at the NIHR Greater Manchester Patient Safety Research Collaboration (GM PSRC) aims to explore and understand cultures of safety. This will help researchers to identify how to develop positive cultures across health and care settings to improve patient safety. 

Dr Louise Gorman: We are no strangers to hearing about NHS organisational culture. For a long time, it’s been the hot topic for organisations, for investigations, for the media and for research. Organisational culture is a collective way of thinking and interacting within an organisation. It’s not only having our mission and our values, all those statements on our website, but it’s actually truly living it. How we work, how we interact with each other, how we deliver for our day-to-day tasks, how we work in teams, and how we conduct our meetings all impact our staff. And it’s not solely a healthcare issue.

A good organisational culture is important in every single workplace. Having a healthy staff culture affects how we, as service users, will be treated. If we take care of our staff, our patients, and our service users will be safe as well.

[Music]

Hello, welcome back to Voices for Safety, the podcast from the NIHR Greater Manchester Patient Safety Research Collaboration, where we discuss all things patient safety.

I’m your host, Louise Gorman. In this episode, we’re going to be talking about one of the key foundations of the NHS Patient Safety Strategy – that is, safety culture.

In all of its variations, of good, bad, large, and small scale, culture has a role in determining patient safety. But what is a positive safety culture? Well, NHS England defines positive safety culture as an environment that is collaboratively crafted, created, and nurtured so that everybody can flourish. And this involves creating a psychologically safe environment that supports continuous learning and working to improve safety risks. But how do we do that? And how do we operationalise those values that promote patient safety?

To discuss this further, we’re joined by two of the researchers from our Greater Manchester PSRC Enhancing Cultures of Safety theme. This research theme of work aims to deliver theoretically informed yet practically useful research to enable cultures of safety within health and social care organisations.

I’m really pleased to welcome Professor Nicola Mackintosh and Dr Jennifer Creese to the podcast to tell you more about this fascinating yet complex area of patient safety.

 

Prof Nicola Mackintosh: Hi everyone, I’m Nici Mackintosh. I’m a professor in social science applied to health within the SAPPHIRE group at the University of Leicester, and I’m also co-lead for the GM PSRC.

 

Dr Jennifer Creese: Hello, I’m Jennifer Creese. I’m a lecturer in Health Services Research here at the University of Leicester. I’m a sociocultural and a medical anthropologist, and the kind of culture I study is healthcare and healthcare professions. I’m a lead of one of the projects within the GM PSRC.

 

Dr Louise Gorman: Wonderful. So, I’m hoping that we’ll have a really good discussion today about enhancing safety culture in health and social care. Now, we know that that word “culture” is used frequently day-to-day in a much wider context, but I wonder if we could start with you telling our listeners what culture means in the context of patient safety?

 

Prof Nicola Mackintosh: I think when we were undertaking our research, one of the areas we wanted to look at was to sort of move away from maybe more professional ways of thinking about culture, because there’re disciplinary differences in how people see what culture is. And we wanted to make it much more accessible. So, in the realms of patient safety, we were trying to make it quite practically accessible in terms of thinking, how does culture affect the way people work, but also, importantly, in the way they relate to one another and in the activities that they take in shared practices. So making it sort of much more about the day-to-day world that we live in, particularly in health and social care and in those relationships between staff and also with their service users, patients, and families. And thinking about how does that cultural glue, in a way, influence what we do and how we make sense of it. So, I think that’s what we were trying to get at in our research was to say, move away from these very intellectual definitions to something that people could really understand and get a handle on.

 

Dr Louise Gorman: Yeah, and I think that’s really important, isn’t it? To be able to translate that practice and make it meaningful to everybody within the health service and within social care settings as well, to understand what it is that’s actually coming out of your research. Essentially, you’re talking about culture and how people relate to each other, what they do, and how they do it at work. How do you explore safety culture through your work? Is it a series of projects? What type of projects are they?

 

Prof Nicola Mackintosh: So, I think we have a track record within our research group of looking at safety and culture, and so I think our learning is sort of built on that. Our work really is around using social science theory and methods, so we draw on that sort of wider literature, which is informed by psychology, anthropology, and sociology, to perhaps look differently from a clinical lens. So, to try and use some of that broader theory to think how does it relate? And in terms of our methods, we are methodologically sort of in the qualitative methods camp. So, our work involves interviews, focus groups, and also observing, actually going in—almost living amongst staff—to actually understand their world. So, I think what we try and do is inform some of the understanding around what safety culture is and how we can best nurture it by drawing on that literature and also trying to really understand people’s own experiences.

 

Dr Louise Gorman: I know that you have been working on quite a large project called MOMENTs. So, Nici, can you tell us a little bit about what MOMENTs is and what MOMENTs is all about?

 

Prof Nicola Mackintosh: So, MOMENTs is a set of practical resources that have been developed to help staff have conversations and think about how best to enable their cultures of safety locally. It originated from some previous research that we did within maternity and neonatal services, which focused very much on enabling cultures of safety in those settings. So, we used the research findings to generate some ideas for how we could practically help staff make safety culture more accessible and think about how to generate new understandings and think practically about how they could work in their local teams to think about enabling development in that area. So, I think what makes MOMENTs quite different, in a way, with our starting point was to try and work from a position of where things have worked well. So, rather than looking at learning from incidents or adverse events, what we wanted to try and do was understand what good looks like in a variety of different ways and how people make sense of when they feel things are working well in their own particular area.

So, the project started as a commissioned call from NHS England, and we worked with 10 organisations to try and understand what that meant for them. The way we identified the organisations was that NHS England had undertaken a safety culture survey throughout the whole of England, and we used the scores of those surveys as a point of entry to understand those organisations that had scored highly and also had high response rates, so staff had been motivated to fill it in. But we weren’t really interested in the scores as such; it was just a starting point for us to then investigate what did that survey mean to them? How did they actually feel in terms of whether that score represents reality? It allowed us to get in and really have conversations about what safety culture is. Following on from that project, we became interested in how people understand what interventions, the role of interventions, in terms of enabling safety culture. Rather than seeing interventions as a form of solution to actually helping safety culture, we started to think about interventions as a window into perhaps enabling people to see actually what was going on locally. And so it enabled us to think about how we could develop a resource to help people think about their own safety culture and actually what they were doing well, but perhaps areas for improvement.

We drew on social practice theory to really try and give an aid memoir to staff. So, as well as thinking about relational elements, social practice theory also draws attention to the structures and the material elements that staff are working with, which we know can really influence culture. It also draws attention away from individual behaviour to competences. So, how staff work, do they have the right competences to actually do what they’re supposed to be doing? And, importantly, what are the meanings that, actually, are implicit in certain ways that we work? And that was how we developed a resource. So, I think that’s a nice example of a project where we’ve drawn on theory, but we’ve also tried to make something quite practical for staff at the end.

 

Dr Louise Gorman: Yeah, and by materials, we’re talking about tools like infrastructure, training, any policies that exist, and those guidelines, and how they play a role in staff activity on the ground.

 

Prof Nicola Mackintosh: Absolutely. And we’re also talking about things like space. Space can have a really important effect in terms of what we found is collocation is actually a really important enabling factor. So, maternity and neonatal units, for instance, if staff are located next to each other, they can pop in and check on, “Are they doing okay?” Whereas if you have to run up three flights of stairs, that can be quite a barrier. So, materials are the structures, the things that we work with, that can really shape how we work. But I think one of the really important factors that came out in our findings that staff alluded to through their narratives were the values that were implicit in whether things were felt to work. This sense of core values that were enacted in the way that people did things. So, if, for instance, staff talked about walkarounds or safety huddles, what we started to see is that those only had meaning if certain values were explicit and obvious through them. Whereas often interventions can be utilised, but they become detached from what they’re actually supposed to do, and the values, in a way, create a bit of discordance there. So, actually, what we could see was that sort of central process of actually trying to work out what is being enacted through this practice, how is it actually working, and how are people making sense of it?

 

Dr Louise Gorman: And by those values, are we talking about that idea of having transparency, openness, respect, and compassion?

 

Prof Nicola Mackintosh: Absolutely. They’re core values that are part of NHS and social care, which is that thing about respect, transparency, openness, dignity—it’s those. And we talk about them, but actually, they can be quite hard to operationalise in a way and see. And I think some of the conversations we were having, interestingly, is some people would see some form of practice, say a team meeting, and they might have quite different ideas of the values that are being enacted in that, and that’s quite an important conversation to have to actually say, “Actually, my interpretation of what’s going on here is quite different.” So, what we found was it was those conversations that were really important, but they were anchored around everyday activities, which makes it much easier to have those conversations rather than talk about, “Well, how is your culture?” which feels very abstract and difficult to get hold of.

 

Dr Louise Gorman: Absolutely. And I think the one thing that you’ve drawn upon there is, you know, how do people feel that they feel empowered enough to talk about how they interpret what’s happened in a meeting, their value versus somebody else’s value, and having that open conversation. A key part of the NHS People Promise is ensuring that all people have a voice that counts. So, Jennifer, I wonder if you can jump in there and tell us a little bit about this idea of speaking up and why it matters so much.

 

Dr Jennifer Creese: Okay, so we know that healthcare is this world with lots of policies and procedures and a lot of safety netting, but it’s, at the end of the day, also a world full of people—human beings. The patients are human beings, doctors are human beings. And so, sometimes in human life, sometimes things don’t work, some things don’t get done, or they’re not happening in an effective or appropriate way, and that could be for lots of different reasons. And they can have a real effect on patient and staff safety. But healthcare is also so busy, particularly when the system’s under a lot of pressure, these things can get missed and slip through the cracks. So, it’s really important for people who do notice something, when something’s not right, to be able to say something—to stop the problem, fix the problem before it happens, or to flag a change that’s needed so things can improve.

But we know that a lot of the time, people don’t say anything when there’s a problem situation. Sometimes they’ve tried raising the problem before, and nobody’s listened or nobody’s done anything, so they feel quite apathetic, like there’s maybe no point in saying anything again. And sometimes people feel afraid to speak up. They maybe don’t want to confront a colleague, maybe they don’t want to confront someone who’s senior to them or the manager. They might be afraid that they’ll get blamed, or they might be afraid that it might label them as a troublemaker and it might risk their career. And so then they end up not speaking up, or they don’t speak up, or they decide their only option is to leave that place because it’s not safe for them anymore. And then the problem doesn’t get fixed, and in the worst-case scenario, something unsafe happens, and it’s not caught, and that can be catastrophic in terms of consequences for the patient and for the staff. So, that’s why speaking up really matters.

 

Dr Louise Gorman: Are there particular groups of staff, do you know, that are affected by an inability to speak up, or not feeling empowered enough to speak up, or is it something that we see generally across health and social care?

 

Dr Jennifer Creese: Well, we know from… we have really good national data like the NHS staff survey, which asks a question of all staff in the NHS. It asks them to agree or disagree with whether or not they feel like they can speak up when they see something unsafe at work. We know from that data that people who identify as non-white British, they report feeling much less able to speak up. We also know that women feel much less able to speak up, or non-male people feel much less able to speak up. LGBTQ people feel much less able to speak up. Migrant and temporary working doctors and nurses feel much less able to speak up, and junior staff—so, people who are in junior nurse or resident doctor roles or in auxiliary staff roles—feel much less able to speak up.

But the thing with the big surveys is they kind of don’t tell us why they feel unable to speak up. So, we felt that there was a real need for some qualitative work, which is actually hearing directly from these staff about what the reasons are, why they’re saying they don’t agree that they could speak up at work. So, that’s why we did the work that we did.

 

Dr Louise Gorman: Okay, brilliant. It sounds like it’s really, really interesting work. Can you tell us a little bit more about the work that you have been carrying out to date? I know that it’s not in its full completed status at the moment, but yeah, if you could give us an insight into what you’ve been doing and what you’ve potentially found out.

 

Dr Jennifer Creese: Okay, so we started off by interviewing frontline NHS staff from all over the country to ask them about their thoughts and experiences about speaking up or feeling unable to speak up. We started by inviting any non-white British staff in any patient-facing role at all to have an interview with us, and we spoke to 12 people in the end from all over the country. We also wanted to see what it was like from the other side, so what NHS Trusts felt like they were doing already to try and encourage this speaking up and a culture of speak up and safety for all staff, and what they were doing to try and make non-white British staff feel like speaking up was wanted and safe and would be heard. So, we wanted to get a sense of both sides of the story and see where there was a misalignment or whether there were things falling through the gaps that we might be able to help fix.

So, we spoke to 17 people who were in quite senior roles—key roles related to patient safety. Some of them were speak-up guardians, heads of patient safety, other related kind of senior governance roles from NHS trusts all over the country, to see what was their perspective on what they were already doing.

 

Dr Louise Gorman: So, what did you find?

 

Dr Jennifer Creese: So, we did find that ethnicity played quite a big part in the decisions that people were making about their own speaking up. That when they felt that there was a cultural divide or a difference between them and the people they were trying to speak up to, they found it was much more difficult to speak up or even to summon up the courage to speak up. A lot of them spoke about fear of discrimination if they might speak up or discrimination against them if they did speak up. A lot of them spoke about a fear of discrimination if they might speak up. Some of them spoke about discrimination that they did experience when they did speak up. Many people spoke generally about if they had the kind of work environment where discrimination was common. Even we call them microaggressions—so, kind of small stereotypes and just casual little pointing out differences that isn’t actively trying to be racist or discriminatory, but it creates this kind of environment where people feel different and they feel less safe to speak up.

We saw that hierarchy in seniority did play a big role in further influencing who felt safe to speak up. So, we did find that nurses in lower bands, non-consultant doctors, no matter what range of resident doctor they were, auxiliary staff, healthcare associates, those were the kinds of people who said, “I feel less confident to speak up, and I probably wouldn’t in the first place.”

We also heard that where people did speak up, lots of people felt like it wasn’t welcome, or that it was welcome but it kind of went nowhere. And that inability to be heard, when you’ve summoned up that courage to speak out over the fear of or the feeling of unsafety that you’re working with, for a lot of people, that resulted in really feeling unsatisfied in their job, with resentment or breaking down relationships with their colleagues, and they felt a real sense of disconnect and isolation. That often leads to making career choices to leave that trust or to completely leave the NHS or the country, even.

And then, interestingly, we heard from the people in senior speak-up-related roles that they weren’t completely blind to this reality. They knew that staff didn’t feel safe, and they knew that trusts were kind of trying to create this sense of what we call psychological safety—so, feeling safe to be able to say what you need to say with no fear of repercussions. The NHS trusts wanted to have this psychologically safe environment, but a lot of the time, managers and people that were the sorts of people that you would speak up to, they weren’t really trained for how to create that environment for people where they can speak up and feel listened to. And that managers were also under this immense pressure to deliver and meet performance targets and meet performance standards. Stopping and taking time to go, “We’re going to take that person out of the care arrangement,” or, “We’re going to change this practice,” or, “We’re going to give you this thing,” or, “We’re going to repeat this,” or undertake a big investigation of it, would disrupt that flow of what they were being measured on. So, it was kind of trying to decide what to prioritise, and often voice got prioritised lower than meeting other targets.

 

They did feel that there was training for staff and managers around some of the issues that we see around speaking up. There was a lot of EDI training, a lot of bystander training, and things like that, but that didn’t really do what was needed for the purposes of breaking down some of the barriers that we identified to speaking up and listening.

 

Dr Louise Gorman: So, there’s obviously not necessarily a mismatch there. It doesn’t sound like there’s a mismatch between senior staff and organisations. They seem to be aware and acknowledge how these more junior staff or lower band staff are feeling about being able to speak up. But I wondered, do you have any insight into what organisations can do? Because it seems like there’s knowledge there; there’s knowledge that people don’t feel that they can speak up, but what can they practically do? We can all say, I think, that, you know, we can all acknowledge that people are busy and they have targets to meet, but what practically can organisations do to help?

 

Dr Jennifer Creese: So, this is something that we’re aiming to work on directly with some of these stakeholders in a lot of the trusts who are affiliated with the GM PSRC, and we’ll be having a policy dialogue in the next month with many of these senior regional and national leaders to try and translate these findings into something more practical.

I think the key message is that the NHS, as a whole, and organisations within it do need to do more in order to listen to all staff and provide safe, good-quality care. So, this means things like encouraging ethnic minority staff to speak up, and there are lots of different forms that that could take. A lot of suggestions came from our participants that might be worth exploring. We think that senior leaders do need to be part of the solutions more to encourage speaking up. But I think, more importantly, speaking up and listening have to become part of that organisational culture that Nici was talking about for everybody. It’s got to be a normal, everyday practice to be able to speak up and say things and to be able to listen to people. It’s got to be meaningful, it’s got to be accessible, and it’s got to be acceptable in whatever form it takes. So, we’re looking forward to this dialogue to see how we can turn those kinds of visions into something that’s practically actionable at lots of different levels of the NHS.

 

Dr Louise Gorman: It sounds really valuable, very timely, and very needed as well to have that conversation with all of those stakeholders, hopefully in the same room as well.

Nici, I’m just in my mind thinking back to the MOMENTs work, and I know from the MOMENTs website you have some resources on there to enable people to start having those conversations around the moments in their everyday practice that help to improve that safety culture, or at least have those conversations around safety culture. Is there anything from there, do you think, that would align with Jennifer’s research? Anything practical that trusts can do or implement from MOMENTs to help really raise this idea of “it’s okay to speak up”?

 

Prof Nicola Mackintosh: So, I think the MOMENTs resource is a framework, really, to enable conversations. It doesn’t provide a solution, but I think the reason for that is that often we jump to coming up with uniform solutions that may not fit local practice or local areas. So, we wanted to move away from that to enable people locally to actually take agency and ownership of their own solutions. But often, it’s the slow science, the reflexivity, the thought before that’s the important bit that we skip through to get to the solution.

So, I think, definitely, in terms of thinking about speaking up, escalating care, and all of those areas, they involve everyday practice that can be used as a moment to actually try and unpack what’s going on here and what the cultural issues are within this everyday team activity that we’re undertaking.

So, MOMENTs has the potential to maybe enable people within a ward team to think about, “Okay, who is able to speak up in this team and who isn’t? When does it happen, and who to? What are the structures and relational barriers around that?” To make it much more locally driven.

 

Dr Louise Gorman: Yeah, it’s really encouraging to see that movement away from that one-size-fits-all approach, more to bespoke solutions that can be embedded into individual teams in the best way that those teams see fit.

Nici and Jennifer, it’s been absolutely wonderful to have the time to talk with you both today. Thank you for allowing us to dip our toes into your fascinating field of research and for helping us understand how healthcare teams can really nurture those unique moments and build better safety throughout their working day.

Listeners, if I were you, I’d head straight to the MOMENTs website and immerse yourself in the wealth of resources that are there, that will support you in exploring your own safety cultures. You can check out the MOMENTs website at moments-safety.com

Keep listening for the next episode, where we’re going to be discussing what policy around safety culture looks like, how research impacts policy, and how policy, in turn, impacts practice. See you there!

[Music]

You’ve been listening to Voices for Safety, the podcast that explores the forefront of patient safety research, brought to you by the NIHR Greater Manchester Patient Safety Research Collaboration (GM PSRC). If you enjoyed today’s discussion and want to stay updated on the latest in patient safety, be sure to follow us for upcoming episodes. You can also find us on X, Bluesky, LinkedIn, and on our website: www.psrc-gm.nihr.ac.uk.

Join us as we continue to uncover insights and innovations that make healthcare safer for everyone. Thank you all for listening, and we’ll catch you in the next episode.

Louise Gorman:

Hello, and welcome to Voices for Safety, a podcast from the NIHR Greater Manchester Patient Safety Research Collaboration, or GM PSRC. I’m your host, Louise Gorman, the Public and Community Involvement and Engagement Manager for GM PSRC. I’m very excited to introduce to you our brand-new podcast, where we’ll explore the latest issues and breakthroughs in patient safety research.

Today’s episode is extra special. Besides being our very first episode, kicking off our journey together, it also marks this year’s World Patient Safety Day, celebrated on September 17th, 2024.

World Patient Safety Day is an initiative established by the World Health Organization to raise awareness and emphasise the importance of patient safety globally. But what exactly is patient safety, and why does it matter?

To help us unpack this critical area of health, I’ll be joined today by Professor Darren Ashcroft, Director of GM PSRC, and Neil Walbran, Chief Executive Officer of Healthwatch Manchester. Together, we’ll explore what patient safety truly means and why it should be a priority for everyone.

Then, later in the show, we’ll dive into this year’s World Patient Safety Day theme: improving diagnosis for patient safety. I’ll be joined by Tom Blakeman, a GP and Professor of Primary Care at the University of Manchester, Umesh Chauhan, a Professor of Primary Care and GP Partner from the University of Central Lancashire, and Tony Avery, Professor of Primary Care, a GP, and also the National Clinical Director for Prescribing from the University of Nottingham.

Anyway, enough from me. Let’s get on with the show!

[Music]

So, Darren and Neil, welcome to Voices for Safety. It’s really great to have you here. So, what is patient safety?

Darren Ashcroft:

From my perspective, patient safety is really a discipline where we look to identify where risks, errors, and harm occur to patients. The research arm of that focuses on how we address those issues.

Neil Walbran:

From our perspective, as Healthwatch, it’s about members of the public having the right to feel safe entering any health and care system and knowing that their safety is a priority for the people treating and caring for them.

Louise Gorman:

Is patient safety a local issue?

Darren Ashcroft:

It’s very much a global issue. But within the NHS, we regularly see news reports of problems that occur within our health and care systems. We’ve conducted research that starts to identify and quantify how often some of these errors occur, so we have a good measure of how often adverse or preventable events happen within our health system. A lot of our research focuses on how we address some of those problems, co-develop interventions with patients and practitioners, and try to get them embedded into our NHS to improve safety overall for everyone.

The WHO have established a special interest group around safety, and they’ve had three international campaigns to date. The most recent one was around improving medication safety and reducing harm from medicines.

As part of the global initiatives, governments in different countries are often asked to challenge and test the systems they operate. For instance, in the UK, we brought together groups of experts to consider the recommendations from the WHO, which led to some recommendations that were implemented. In fact, one of our interventions from the Greater Manchester Patient Safety Research Collaboration was rolled out nationally to try and reduce harm from medicines in primary care, and we’re in the middle of evaluating what the impact of that intervention is at the moment.

Louise Gorman:

So, locally then, to what extent is patient safety an issue for our NHS?

Neil Walbran:

I think it’s a massive issue. It’s an ongoing issue, and it always will be. Whether you’re somebody who requires medicines use review from your pharmacy because you’re being prescribed 35 different medications and experiencing contraindications, or somebody in full-time care who needs turning and your pressure sores are treated, to someone who is unable to understand the letter they’ve received from the hospital and doesn’t know where to go for their appointment. The more you think about it, the more it unravels. Patient safety runs right through—it’s the golden thread that runs through all our health and care services.

When a patient goes into hospital, when we… Any of us are a patient at any time in our lives, when we go into hospital, we become more vulnerable. Now, if you add to that somebody with a protected characteristic, say someone with a learning disability who goes into hospital, they’re even more vulnerable in that situation. Those things have to be taken into account.

Louise Gorman:

So, who are the key groups we want to highlight as being important for improving patient safety, both on the health service side and on the public side?

Darren Ashcroft:

I personally think it’s everybody’s business, really, around safety. Clearly, healthcare professionals—doctors, nurses, pharmacists, and other allied health professionals—have an important role because they’re often on the front-line delivering health and care services. But patients themselves, when they’re actively engaged in their own care, can be excellent advocates for improving safety by identifying when things go wrong or reporting when things just don’t feel right in a particular situation.

Within healthcare organisations, I think it covers all levels. You know, the leaders and managers have responsibilities for the policies and procedures set around safety and for monitoring how effective those are. But beyond that, we’ve got regulators responsible for monitoring safety and protecting public safety, and educators, too, who educate the workforce that will work in our health and care services in the future. So, I think it really is everyone’s business.

Louise Gorman:

Absolutely.

Neil Walbran:

Yeah. Definitely. I mean, it’s the people that work in the healthcare system that need the ability—the freedom—to speak up. Freedom to Speak Up Guardians are an example of a step towards creating better patient safety. But out there in the real world, outside health and care, it’s the citizens who speak up, who decide, “This isn’t good enough,” whether they’re from those communities or just as a family. fa springs to mind—that’s fairly recent now, and it’s being rolled out across all our hospitals. That’s because those parents decided that simply wasn’t good enough the way their daughter was treated and how she died. So, yes, I would say from the citizens’ perspective, it’s those champions who speak up.

Louise Gorman:

So, Neil, I think this is a really good point. Can you tell us a little bit about what Healthwatch Manchester actually is?

Neil Walbran:

Okay, well, Healthwatch was set up in 2013 through national legislation brought about by the Health and Social Care Act in 2012. In each local authority area in England, there is a Healthwatch by law. We are independent, not-for-profit organisations with a board of directors or trustees and a small staff team, usually. It’s our job to inform and signpost people to health and care services, to speak up for people, and to direct them to their rights as citizens, patients, and users of health and care services.

We also collect the views, opinions, and experiences of people around health and care, and use those in our reviews and reports to influence health and care services and improve them by having conversations with the planners and commissioners of those services.

So, we are Healthwatch Manchester. We are also part of the Greater Manchester Healthwatch network, which includes all ten local Healthwatch organisations in Greater Manchester. We meet regularly, and we have people in post to support us, commissioned through the Greater Manchester Integrated Care Board (ICB).

What we do locally is inform and signpost people to health and care services. This could be anyone phoning or emailing us, asking, “Where can I get an NHS dentist?”—which happens almost every day at the moment and has been for a few years—or someone asking, “Where can I make a complaint? I feel like I’ve been treated very badly.” We also do outreach, engaging with people to find out their views, experiences, and opinions of health and care services. If we see anything concerning, we act on that by doing an interview or a review of that service.

I can give you an example of that recently, if you like.

Louise Gorman:

Yes, please.

Neil Walbran:

A woman was on her way to work when somebody collapsed at the bus stop. They dialled 999, and the ambulance service told them to go to a defibrillator site. They went there, but there was no defibrillator. They called up the ambulance website and tried to find another defibrillator, but there wasn’t one there either. After 15 minutes, they returned to the person who, luckily, was being resuscitated and survived. But they came to Healthwatch in an absolute state, saying this had happened.

So, we’ve just completed our review of defibrillator sites—are they there? They say they are there, but are they actually there? It’s not looking good. 40% of the time, they’re not there, nobody knows anything about them, or they’re not in a condition to be used. We’re taking that report nationally. There doesn’t appear to be any regulation around the information on defibrillators. Anyone can pick one up, but if they decide not to have it anymore, there’s no obligation on them to inform anyone or say, “We’re not using this defibrillator anymore, we’re not providing it”.

We don’t think this is good enough. We’re going to call for regulation around this information so that this never happens again. It’s not like, “Oh, try again next time.” There is no next time in this situation—someone will die.

Louise Gorman:

So, helping to identify those areas where patient safety errors or unsafe practice can occur.

Neil Walbran:

Yes.

Louise Gorman:

As well as helping to find out exactly what’s going on in those areas and trying to figure it out.

Neil Walbran:

And learning from them.

Louise Gorman:

And learning from them, exactly. And, I suppose, sharing that learning as well.

That links nicely to Darren. Would you be able to explain to us what the Patient Safety Research Collaborations (PSRCs) are?

Darren Ashcroft:

The Patient Safety Research Collaborations, or PSRCs for short, are an initiative funded by our national research funding scheme, the National Institute for Health and Care Research (NIHR). They’ve awarded just over £25 million over a five-year period and funded six PSRCs to conduct research to address patient safety problems and, in particular, to start reducing inequalities in safety. That’s the main focus of the PSRCs.

Within Greater Manchester, we’re a collaboration that brings together safety scientists across the Universities of Manchester, Nottingham, and Leicester to tackle some of these problems. We have four main research themes. One is around improving medication safety—medication is the most common intervention used in healthcare, and it does a lot of good, but from time to time, medicines can also cause problems. We’re trying to address some of that hazardous prescribing or misalignment of medicines to the wrong patient or at the wrong time.

We have another theme focused on developing safer health and care systems. Many innovations come into our health service, and while they’re intended to bring a lot of benefits, sometimes there are unintended consequences. It’s important that we evaluate these systems and understand not only the effects but also some of the adverse consequences so we can develop better systems going forward.

We have a theme around enhancing cultures of safety. Often, when we look at major incidents within healthcare, the underlying culture within those organisations is flagged as a key factor in why things go wrong. So, we’ve got a team focused specifically on trying to understand and improve organisational culture.

And finally, we have a theme focused on mental health, particularly around preventing self-harm and suicide. Unfortunately, too many people die through suicide, and rates of self-harm have increased in recent years, especially in particular groups of patients. We’re developing initiatives to try to address some of these issues and reduce the inequalities that occur within our society as well.

Louise Gorman:

And how does Greater Manchester PSRC relate to other PSRCs in England?

Darren Ashcroft:

We were very fortunate that, through the national funding body, we were awarded a project fund that allowed us to create a network. So, we have a network called SafetyNet that brings the six PSRCs together around some common themes. We take responsibility for different areas of those activities, and we’ve established a number of working groups across that network, allowing us to bring expertise from across the country together around key areas of work.

Louise Gorman:

How do you see our own PSRC in Greater Manchester working with organisations such as Healthwatch to improve patient safety?

Darren Ashcroft:

It’s hugely important, and across our own PSRC—and likewise for the other PSRCs—public involvement, along with the involvement of charities and other organisations, feeds in at various levels across the infrastructure. As Neil has highlighted, we’re really fortunate that he is a member of our Strategic Advisory Group, along with many other organisations. That plays a key role because they are seeing lots of problems in the system, which allows us to hear about their experiences and think about what some of our research priorities should be going forward.

Within our governance board, we have patient and public representation, so they’re holding us to account in terms of what we say we will do and whether we meet those goals in due course, which is appropriate. But also, when we get down into our themes and individual projects, all of those projects have public involvement anchored into them as well. It’s really important because, if our focus is on co-developing interventions, we need to work closely with patients and practitioners who are going to use these interventions in the future to make sure we’re developing interventions that are likely to be adopted, are sustainable, and have evidence of impact going forward.

Neil Walbran:

Well, it’s great to be able to add the patient and public voice to the mix as well. From my perspective, it’s all about building responsivity into the system in terms of taking that patient voice and making it heard. That’s how I see the role of Healthwatch at the PSRC.

Yes, and how important is research in the whole topic of patient safety?

Darren Ashcroft:

Through research, we can often identify some of those problems and quantify the impact and size of the problem. We can use research to develop solutions to address some of those problems. But also, as I mentioned earlier, many things are rolled out into systems with the intention of doing good, but sometimes there are unintended consequences. So, we can also evaluate some of the innovations that happen in our health and social care systems, making sure they land on the right tracks, deliver what they were hoped to deliver, and, hopefully, result in better care, not worse care.

Louise Gorman:

Thank you, Darren and Neil, for talking to us today about what patient safety means.

This World Patient Safety Day focuses on improving diagnosis, but patient safety incidents and avoidable harm don’t just happen in hospitals. Primary care is often the first point of contact for most patients seeking healthcare. But what do we mean when we say primary care?

Primary care is described as the front door of the NHS. It is made up of around 7,500 practices, 11,500 pharmacies, 7,000 optometrists, and 8,500 dentists. High-quality patient care at every contact is the aim of every healthcare team. There are approximately 340 million consultations in the UK each year in general practice, and on average, a GP has 42 patient contacts a day.

Although the vast majority of these consultations pass without incident, the sheer volume of contacts can significantly increase the likelihood of patient safety incidents occurring. A review by the Health Foundation in 2014 estimates that patient safety incidents may occur in around 2 to 3% of all family practice consultations, and one in 25 of those involves serious harm to the patient. This means that there are several million patients potentially at risk of avoidable harm each year.

A paper published in 2021 by Professor Tony Avery and colleagues concludes that diagnostic error accounts for the most avoidable significant harm seen in primary care. So, I’m utterly thrilled today to welcome Professor Tony Avery, Professor Tom Blakeman, and Professor Umesh Chauhan to the show. All three are general practitioners, amongst their many other roles. Would you like to introduce yourselves?

Tony Avery:

Yeah, hi, I’m Tony Avery, a GP in Nottingham. I’m Professor of Primary Healthcare at the University of Nottingham, and I’m also the National Clinical Director for Prescribing for NHS England.

Louise Gorman:

Welcome, Tony. And Tom?

Tom Blakeman:

Hi, nice to be here this morning. I’m Tom Blakeman, a GP, and I work in Harehills, inner-city Leeds. And I have a transpennine experience in that I’ve been a researcher at the University of Manchester for over 20 years as well.

Louise Gorman:

Wonderful, thank you for joining us. Umesh, it’s lovely to have you here as well.

Umesh Chauhan:

Thank you. So, I’m Umesh Chauhan. I’m a GP in East Lancashire in Brierfield. I’m also Professor of Primary Care at the University of Central Lancashire and the Quality Place-Based Lead for Lancashire and South Cumbria.

Louise Gorman:

Wonderful, well, thank you all for being here this morning. I wondered if you could tell our listeners what diagnosis means and, importantly, what a diagnostic error is.

Tony Avery:

A diagnosis identifies a patient’s health problem and is the key to making sure that people get the treatment they need. Now, in general practice, we don’t always come to a clear diagnosis at the end of one consultation, and it may not be necessary to have a clear diagnosis. But the most important thing is to have a good idea of what is going on for the patient and what you need to do, particularly in order to either identify or exclude a serious illness. So, I think that’s the important thing: having that approach to really thinking about what is going on for the patient and what needs to happen next.

A diagnostic error occurs if you either don’t manage to get the right diagnosis or the right idea of where you need to be going with things, and fail to do that in a timely way. This can then result in an incorrect diagnosis or approach, which can waste time and potentially be harmful, delaying or actually missing the diagnosis. The key risk is that what is really causing the problem for the patient doesn’t get picked up, and a patient may be harmed as a result. A particular example is cancer, one of the areas where we want to be identifying cancers as soon as possible. Although we’re doing much better than we were, there can still be delays in diagnosis, which obviously has an impact on patients.

I think it’s really important to get the right balance, and that’s where organisations like NICE (National Institute for Health and Care Excellence) and the National Screening Committee are helpful in advising us on the sorts of tests and approaches that are useful for picking things up. The approach we have to the two-week wait system for picking up cancers, I think, is helpful. You’ve got a clear set of criteria, and if people fit the criteria, we can refer them for further investigations.

The challenge, I think, is with people who don’t quite fit those criteria. There’s a risk they slip through the net or end up on a prolonged waiting list to be seen. I think it’s with that group that you’ve got to be particularly on your toes. As a GP, you might think, “I know they don’t quite fit the criteria, but I’m still worried about this person.” It’s making sure that, in general practice, we talk about safety netting, making sure those people don’t just drop off and don’t get reviewed.

Making sure you have some systems in place to follow up with that patient—not just keep following up, following up, following up and doing nothing, which can waste weeks and sometimes months—but to get to a point where you say, “Hold on, we’re going to bail out on this; we need to get another view on this.”

Louise Gorman:

Absolutely. So, the complexity of the patient and what they’re presenting with—the signs and symptoms—are very difficult for you in general practice to make decisions, I suppose, quickly and cleanly. Particularly when you have, from the initial statistics, 340 million consultations in general practice alone in the UK, it is absolutely staggering to me. An average of 42 patient contacts a day for GPs makes it clear how challenging that is on so many levels, especially when you have that complexity for each individual that you’re seeing as well.

Tony Avery:

It is phenomenal what we manage as GPs from just what you have said. That was one of the things that came out from our major study on avoidable harm in Primary Care. To reassure people, when we looked at over 100,000 consultations across the country, we found that 97%, 97 out of 100 consultations were done well. We didn’t identify any significant patient safety issues. It was only in the 3%, but of course, when you multiply that by all the consultations, we did detect problems. Often, it was where GPs are having to deal, as you say, with highly complex problems presenting with multiple issues at the same time, and in the context of extreme demand. This requires tremendous ability to sift out what’s important and, most importantly, to do the necessary follow-up and safety netting.

Tom Blakeman:

I agree with Tony’s points. In a way, how a diagnosis helps in the ongoing planning of care is crucial. Identifying the problem and how diagnosis helps with that, having systems and care planning in place to see things through, is really important. Going back to the diagnosis, we need to ensure that they are helpful and don’t add to the complexity. How are they useful in planning care for somebody, and how do we minimise noise around making a diagnosis?

New diagnostic entities have come into place over the years. For instance, chronic kidney disease is a relatively new classification, a new diagnosis in the systems of care, which has been around for 22 years—which is nothing in the history of medicine. How we introduce it in a way that’s helpful and helps frame care for people. We need to ensure that it is understandable and doesn’t create extra noise and additional work. That requires careful consideration.

Umesh Chauhan:

I’m just conscious that the terms we’re using at the moment are very medicalised. A person, a patient, will present with a complaint or problem, and what we label it as is a diagnosis—what we think the cause of the complaint or problem is. In the context of working with people with learning disabilities, issues such as diagnostic overshadowing can arise. A person may present with something we don’t fully understand, and we put a label on it, saying this is the problem and this is how we’re going to manage it. This often leads to issues where it causes more harm than good to the person.

 

Inherently, I think it’s important for us to understand where we can avoid harm and where we’re causing more harm than good. Much of our work focuses on avoiding things that can be avoided and not causing unnecessary harm.

Tony Avery:

I think that’s a really good point, Umesh, because one of the biggest dangers, I think, is actually coming too early at a firm diagnosis. Once that’s done, once you’ve stated, “these upper abdominal pain symptoms are due to reflux or acid coming back into the esophagus or gullet”, or another example, it can lead both you and those following you to assume that the symptoms are only due to that issue. You need to ensure that your diagnosis is well formulated and that you keep an open mind as things develop, and thinking “perhaps that wasn’t quite right, perhaps it’s something else”.

Louise Gorman:

I think, for me, the point that Umesh was picking up on well is that how we talk about and define a diagnosis can potentially have consequences for patients, caregivers, practitioners, as well as the health system. It’s not just about the patient; it’s also about how that information is communicated and understood, affecting how you proceed both in medical diagnosis terms and in how the person and their caregivers interpret the information.

Tom Blakeman:

The risk often arises when you treat a working diagnosis established elsewhere in the system, by another GP or in A&E, at base value. Sometimes this can be a problem. It’s those points when you think that when you’ve seen somebody, and there’s something about preparing in advance of consultations, but also when you’re seeing somebody and you’re thinking “this doesn’t quite add up”. Using your clinical acumen and time and listening to somebody. And, so, that’s the moment to slow things down a little bit.

Tony Avery:

The most important thing from our study and experience is the value of rigorous training we have. It takes at least 10 years to train to be a GP, and experience continues to develop beyond that. But, starting out with that thing that we have had reinforced to us so much; starting with listening, really listening to what the person is telling us. Performing an appropriate examination and investigations, formulating an idea of what might be going on without fixating too early on a specific diagnosis, and ensuring appropriate follow-up with the safety netting.

Umesh Chauhan:

Tony and Tom will probably reflect on their training. One of the simple rules that I was taught is that if you’ve seen the person for the third time, or within the system for the same problem, you need to think again because, clearly, you can’t assume that whatever the diagnosis was, was the right diagnosis if the symptoms haven’t gone away. So, there has to be triggers in order to support you to think about this. Part of it is about our training, but also the system. There need to be ways to make you think: have I got the right diagnosis here? Have I gone down the right route? Should I be thinking of something else here?

Tom Blakeman:

In practice, my experience over the last 20 years—being in the same practice for over 20 years—is that uncertainty is inherent in everyday practice. Meeting people, listening, and thinking things through are crucial. I think listening is absolutely the key aspect of care. And with that, when you’re uncertain, having a safe environment to share those uncertainties with colleagues is vital. Corridor conversations, clinical meetings, team meetings, multidisciplinary meetings—you learn from them. You learn from the reception staff, clinical admin, the advanced clinical practitioner in the practice, and the social prescribing link worker, who has an insight into the person. This is where you begin to generate safe practice. This is what I’ve learned in my experience, in how to thrive, and how everybody begins to thrive, in general practice.

Louise Gorman:

Is that heavily relied on having a good culture to work in?

Tom Blakeman:

I think so, that doesn’t just come on its own. It requires active work. It requires leadership to get to that point, and it requires resourcing as well. You have to create spaces for people to meet and actively engage. You have to create a shift. In our practice, we’re trying a shift now (and I don’t think we’ll go back) to 15-minute appointments. There is agreement in the practice that this is the best way for us to begin providing care.

Tony Avery:

One of the key things is actually—we talk about the 10-minute consultation, the 15-minute consultation—it’s having that flexibility as a GP. It’s recognising that for some people coming to see you… So, I saw a gentleman with abdominal pain last Thursday who had what we call an obstruction—his bowels weren’t working. That probably took me about 40 minutes to get sorted, right from the point of actually getting him admitted to hospital. But then, we’ll perhaps make up the time with a relatively simple medication query that, on the phone, may take only five minutes.

The key thing is that the 10 or 15-minute consultation is only part of what goes into a typical general practice surgery, and it’s having some flexibility around that.

Tom Blakeman:

There is something about ownership of the space, and the spaces that exist in general practice, and that includes people—patients—having a sense of ownership of the space, and that space being, you know, maybe the consultation itself. And knowing when, as Tony’s example shows, when to speed things up and when to slow thinking down a little bit, and having the flexibility and ownership to do that. Because, there are moments when you really have to slow down and listen, and be listened to—to be understood and to understand—and then there are moments when you really have to speed things up. That’s the beauty of general practice. I mean, it’s amazing, really. You meet so many people, but it’s about creating spaces where you have ownership of the work you’re doing, as a GP, as a patient, or as a carer. As we all experience in our lives, having a sense that this is part of, you know, my everyday life—that I can come to this practice, and I can feel that I can say what I need to say, and begin to, you know, share whatever thoughts or difficulties you’re experiencing as a person.

 

Louise Gorman:

Well, there’s a couple of things going on in my head there. Tom, does that come with training? Does it come with experience? Because I can imagine that’s a very interpersonal skill that you need to have or develop in general practice, which probably feeds into the 8–10 years of training to be a GP.

Tom Blakeman:

Just one immediate thought that comes to mind—and it links back to a patient safety lens—I think there have been various reports over the years, and you referred to the Health Foundation one, I think, that was mentioned earlier. But the Francis Inquiry, the Berwick Report, and how you begin to strengthen systems of care and people ownership within, are really important.

The Berwick Report—there are key points on page two or three of that report. Patient safety issues exist in the system and always will, and NHS staff and patients aren’t to blame. In the vast majority of cases, it’s system issues that need to be strengthened. And then you can take the point: how do you begin to think about strengthening systems of care? Do you look at just significant events and where things have gone wrong, or do you look at people’s everyday work? By understanding those, you begin to say, “well, things made sense at that point, but this is how we can strengthen it?” And by creating spaces where you can reflect on how we went about something that went well, and how we achieved safe care—as well as moments when things didn’t go quite as well—you begin to create an environment where you feel safe to talk about things.

That doesn’t just happen. In our practice, it’s taken 20 years to get to a point where you feel very safe to bring things up, because you’ve built trust. You understand that’s how we frame things, and we’re looking after each other. So, I think patient well-being and staff well-being—staff well-being is absolutely paramount to the success of patient well-being. And I think there’s a recognition of that, and that requires resourcing.

Umesh Chauhan:

I just want to say, I know Tom mentioned chronic kidney disease earlier in our conversation, and that’s a really interesting condition or diagnosis in the sense that, you know, when I look at our register, even two or three years ago, the prevalence—the number of people with chronic disease labelled as having chronic kidney disease—was around 2%. Through quality improvement work, we brought it up to just over 4%. But the biggest challenge we had was actually trying to explain to patients what that means in terms of their life, the complications it can lead to, and how we can try to avoid those.

There are also issues around prescribing non-anti-inflammatories and what that might mean for them, or, when they go into hospital, what that might mean. It’s quite a challenge because it’s a very new condition for people to understand. I think there are lots of challenges around how we communicate that as a condition people understand, especially when largely it’s asymptomatic—you don’t know you have it until it becomes a real problem. Communicating that is a real issue for me.

Tom Blakeman:

Sorry, I mean without getting drawn down into chronic kidney disease, there is something about how to navigate that challenge of how to frame things better and how to place certain diagnoses in clinical context and in the context of people’s lives. There are perhaps better ways to frame things than coming in with a medical term like chronic kidney disease. You may want to frame things more around kidney health, for example, and then begin a conversation that is less frightening and less problematic. It places the issue in the context of maintaining someone’s vascular health, general health, and also safety in medicines.

So, there are perhaps better ways of framing things than the historical approaches, which have created a challenge. When you’re not clear on how to frame it, you might avoid having the conversation in the first place, and avoiding it isn’t a biopsychosocial approach. The medicine really matters. If we talk about medication, it’s a really important part of a biopsychosocial approach to improving people’s lives.

Louise Gorman:

How do we begin to overcome that challenge? Is it a factor of just more training?

Tom Blakeman:

Two quick responses to that would be: I think multidisciplinary engagement is key in how you think about things. It’s not just a secondary care issue or a primary care issue, or a patient issue. Multidisciplinary, in the sense of having patient voices and expertise in understanding and driving how you might improve talking about things, is fundamental. It’s central. In the history of medicine, it’s relatively early that we’ve fully recognised the importance of people’s voices in the design and strengthening of systems of care.

Louise Gorman:

Alongside that, research carried out by one of our colleagues, Sudeh Cheraghi-Sohi, concluded that estimating diagnostic error is, as we said, challenging for many reasons. But, because we’re a research organisation, how we measure diagnostic error can be very complex. How do you think having good measurement instruments plays into the idea of improving diagnosis?

Tony Avery:

Yeah, having good instruments is helpful, but because of the complexity of it, we’re probably not going to get a perfect instrument. I think, for example, when we did our study of avoidable harm in primary care, I thought, “Well, if the end result was plus or minus 50% of what we found, would that make a lot of difference?” The most important thing, I think, is actually what we have found from it. What are the different types of errors, the different categories of error? Which parts of the care process have the most effect, and most importantly, what are likely to be the most important solutions?

So, while there’s still room for doing more, I think the work that Sudeh has done, and the work we’ve done on our avoidable harm project, and of course work done by others around the country and around the world, has probably given us enough to say we’ve got a pretty good idea of what the problem is. I think focusing our research around the solutions is going to be one of the most important things for us to be doing.

Tom Blakeman:

There’s something about the solutions not being transactional in nature. I mean, there’s a risk that we can be showing on paper that we’re improving care through metrics, achieving incentives for hospitals or primary care to improve processes of care, and that’s important. But it’s also important that the way we go about it is relational, relationship-based, and person-centred, as opposed to just looking good on paper. There’s a real risk that we can seem to be doing the right thing but miss the point in the process.

Tony Avery:

Yes, and in terms of solutions, one of the things we’ve not touched upon so far is the importance of continuity of care. We found that in 14% of the significant harms we identified, there was a problem related to continuity of care. It can cut both ways—it can be a risk that, as a single practitioner, you might go down the wrong route and keep seeing the same person again and again. But, as Umesh made the point about, after seeing the person three times, you need to be thinking again.

Overall, numerous research studies, including systematic reviews, demonstrate a strong association between having continuity of care and better outcomes, including reduced death rates for patients. Of course, we’re in a difficult position for that in general practice, but we do need to be identifying those patients where continuity of care is likely to make a difference. We may not be able to provide it for everyone, but we need to recognise that for some people, particularly those with complex problems, having someone follow through with them makes the most difference. I’d like to make a particular shout-out for that and its importance.

Umesh Chauhan:

At least in my reflection, in terms of what’s happening in primary care at the practice level, what I’m getting good at is coordinating continuity of care. There’s so much information coming in from different healthcare professionals, and what I need to ensure is that the person is getting the right care, at the right time, by the right person. Continuity matters in the context of knowing that if the person isn’t in a position to inform healthcare professionals about where they’re at in terms of their care—and this is really important for vulnerable people, for example, those with dementia or learning disabilities—someone needs to take control of what’s happening to them in some capacity. If it isn’t a carer, then there needs to be a healthcare professional who takes responsibility for coordinating that person’s care across different healthcare systems. More importantly, the focus is on providing care within the person’s home, rather than thinking about primary care as being the place where most care happens. We have so many patients now who are housebound or living in environments that require us to provide care at home. This coordination of care is a key element of how we do that now.

Tom Blakeman:

Yeah, I agree with this. In our practice, we have a housebound team. Recently, I was chatting with a nurse colleague, and we talked about how there’s an aspect of holding people—that you take responsibility for holding people, individually as a practitioner and as a team. In doing so, you begin to understand somebody in their context, identify key issues at that moment, make a plan with that person, and see it through. In pressurised systems like the NHS, where we look at the policy and recognise that the NHS is under strain due to workforce pressures, there’s a risk when making quick decisions, especially with uncertainty. The risk is that you push the problem to someone else, devolve it, dilute it, or defer it, and in doing so, fail to handle it properly. It’s the handling and holding of people with complex health and care needs that’s crucial, as Tony said.

Tony Avery:

Another potential solution is technology. I don’t want to overplay this, but there are ways in which our computer systems can help us. You need to get the balance right. If doctors and other professionals are being over-alerted all the time, that’s not helpful. But there are some tools that can be helpful. For example, I had a patient last week where I put an entry into the computer system. It recognised that this patient had a history of cancer and flagged up to say this symptom could be related to their cancer. Now, I think I was on top of that anyway, but I found that to be a helpful intervention.

Another thing that can help reduce diagnostic delay, though it’s not quite diagnostic, is when you plan to refer a patient to hospital, and for some reason, it doesn’t happen. Perhaps the message gets lost in the system. We have systems now that can flag this up, asking, “Do I need to tell the secretary about this?” It keeps someone else in the loop when I’m planning to refer someone to hospital. So, while I don’t think technology is a panacea, it can help us in some ways with reducing diagnostic error or delay.

Tom Blakeman:

In terms of technology, it can enhance continuity. When confident in a diagnosis, coding it properly in the records helps down the road. For example, if someone had acute kidney injury years ago, you can be aware of that in decision-making during a home visit five years later. Technology is really important. In Leeds, I can look into hospital records if someone is admitted and see what’s happening. You can get a sense of when they might be discharged and what happened. And that generates learning. You begin to have an understanding of a person’s story in hospital, rather than just sending them in and waiting for them to come out as if it’s a black hole they got into.

Umesh Chauhan:

One thing worth reflecting on is that we’re all academics, and as academics and GPs, there are certain things we need to think about. One challenge for us has been around creating measures we can look at. Increasingly, we’re training people to be co-researchers, so people with lived experience who can help us develop and design studies that reflect their experiences. This has been a real challenge, but also where we’re really developing our understanding and creating better research studies, because we’re involving people, rather than just being academics and clinicians, we’re actually involving people with lived experience to tell us what we should be looking at and how we should be looking at, and actually analysing the data, and disseminating when it comes to findings. So that’s a really important element of creating measures that are important and how we can disseminate the findings once we come to realising the fruits of our labours.

[Music]

Louise Gorman:

Unfortunately, that’s all we have time for today. I want to extend my thanks to Neil, Darren, Tom, Umesh, and Tony for their insightful discussion on what patient safety is, what patient safety means, and improving diagnosis for patient safety in primary care. Thanks for listening and see you in the next episode of Voices for Safety.

[Music]

You’ve been listening to Voices for Safety, the podcast that explores the forefront of patient safety research, brought to you by the NIHR Greater Manchester Patient Safety Research Collaboration. If you enjoyed today’s discussion and want to stay updated on the latest in patient safety, be sure to follow us for upcoming episodes. You can also find us on X (formerly Twitter) at GM_PSRC, and on our website, http://www.psrc-gm.nihr.ac.uk. Join us as we continue to cover insights and innovations that make healthcare safer for everyone. Thanks for listening, and we’ll catch you in the next episode.

 

ENDS