Aneez Esmail: Understanding patient safety in general practice

Aneez EsmailIt was a comment that I made in an interview for a BBC 4 File on Four programme that caught the eye of producers at Channel 4’s Dispatches programme. I had been speaking about the problems of understanding patient safety in general practice and how we knew so little about issues related to wrong diagnosis or to misdiagnosis. I also raised the issue of who would monitor the GPs in the brave new world of commissioning. Would I be willing to take part in a documentary which would open the lid on some of the issues?

Improving patient safety in primary care is one of my research interests and I have investigated where the main problems are, and how we can monitor and improve things.
As the medical adviser to Dame Janet Smith on the Shipman Inquiry I was also part of the team that tried to put in place systems that would prevent GPs harming their patients. I therefore have a keen interest in identifying poor and unsafe practice, not to shame and blame but to show that it exists and that we can and should have mechanisms to improve poor and unsafe practice.
When I was asked whether I would be willing to be involved in consulting on the secret filming of GPs my first reaction was to run a mile. How could I justify being involved in subterfuge and filming unsuspecting GPs? What were the ethics of it all? Critical to my agreement to take part was a realisation based on my research that there was poor and dangerous practice which the public were totally unaware about, that the quality of general practice was variable and frankly very poor in some areas. I also knew that the monitoring of GPs who had been brought before the GMC and who were criticised for poor performance was grossly inadequate. In my view, the overriding public interest justified the secret filming.
In my own research in 1993 with my colleague Dr Sam Everington, we had used false CVs to prove that many Asian doctors were being discriminated against. Although we were heavily criticised at the time by the medical establishment and were even accused of professional misconduct by the GMC, we exposed a gross injustice and because of the furore that followed, the problem of discrimination which had never been acknowledged was brought out in the open. The research ultimately led to major changes in the recruitment of doctors, changes in the way that the GMC investigated and dealt with complaints, the selection of students to medical school and the way in which aspects of doctors’ remuneration were determined through changes in the allocation of clinical excellence awards.  
I helped the Dispatches team develop case scenarios based on my experience of using actors in the training of medical students. The case scenarios themselves were based on examples of patients who had taken cases to the GMC or to the medical defence unions seeking action and sometimes compensation where doctors had failed to make the correct diagnosis. The scenarios we used were not difficult to diagnose and most doctors would easily recognise the red flag symptoms that we had used to highlight cases where further action should be taken. 
Overall I think Dispatches painted a picture of general practice where there are still some fundamental problems concerning the monitoring and regulation of doctors where there is cause for concern. The Shipman Inquiry cost £25 million and lasted nearly six years. It was the most comprehensive investigation of the state of primary care since the creation of the NHS. But sadly many of the recommendations in relation to safeguarding patients are still to be implemented despite consensus from all the medical professional organisations and the political parties (at least until 2010).
So what have we learnt? Last week the secondary school where I am chair of governors was inspected by OFSTED. We were given three days’ notice of the inspection and over 60 lessons were observed by the inspectors. Where is that same scrutiny of general practitioners? During the Shipman Inquiry we were given examples from Canada where part of the monitoring mechanism involves random visits to practices to assess the quality and safety of care. Do we really know how safe general practice is? And where we identify problems, what sort of mechanisms do we have to ensure that the sort of poor practice that the programme identified is addressed? The secret filming showed that there are mechanisms to identify poor practice and if we can do that, only then can we begin the task of improving standards and safety.

Aneez Esmail is professor of primary care, University of Manchester.

  • Dafyddcym16

    An excellent programme raising important questions about the HUGE variability of GP quality and the lack of mechanisms to address this.  Primary care needs modernisation and cannot any more hide behind the public belief of the mantle of Dr Finlay and the myth of the GP knowing you and your needs.  We need a safe, professional and well regulated primary care for today's world.

  • Rdeacon

    There is noone out there who knows how safe General Practice is – and that is a great shame! Speaking as a GP, we need an independent body who has the power to scrutinise at will. If my colleagues disagree then I think we can be highly suspicious of their motives. No we are in this period of 'transition' it is a great opportunity to take the bull-by-the horns and set the process in motion – it needs to be completed separate from PCT, BMA, GMC influence – bring it on!

  • Prog Esmail, you are a hero of mine since your groundbreaking work on former racism in job applications. I have found myself defending you with this introduction over the last four days.The programme was good at causing debate and reflection at my Regional Appraisers' meeting yesterday about the need for robust appraisal. I liked the mystery shopper idea myself. It is not true however, that complaints can only be made to the Practice. Patients can and do go directly to the GMC and post criticisms on NHSChoices. The programme was very one-sided and if the filming had gone on to film more than a further three GPs after each case I think the ratio of poor practice to good practice would have massively increased. Thought provoking but biased. Perhaps we need a follow-up?

  • Who would argue that improving patient safety in not important? Prof Esmail is a respected authority, who has been involved in this for a long time. As he says, identifying poor practice is important, not to shame or blame, but to improve poor and unsafe practice. But the sensationalist, biased approach taken by the Dispatches can only muddy the water and how this will help improve understanding the reasons leading to poor practices is beyond me to understand. UK's poor cancer survival statistics were alluded to repeatedly in the program and the impression was that GP contributed grandly to this. Such cancer survival statistics deviously incorrect. Professor himself tweeted a link to this article earlier this year… and Ben Goldacre wrote about the dodgy statistics here…. 

    Most GPs really want to help their patients, but “to help” is a very nuanced art and GPs need a lot of support to be able to do that.

  • Hugh Robertson-Ritchie

    Well done for showing that some GP consultations go wrong. Of course, it is much easier to find poor consultations if you deceive doctors who have had problems in the past. (Filming covertly is deception, isn't it? Would you approve if a GP were to deceive her or his patients?) We don't even know from your article or the film how many times you filmed successful and safe consultations performed by GPs – perhaps there were some by these pilloried GPs.
    What you have not shown is that severe problems with GP consultations are common enough to justify your contention that there is a major problem, nor to justify your wish to impose checks on all doctors. In the film you say, “The value of doing something like this is that it actually gives you an idea of how big a problem you might be dealing with”. This is not accurate. Nothing in the film or the article gives any concept of how frequent errors are. People in this country consult a GP about five times a year, on average; that makes somewhere in the region of one third of a billion consultations per year. Do one in a hundred consultations go wrong, or one in ten, or one in a million? You claim, as an assertion and without evidence, that some people's estimate of 1% of GPs being inadequate must be too small a figure.
    Whatever response we have must be proportionate to the size of the problem, particularly bearing in mind that there are already many checks and controls, including, as shown in the film, the complaints system, the GMC, the monitoring of prescribing costs and referral rates, as well as the duty imposed on all professionals to monitor the quality of their colleagues and to intervene when there appear to be problems.
    You certainly have not shown that appraisal/revalidation system finds 'failing doctors'. Appraisal and revalidation should be adequate, appropriate, proportionate and economic; if they have not been shown to be all these things then they are a waste of resources and a deception of the public.
    Competing interests: I am a GP.