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.