Project objectives originally outlined in proposal

What contribution can patients make to understanding and improving the safety of their care in general practice?

This research is expected to identify features of general practices with a priori 'high' safety, from the perspectives of patients and to show how safety culture has become embedded within their service delivery, potentially benefiting every person registered with a general practice.

Changes to project objectives 

No changes were made.

Brief summary

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety.

Methods

Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio-demographic information; thereafter, topics were largely introduced by interviewees themselves.  Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison. 

Results

Thirty-eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed.  Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety.  Three broad themes were identified: (i) trust and psycho-social aspects of professional-patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems-level tensions constraining safety. 

For patients, relationship continuity was not simply a matter of service quality but an important safety concern that offered greater psychosocial security than consultations with unfamiliar GPs.  Relationship continuity enabled the GP to become a repository of information; acquire specialist knowledge of a patient's condition; become familiar with the patient's consulting behaviour; provide holistic care; and foster the development of trust.  Patients were also aware of the risks: a false sense of security and lack of a fresh perspective.  Their desire for continuity varied with the nature of their concerns, psychological vulnerability, and perception of GPs' qualities and skills.  No one supported a return to imposed continuity.

Discussion

Conceptualisations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context-dependent.  For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient.  However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization. 

Relationship continuity and choice of GP were important safety strategies, neither of which is adequately supported by recent policy changes.

This research identified features of general practices with a pirori 'high' safety, from the perspectives of patients and has shown that whilst safety culture has become embedded within their service delivery, potentially benefiting every person registered with a general practice, there are significant contributions that patients can and do make to safe general practice that health practitioners and policy-makers need to respond to. 

Plain English Summary

The first maxim of medical care is 'first, do no harm' (Hippocrates).  All patients are entitled to access and receive safe and effective health care.  Avoiding errors, or identifying and correcting them, is a high priority for the NHS.  Patient safety research has tended to emphasise mistakes made by practitioners.  However, there was little research on a patients' perspectives of what constitutes a 'safe' practice specific obstacles or promoters of successful adoption of 'safe' practice.  We asked patients about their understanding and experiences of safety in general practice using interviews, which are commonly defined as a conversation with a purpose, and focus groups to address the questions:

1) What contribution can patients make to understanding and improving the safety of their care?

2) Are concepts and terms used commonly in patient safety literature understood by patients and how do patients define safety?

3) What factors help or hinder safe' practice from a patient perspective?

This research identified features of general practices with 'high' safety, from the perspectives of patients and that their patients can and do make a significant role in making safe general practice that health practitioners and policy-makers need to respond to. 

Dissemination

1. Rhodes P, Campbell SM, Sanders C. Relationship continuity - when and why do patients think it is safer? British Journal of General Practice 2014;64(629):e758-64

https://doi.org/10.3399/bjgp14X682825

2. Rhodes P, Sanders C, Campbell SM. Trust, temporality and systems: How do patients understand patient safety in primary care? A qualitative study. Health Expectations 2015 Feb 3

https://doi.org/10.1111/hex.12342

3. Sanders C, Rhodes P, Campbell SM, Macdonald R. Sensemaking and the co-production of safety: a qualitative study of primary medical care patients. Sociology of Health and Illness (In Press)

Public involvement

Members of the public were research participants and the study looked at patients’ views and perspectives of patient safety in primary care. The interview schedule was inductive and responded to patient views and priorities. We included PPI at all stages.

Impact

It addresses one of the key recommendations from the 2013 Berwick review in to patient safety that “all organisations should seek out the patient and carer voice as an essential asset in monitoring the safety + quality of care”.