HSSIB investigation. Continuity of care: delayed diagnosis in GP practices (30 November 2023)

Summary

Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient.

While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices.

The investigation focused on:

• How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system.
• Workload pressures that affect the ability of GP practices to deliver continuity of care.

This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS.

Content

Reference event

Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Initially the pain was so severe that Brian visited his local emergency department (ED). He was discharged from the ED with pain relief and was advised to contact his GP practice.

A month later, Brian telephoned his GP practice and saw his named GP. The GP referred Brian to the GP practice’s physiotherapist and requested a blood test. Brian saw the physiotherapist, who gave him advice about exercises to help relieve the back pain. The exercises did not relieve Brian’s pain and over the following 8 months he saw two out-of-hours GPs and six practice GPs, a nurse and a physiotherapist at the GP practice.

Brian also had consultations with healthcare professionals during this time for other conditions not relating to his back pain. When Brian saw a GP at end of the 8-month period, the GP found a lump on his spine and advised Brian to go to the local ED.

At the ED, Brian had a computerised tomography (CT) scan. A lump was found on his spine which was later diagnosed as metastatic breast cancer (that is, breast cancer that had spread to his spine).

Findings

• The GP contract, which sets out the mandatory requirements for GP services commissioned by the NHS, does not specifically require GP practices to adopt an approach that ensures continuity of care, but practices can do so voluntarily.
• Many GP practices do not operate a formalised system of continuity of care.
• There is no standard framework to deliver continuity of care in GP practices, so it is done differently across the country.
• Many GPs understand the benefits of continuity of care; however, some practices did not believe that it was possible to deliver such a system. Other practices were able to maintain continuity of care through systems developed by those practices.
• There is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information (that is, identify and flag up relevant patient information) to GPs when they see a patient with unresolving symptoms.
• Patients told the investigation that they found it beneficial to see their named GP for long-term health conditions, including mental health conditions.
• GPs working in a practice with a system of continuity of care had more time to process information during consultations and to carry out any follow-on actions to ensure patients received the care they needed.
• GP practices that operated a system of continuity of care reported to have better staff welfare and retention, and fewer recruitment issues, than those that did not.

Safety recommendations

• HSSIB recommends that the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information.
• HSSIB recommends that NHS England updates the GP IT standards to ensure that patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms.

Safety observation

• GP practices can improve patient safety by aligning their staff wellbeing and patient safety policies to those of NHS England’s proposed patient safety strategy.