Patients are at risk of having serious health conditions missed because of the lack of continuity of care provided by GPs, the NHS safety watchdog says.
Investigators highlighted the case of Brian who was seen by eight different GPs before his cancer was spotted as an example of what can go wrong.
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.
Over the following eight months, he saw two out-of-hours GPs and six GPs based at his local practices as well as a physio and GP nurse, before he was sent for a hospital check-up in late 2020.
A secondary cancer had developed on Brian's spine, but it was too late to offer him curative treatment and he was given end-of-life care. He has since died.
The watchdog said the lack of continuity of care resulted in the diagnosis of Brian's cancer being missed.
One of the key problems was that the different GPs he saw missed the fact he was attending repeatedly for the same issue.
Senior investigator Neil Alexander said Brian's case was a "stark example" of what can happen when there is a breakdown in continuity of care.
"He told our team 'when I am gone, no-one else should have to go through what I did'."
Source: BBC News, 30 November 2023
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