Continuity and quality of care, safety and prescribing

• It is an essential part of your role as a doctor to regularly review the standards of practice and care that you and your team provide. Improving patient safety and quality is fundamental to reducing the risk of preventable injury, suffering, disability and death, and is necessary to enhance the experience and outcomes of care.
• The working environments, systems and behaviours of those working in health can all influence patient safety. Working in partnership with patients and carers and promoting an organisational culture that allows everyone to be honest (and raise concerns openly) is an essential part of sustaining a safe working environment.
• Clinical governance is the system through which organisations are accountable for continuously improving the quality of care and maintaining high standards. Understanding how to apply tools and metrics to monitor this is key to improving the quality of care.
• Safe, effective prescribing and monitoring of medications (and other healthcare interventions) is essential to ensure high-quality and safe care. Patients are vulnerable to mistakes being made in any one of the many steps involved in ordering, dispensing and administering medication and other healthcare products.

Continuity of care, along with generalism, is a fundamental feature of general practice. The World Health Organization (2018) defines primary care as providing a “positive continuing relationship with a named primary care professional”. In the UK, continuity is defined as: “a patient having repeated consultations with the same GP”. Continuity has a particularly strong research base showing it is statistically significantly associated with many important outcomes in the whole of medical care¹.

Patient benefits include receiving higher quality GP care and more satisfaction, being better informed and more able to self-care, receiving more personal preventative care (such as immunisations and cancer screening), a reduced need for patients to repeat their story, and even having a lower rate of dying.^2,3,4

GPs benefit significantly by working more with patients who more often follow medical advice and reveal confidences. GPs have more job satisfaction when working with patients they know and understand. Patients will be more likely to forgive GPs who make moderate mistakes, which can save much time and anxiety by preventing formal complaints. In particular, the practices of GPs who provide GP continuity may have a smaller workload because patients who have seen their regular GP have a significantly longer period of time before they need to consult again.^5,6

Studies have found that GP continuity is significantly associated with fewer emergency department attendances and hospital admissions, particularly for older people with ambulatory care-sensitive conditions.⁷

Some disadvantages reported include that patients may wait too long to see their preferred GP when they needed to be seen earlier, or becoming dependent on their GP.⁸

Patients who have seen their GP repeatedly develop significantly more trust in them. They then confide more in their GPs, who become better informed and so acquire progressively deeper understanding about the important social determinants that affect many consultations. Continuity enables GPs to tailor care to patients’ individual circumstances, differing from GPs without continuity in hospital admission rates.⁹

Despite all these advantages, GP continuity is falling nationally and only a minority of practices provide it. This may relate to the internal organisation and resources of the practice. Every patient should have a named GP, and staff and systems should encourage patients to see their named GP when possible (accepting that with holidays, leave and part-time working this will not always be possible).

Measuring GP continuity in general practice enables practices to know where they stand and to track improvements.¹⁰

“In order to practise medicine in the 21st century, a core understanding of quality improvement is as important as our understanding of anatomy, physiology and biochemistry.”

Stephen Powis, Medical Director, Royal Free London NHS Foundation Trust, 2015¹¹

Quality of care requires continuous improvement through critical thinking and understanding the complex healthcare environment, application of a systematic approach to design, and testing and implementation of changes while measuring and reviewing outcomes. The aim is to understand and make a positive difference to patients by improving healthcare processes and services, including safety, effectiveness and experience of care.

This requires a working knowledge of:

• the principles of quality improvement
• how quality improvement benefits patients, staff and organisations
• the importance of context and organisational culture and how this impacts quality improvement work
• the importance of safety, teamwork and human factors
• the importance of involving patients and carers in quality improvement work, and how to do this effectively
• the role of data to both assess improvement needs and measure improvements
• the effectiveness of small cycles of change
• the role of critical incident reporting and significant event analysis
• the common barriers that prevent teams from introducing clinical quality improvements and ways to identify and address these.

As a GP the following knowledge and skills are required to successfully undertake quality improvement activities:

• the role of systems in healthcare and understanding variation
• the likely differences in impact and sustainability between changing systems and changing within systems
• management theory and change concept models used to improve system and process reliability
• the effects of equipment, environment and human factors, including teamwork, culture and organisation, when designing or evaluating system safety or reliability
• application of root cause and systems analysis methods
• systems design principles that make it easy for healthcare workers to do the right thing or to make errors
• definition of processes, process mapping and assessment of process value
• outcome theories relevant to quality improvement in healthcare
• improvement models including Plan Do Study Act (PDSA) cycle and its application to healthcare
• setting a specific improvement aim statement including how much by when
• understanding of statistics and application of tools (such as run charts, process mapping, tally charts, Pareto charts, statistical process control charts, driver diagrams)
• clinical audit cycles, their role as quality improvement tools and their limitations
• methods for defining outcomes and how improving outcomes are linked to improving processes
• rationale for predicting outcomes before the test
• methods and practices for implementing a change and spreading, evaluating and sustaining improvement
• understanding stakeholders and the features of effective team communication and ways to influence others (that is, adopting an approach that is safe, inclusive, open and seeking common goals and consensus).

Patient safety

Quality in general practice can be considered in terms of the following six areas:

1. Safety: avoiding injuries to patients from the care that is intended to help them
2. Timeliness: reducing waits and sometimes harmful delays for both those who receive and those who give care
3. Effectiveness: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit
4. Efficiency: avoiding waste, including equipment, supplies, ideas and energy
5. Equality: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socio-economic status
6. Person-centredness: providing care that is respectful of and responsive to individual patient preferences, needs and values.

It is important to be aware of each individual’s own capabilities, values, ethics and accountability. There may be ethical tensions inherent in governance processes and resource allocation. Personal health and wellbeing must be maintained (for example, being immunised against common or serious communicable diseases where appropriate). It is important to protect patients and colleagues by managing risk while adhering to General Medical Council (GMC) fitness to practise guidance.

The working environment, systems in place (including information technology, the quality of data entry and communication between professionals) and behaviours of those working in health can all influence patient safety. It is important to review and reflect on the standards of practice and the care that is provided. The diversity of practices and the variation in patient demographics means a variety of measures is important for a broad, balanced view.

Clinical governance

Clinical governance is the system through which organisations are accountable for continuously improving the quality of services and standards of care. This involves recognising and responding to practice variation, understanding quality improvement and applying key tools such as clinical audit, significant event analyses and improvement methodology. Patient safety incidents, near misses and complaints are part of a jigsaw of information that can be used to share and learn lessons. Understanding how to monitor and when to apply tools and metrics to improve the quality of care is a key skill that should be learned and developed; this is essential for personal and collective professional development.

Working with patients and carers and promoting an organisational culture that allows them and all staff to be honest and raise concerns openly is essential. Some patient groups may be more at risk due to characteristics such as language, literacy, culture and health beliefs.

Immediate action must be taken when risks to safety happen (for example, an error in patient diagnosis, inadequate resources or a colleague who is not fit to practise and is putting patients at risk). Where appropriate:

• record or report the concern or incident
• offer help in emergencies
• admit when an error has occurred
• communicate openly with those involved
• apologise and explain fully to those affected
• advise on how patients can raise issues or complain
• personally reflect and share any learning.

Prescribing

The term ‘prescribing’, as used in the RCGP curriculum, describes many clinical activities closely related to safety and quality, including prescribing medicines, devices, dressings and other products, as well as advising patients on the purchase of over-the-counter medicines and other remedies. Prescribing may also be used to describe written information provided for patients (information prescriptions) or advice given. This topic guide will mainly focus on illustrating the general principles around the prescribing of prescription-only medicines.

The prescribing and monitoring of medications and other products needs to be understood, developed and explored to ensure high-quality, safe care.

The causes of medication errors include a wide range of factors, including:

1. Inadequate knowledge of patients and their clinical conditions
2. Inadequate knowledge of the medications
3. Calculation errors
4. Illegible handwriting on the prescriptions
5. Confusion regarding the name of the medication
6. Poor history-taking.

When prescribing, it is essential to follow the law and GMC guidance and to take account of licensing and local prescribing guidance as well as other relevant regulations. This includes clinical guidelines published by:

• National Institute for Health and Care Excellence (NICE) in England and Scottish Intercollegiate Guidelines Network (SIGN) in Scotland
• Scottish Medicines Consortium and Healthcare Improvement Scotland (Scotland)
• Department for Health, Social Services and Public Safety (Northern Ireland)
• All Wales Medicine Strategy Group (Wales)
• medical royal colleges and other authoritative sources of specialty specific clinical guidelines
• The British National Formulary (BNF) and the BNF for Children.

Prescribing can be considered in relation to the following three areas:

1. The prescriber
2. The patient (and/or carer where appropriate)
3. As part of a team and the wider system.

The prescriber

As a prescriber, your role is to:

• recognise and work within the limits of your competence
• maintain and develop your knowledge and skills in pharmacology, therapeutics and medicines management relevant to your role and prescribing practice
• be responsible for all prescriptions signed and for decisions and actions when prescribing, including if prescribing at the recommendation of another healthcare professional
• avoid prescribing for yourself or anyone with whom you have a close personal relationship wherever possible
• be aware of your own prescribing practice (using local data where appropriate) and the potential influence and expectation from peer, patient and commercial pressures
• consider the benefits, impacts and risks of prescribing in the following situations:
  • via telephone, video or online consultation
  • signing prescriptions generated by others
  • generating repeat prescriptions
  • when prescribing unlicensed medication
  • your own previous experience of medications.

The patient

Safe and effective prescribing always involves consideration of the patient and their unique circumstances. For example:

• Take into account prescribing in special conditions such as with patients who are pregnant, breastfeeding, have renal or hepatic impairment or palliative care needs, or for whom genetic test results/genomic information is available and relevant.
• Provide patients with patient information leaflets (PILs) and other reliable sources of information (such as the NHS website and resources bearing The Information Standard quality mark) where appropriate.
• When prescribing, consider whether requests for repeat prescriptions received earlier or later than expected may imply poor adherence, which could lead to inadequate treatment or adverse effects.
• It is important to apply effective strategies for communicating about and reducing the risk of dependency or addiction to medicines where this may occur (such as opioids, benzodiazepines and gamma-aminobutyric acid (GABA) drugs) as well as supporting and managing patients who have become dependent on medications, seeking specialist advice and intervention when appropriate.
• If you consider that a requested prescription would not be of overall benefit, you should explore the reasons for the request with the patient or carer. If you still consider the prescription would not be of overall benefit, or is likely to be harmful, you should not prescribe it and should explain the reasons for your decision. You should also explain what other options are available (including the option for the patient to seek another opinion).
• Where patients do not take a medicine as prescribed, a discussion to understand the reasons for this should take place and any further information or reassurance provided where appropriate. The aim should be to reach a shared understanding and an agreed course of treatment the patient is able and willing to adhere to.
• Consider the impact of polypharmacy and, where appropriate, consider support structures such as carers, district nurses or the use of dosette boxes.
• Under current rules, the NHS only accepts responsibility for supplying ongoing medication for temporary periods abroad of up to three months. If a patient will be abroad for longer, then the patient should be given a sufficient supply of their regular medication to enable them to get to their destination and find an alternative supply.
• If prescribing for patients who are going abroad or who are overseas, consider how the patient’s condition will be monitored. Also consider whether there is a need for additional indemnity cover or registration with a regulatory body in the country in which the prescribed medicines are to be dispensed.
• Advise patients on exemptions from prescription charges where appropriate (a full list of exempted conditions is available on the NHS Business Services Authority website).
• Acknowledge the benefits of drug switching but also the potential confusion that may be experienced if the colour and shape of medicines are changed and the impact repeated switching may have on trust and compliance.

The team and wider system

Safe and effective prescribing also requires an understanding of the organisational systems in place for medication prescribing, issuing, monitoring and review:

• Ensure drugs are received, stored and disposed of safely and appropriately.
• Make use of electronic and other systems that can improve the safety of prescribing (for example, by highlighting interactions and allergies and by ensuring consistency and compatibility of medicines prescribed).
• Work with pharmacists and consider their role in delivering medication, conducting medicines reviews, explaining how to take medicines and offering advice on interactions and side effects.
• If unsure about interactions or other aspects of prescribing, seek advice from experienced colleagues, including pharmacists, prescribing advisers and clinical pharmacologists.
• Information about medicines should accompany patients (or quickly follow) when patients are transferring between care settings (such as hospital, nursing or residential placement).
• Ensure any changes to medications (for example, following hospital treatment or due to blood or microbiology results) are reviewed and quickly incorporated into the patient’s record.
• Inform the Medicines and Healthcare products Regulatory Agency (MHRA) about suspected adverse reactions and incidents using the Yellow Card scheme. Where appropriate, inform the patient’s GP and the pharmacy that supplied the medicine.
• Inform the patient’s GP if prescribing for a patient but you are not their GP.
• Drug switching may be externally recommended (for example, by specialists or integrated care systems) for quality reasons such as efficacy or efficiency. Consider the impact of drug switching in the patient’s best interest and the impact of cost saving on the wider system.
• Consider the impact antibiotic prescribing has on the wider system with regards to drug resistance.

Work-based learning

It is essential that GP registrars gain a good understanding of quality improvement, prescribing and patient safety before completing training. Primary care settings, both inside and outside the practice, are ideal environments to learn and apply the key principles.

All GP registrars should complete a quality improvement project relating to patients in their training practice and actively contribute to the practice’s significant event audit meetings.

Recognising this as an opportunity for reflection as well as possible celebration of good care is a particular feature of primary care teams.

Observing the systems developed by a practice to manage repeat prescribing and exploring the team’s decisions about how to manage risk in this process can provide valuable insights. It is also worthwhile considering the variation in impact and uptake of NICE guidance. Likewise, the processes that occur during a consultation when a decision to refer is made, as well as the practical systems in place to achieve the referral, are ideally explored within the primary care setting. Reflecting on cases that illustrate a delay in diagnosis using tools such as significant event analysis (SEA) can help in understanding the complex process of diagnosis within both the primary and the secondary care setting.

Learning about the differences between primary and secondary care will help the GP registrar gain a broader understanding of the principles and practice of clinical governance and how to maximise benefit for patients. There should be opportunities to undertake clinical audits and critical event analysis with hospital colleagues.

Root cause analysis (RCA) is the standard risk tool used in secondary care and familiarity with its application can be best observed in this setting. GP registrars should be able to describe the particular role of risk managers in acute trusts and this is best appreciated while in this environment.

The primary–secondary care interface is especially vulnerable to patient safety incidents.

Observing and understanding how different systems and processes manage this and other key transitions of care (such as between health and social care) can often reveal areas for quality improvement.

Learning with other healthcare professionals

Primary care teams are highly sophisticated multiprofessional groups. The opportunities for you to participate in shared learning with colleagues have expanded, particularly following the extension of non-medical prescribing and extensive collaborative working on long-term conditions and integrated care.

In addition, you have many opportunities in primary care to discuss clinical governance with nurses, allied health professionals and managers, all of whom should be engaged in the practice’s education and clinical governance programmes.

Unscheduled care in the community, both in-hours and out-of-hours, is provided by a variety of different contractors using the skills of practitioners such as paramedics, emergency care practitioners, urgent care centres, crisis mental health teams and walk-in centres. These are ideal places for you to see and understand the use of a skill mix in healthcare and to compare and contrast the benefits and disadvantages of each option, including the use of telephone calls triage and calls using clinical pathways (such as the 111 service).

Applied Knowledge Test (AKT)

• Drug monitoring requirements
• Prescribing in multimorbidity, including polypharmacy
• Safe prescribing and medicines management (including MHRA alerts)

Simulated Consultation Assessment (SCA)

• Your practice nurse sustains a needlestick injury while taking blood from an intravenous drug user
• An elderly woman, whose international normalised ration (INR) is within the therapeutic window for only 40% of the time, attends for review
• A middle-aged man who has recently registered attends for a review of his repeat medication, which lists nine different medications

Workplace-based Assessment (WPBA)

• Log entry about a significant event in which you have been directly involved
• Case discussion on the workflow of blood results for patients taking disease-modifying anti-rheumatic drugs (DMARDs) to minimise the risk of harm
• Completing a Quality Improvement Project (QIP) on a locally identified need, identifying intended outcomes, implementing the changes, measuring their impact and disseminating your learning
• Complete the Prescribing Assessment and reflect on any errors identified

References

1. World Health Organization. Continuity and coordination of care: a practice brief to support implementation of the WHO framework on integrated people-centred health services. Geneva: WHO, 2018.
2. Pereira Gray D, Sidaway-Lee K, White E et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; (6):.e021161.
3. Baker R, Freeman GK, Haggerty JL, Bankart MJ. and Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice 2020; 70(698):e600–e611.
4. British Medical Association. Conference of Local Medical Committees: Resolution on continuity. London: BMA, 2022.
5. This has been calculated in the University of Cambridge to mean 5.2% fewer consultations among regular attenders. See Kajira-Montag H, Freeman M and Scholtes S (2023) Continuity of care increases physician productivity in primary care. INSEAD Working Paper No. 2023/23/TOM.
6. British Medical Association. Conference of Local Medical Committees: Resolution on continuity. London: BMA, 2022.
7. Patients with dementia receiving GP continuity had 35% fewer episodes of delirium and 57% less incontinence through better quality GP prescribing. Delgado J, Evans PH, Pereira Gray D et al. Continuity of GP care for patients with dementia: impact on prescribing and the health of patients. British Journal of General Practice 2022; 72(715):e91–e98.
8. One study reported a delay of seven days in the diagnosis of some cancers, but a later report concluded that GP continuity protects against delayed diagnosis. Health Services Safety. Investigation Body. GP Continuity of care: delayed diagnosis in GP practices. London: HSSIB, 2023.
9. It takes seven consultations with the same GP before the average NHS patient reports that they have a ‘deep’ relationship with their GP. Mainous AG, Baker R, Love MM et al. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Family Medicine 2001;33(1):22–27.
10. Some group practices with many part-time GPs, often using personal lists, report levels between 55% and 65% GP continuity (measured using the St Leonard’s Index of Continuity of Care) and the highest levels are now over 80% GP continuity. Sayers LD, Richardson S, Colvin D et al. Realistic not romantic – real-world continuity in action. British Journal of General Practice, 2024;74(738):11–2. https://doi.org/10.3399/bjgp24X735909
11. For example, https://www.aomrc.org.uk/wp-content/uploads/2016/06/Quality_improvement_training_better_outcomes_140316.pdf