Could a system of risk-based, continuous, consultation peer-review improve patient safety and clinician learning in general practice? Evaluating 9 years of the BrisDoc Clinical Guardian experience

Problem

The "NHS Long-term Plan” seeks to enhance sustainability of general practice through increased utilisation of new roles to do work previously done by GPs, better integration of primary and secondary care, and embracing digital technology. Unanswered questions regarding the safety of such changes highlight the weaknesses of existing safety assurance systems in general practice. These weaknesses broadly pertain to poorly aligned incentives, infrequent data sampling, reliance on self-collated data, and a focus on reactive measures to respond to safety issues. A potential alternative is a risk-based, continuous, consultation peer-review system, used by an ‘out-of-hours’ general practice provider in Bristol over the last 9 years. This system samples a proportion of all clinicians’ consultation records for peer-review based on each clinician’s perceived risk status. Cases are screened by a professionalised peer-review team, with cases causing concern escalated for consensus peer-review. Learning needs are continuously fed back to clinicians, and commonly occurring issues are reviewed at a service level to allow continuous improvement.

Approach

To understand the perceived usefulness, acceptability and potential for wider use of such a system we undertook 20 semi-structured interviews with clinicians with exposure to the peer-review intervention. This included 8 GPs, 3 Nurse Practitioners and 3 trainee GPs subject to the peer-review intervention, 3 members of the peer-review team itself, and 3 senior management team members at the organisation running the service.Interviews have been completed and are being analysed by inductive thematic analysis. Two researchers will independently code a subset of transcripts to ensure consensus over coding and themes. Interview data will be integrated across the 3 participant groups through comparison of themes by parent group.

Findings

Preliminary findings suggest the intervention is perceived to be useful, acceptable and has potential for wider use in general practice. Interviews identified themes of clinical isolation in general practice, an appetite for better supervision at all clinical levels to manage unknown unknowns, variation in organisational learning culture and barriers to meaningful engagement in governance processes.

Consequences

The rapid evolution of general practice requires corresponding evolution of quality and safety assurance methodologies. Our findings suggest further research into the development of risk-based, consultation, peer-review in general practice is justified as a potential adjunct to existing quality and safety assurance methods. This system has the potential to circumvent many weaknesses of existing safety assurance systems; using proactive, continuous sampling to assesses all clinicians on their situational competence, irrespective of their professional status, and providing a potential methodology to standardise inter-organisational clinical governance practices.