The Health Services Safety Investigations Body will recommend that practices are supported to deliver greater continuity of care. This would allow patients to build a closer relationship with their doctors so they do not have to repeatedly explain their medical histories.
Better management of information to allow other staff to deliver care when needed is also recommended. The report highlighted the case of a 67-year-old patient called Brian, who started having back pain two years after he was treated for cancer.
Brian saw two out-of-hours GPs, six practice GPs, a nurse and a physiotherapist at the surgery over the course of eight months, before he was finally diagnosed with breast cancer. And by then the disease had already spread to his spine.
Tragically, Brian died during the investigation body’s inquiry which found information had not been properly passed on between attendances.
Neil Alexander, its senior safety investigator, said it uncovered “clear differences in patient experience and GP welfare between those practices that operate a model continuity of care and those that don’t”.
He added: “Brian’s case was a stark example of what can happen when there is a breakdown in that continuity – it was incredibly distressing for him and his family. “He told our team, ‘When I am gone, no one else should have to go through what I did.’
“Our findings and safety recommendations are a call to action to those at a national level, to help prevent the delayed diagnosis of serious health conditions and ensure patients get safe and efficient care wherever they are in the country.”
The report comes after a study led by the University of Oxford found remote GP appointments by phone or online could put patients at risk.
Researchers, who analysed 95 safety incidents, said mistakes are rare – but there is a risk of patients being under-diagnosed in remote consultations, GPs being swayed by what has been said previously and less qualified staff failing to act on signs of illness.
Some errors related to serious conditions, such as heart disease and cancer “which would likely have been readily diagnosed with an in-person examination”. The study also found patients with pre-existing conditions, the very young and older people are “particularly difficult to assess” by phone.
Campaign groups said too many older people struggle with increasingly digital systems.
Caroline Abrahams, charity director at Age UK, said: “Many are finding it hugely frustrating trying to navigate clunky, sometimes bureaucratic online and telephone systems that can feel like they are designed to fend them off.”
Silver Voices director Dennis Reed said: “This study is a small tip of a very large iceberg unfortunately, and many more tragic cases will emerge unless urgent action is taken to improve direct access to GPs.”
