Safer working across all GP practices in Scotland: Q&A with Neil Houston

The Safety Improvement in Primary Care project was originally funded through our Closing the Gap through Clinical Communities programme back in 2010. Led by Neil Houston, the  GP National Clinical Lead for Safety at Healthcare Improvement Scotland, the project aimed to reduce harm caused by heart failure and adverse reactions to prescription drugs like warfarin and methotrexate. It did this by rolling out safety tools and care bundles and developing safety skills in 43 GP practices across Scotland.

The project achieved some great results and many of the tools and resources it developed have since been incorporated into the Scottish Patient Safety Programme in Primary Care and rolled out to over 900 GP practices in Scotland. We caught up with Neil Houston to find out more.

Tell us about the original Safety Improvement in Primary Care project

The original project ran from 2010 to 2012. We encouraged practices to use a safety climate survey to develop their safety culture, and introduced a trigger tool to provide a structured way of looking at notes to identify and learn from patient safety incidents. Practices also measured how reliable their high risk processes were and identified possible improvements.

Throughout the programme people from practices across Scotland came together in collaborative learning sets, attended by two to three people from each practice (so that it wasn’t just someone’s pet project). They’d take the tools away, try them out locally, and then come together again to discuss and refine the approach.

What were the outcomes from that original project?

The tools proved very successful in developing safety culture in teams. They created opportunities for discussion about safety within a GP practice and provided insight into where systems weren’t as reliable as people thought they were. It helped to shine a light into some dark corners.

That led to people starting to do things differently, but also to less variation between the actions of individual doctors and between practices. For example how practices started to adopt common procedures when they received discharge information about a patient coming out of hospital. This led to more reliable processes and better care for patients. Practices reported experiencing fewer errors and greater efficiency which released capacity.

How did the project come to be spread more widely across primary care in Scotland?

It had already started to spread organically before it was formally adopted into the Scottish Patient Safety Programme for Primary Care. In the first year after the Closing the Gap project finished it spread from around 50 practices to over 300. That was quite helpful as we could see the challenges involved in moving from working with just some to all practices in a board.

How did the wider roll out go?

We’ve now reached over 90% of practices in Scotland, that’s over 900 GP surgeries. There were challenges. Engaging with front-line staff in a very stressed environment was difficult and we had to be realistic about how much time practices could give us, which meant reducing the learning sets to just half a day each.

But patient safety was prioritised by the Scottish Government, so we were able to use the levers in the system. All health boards were told they needed to support the programme, and elements of our work were put into the GP contract. For example practices were given money as part of their contract for three years if they completed the trigger tool and safety climate survey. This meant that over 90% of practices used the tools year on year.

The aggregated figures across Scotland show an improving safety culture over those three years. There’s also evidence in many practices that the skills people learned are being used for more generic improvement in other areas, which is great.

And it’s not stopped in Scotland. Our approach and tools have been used successfully in Salford, Newham in London, and by over 40 GP practice teams in Auckland, New Zealand.

What do you think it was about this project that made it spread so well?

Clearly safety is a national priority for government, so to a certain extent the timing was right. And there was big buy-in from practices, partly because you can’t really argue with safety, but also because the topics we were working on were all issues front-line staff in practices had raised themselves.

I think the leadership role of Healthcare Improvement Scotland was also key. And having had the funding and the protected time to develop the tools and test them rigorously with lots of clinical leadership and improvement expertise in the first place really helped.

Where next?

The Scottish Patient Safety Programme is now looking at key areas for further development in primary care, such as sepsis. We’ve learnt a lot and that’s informing new safety improvement work in other areas. The Health Foundation has been funding a project to develop a similar safety approach in community pharmacy, so our next step will be to spread that more widely. We’re also beginning a similar process with dentists.  

This new work is really creating some energy. It’s great to see that our original safety project has had such an impact, not just in general medical practice but across other professions within primary care. Talking about it makes me realise just how far we’ve come.