RISK: What don't you know?

AS a GP partner are you confident that you know what’s happening at reception whilst you’re busy in surgery or out visiting patients at home? You may feel that managing risks associated with practice systems is the day-to-day role of the practice manager. For some practices this may still be the case, with the PM maintaining a “finger on the pulse”. But for many, the reality is that, as the traditional PM role evolves, they too become more isolated from other staff.

Picture this...

It’s the middle of a hectic Wednesday morning surgery. Receptionists are busy dealing with calls requesting appointments – requests they have to manage as there are already no non-urgent appointments left that day. At the same time they are also fielding face-to-face and telephone enquiries on a multitude of other matters, including outstanding referrals, discharge medicines for housebound relatives and when the district nurse is likely to be calling them back.

A steady stream of patients arrives at the front desk to book in for appointments (the self-service book-in is offline), hand in specimens and collect repeat prescription requests. The receptionists juggle all these in what appears to be an efficient manner, however everyone in the office is feeling a little stretched and worried about the fact that appointments for the day are now gone.

All seems to be well until at 11:05 a receptionist takes a call from a patient who says they would like to see a doctor today. The conversation goes like this...

Patient: I’m phoning to see if I can get an appointment to see a doctor today? 
Receptionist: I’m sorry but we have no more routine appointments available today. I can offer you a routine appointment on Monday or Tuesday next week? 
Patient (annoyed): I can’t wait until next week. I need to see someone today! 
Receptionist (calmly): I’m afraid it’s only emergency appointments we’ve got left. If you can’t wait until next week, you’re welcome to try again tomorrow morning. Every morning, appointments open up for that day and so... 
Patient (angry): This is the third morning I’ve tried that and not been able to get through! 
Receptionist (defensive): I’m very sorry about that but that’s our system and if it’s not an emergency... 
Patient (defeated): Look, I’ve had a really sore throat and a headache for a week or so now. The last couple of days I’ve been feeling really rotten, been really sick and I think I maybe need some antibiotics... 
Receptionist (sighing, relieved): Ah, well you see, there’s really no point in coming in to see a doctor because they won’t give you an antibiotic anyway. Everyone seems to have that virus at the moment. You’d be as well taking some paracetamol, making sure you drink plenty of fluids and wrapping yourself up with a blanket and a hot water bottle until it passes. 
Patient (hopefully): Oh well, if that’s what the doctors are saying about it then... 
Receptionist (brightly): Great - well call us back if you’re no better in five to seven days, and we’ll see if we can fit you in.

At 09:25 on the following Monday morning notification arrives by telephone at the practice that the patient has died in hospital over the weekend. It looks as though he had encephalitis.

Blame the receptionist?

All practices have evolved different systems of ensuring patient access to GP consultations. In this case, the fact that no routine appointments were available contributed to the situation; however this is the reality for many practices day-to-day. The fact that the receptionist maintained that any available appointments were only to be used for ‘emergencies’ perhaps also contributed. You might think that the crucial failure in the encounter occurs when the patient states his symptoms and the receptionist triages these as non-urgent, offering advice outside her sphere of competence. But it is also worth considering some additional factors at play. Could the treatment delay have been avoided if:

• The receptionist had been empowered (or felt supported) to pause the encounter after hearing the persistence of the patient’s concerns, and used this opportunity to take stock with the PM or a clinical colleague?
• The receptionist had felt able to use her judgement to arrange an emergency slot given the persistence of the patient’s request and previous number of contacts?
• The receptionist had asked if the patient felt he could wait another day to see the doctor instead of maintaining that available slots were only for emergencies?
• The receptionist had participated in some practice training highlighting the risks around the receptionist role as gatekeeper to GP consultations, including the need to avoid triaging simply to get around the fact that no appointments are available?

Being aware

We will never know if changing any of these or other aspects of the systems, training or levels of support available would have made a difference in this situation. It is clear though that these and other factors can and do influence what GPs are aware of happening in the practice. The more you know, the better chance you have of achieving safer practice.

Liz Price is a senior risk adviser at MDDUS.