Award Title: Optimising patient risk management in urgent primary care services
Funder: Department of Health and Social Care

Abstract: Research questions 1. What structural/organisational resources are available in urgent care services to keep patients safe? 2. What patient risk management work is performed by staff, and how? 3. To what extent is safety-netting/follow-up advice recalled and understood by patients/carers? 4. How can patient risk management in urgent care services be optimised? Background The accurate assessment and management of clinical risk is challenging in urgent care settings (NHS 111, GP Out-of-hours and Urgent Care/Treatment Centres). Safety-netting (informing patients/carers when to reconsult and how) and follow-up advice (planned future review) are key strategies for managing risk. Inadequate safety-netting and follow-up can lead to avoidable patient harm, reputational damage to staff and providers, and incur high NHS medico-legal costs. Urgent care is provided by a variety of organisations, and no evidence currently exists as to best practice. I will address this gap, with key stakeholder involvement, in order to optimise patient risk management during episodes of care. Research objectives i. To map the resources for patient risk management available across urgent care services; ii. To analyse staff safety-netting and follow-up practices; iii. To identify organisational and staff barriers to patient risk management; iv. To assess patient/carer recall and understanding of safety-netting and follow-up advice; v. To identify patient/carer information needs and barriers to implementing advice; vi. To translate the findings into actionable insights to optimise patient risk management. Methods Following the Donabedian model, I have designed four work packages (WP) to collect data on structure, processes of care and outcomes. In WP1, I will design and administer a national survey of urgent care providers to document the range of structural and organisational resources being used to support the management of patient risk. Data analyses will document barriers, map variation and identify 'typical' and 'atypical' services. In WP2, I will recruit six 'typical' services (two NHS 111, two GP Out-of-hours and two Urgent Care/Treatment Centres) for an in-depth comparative case study on processes of care. I will employ ethnographic and conversation analytic methods to characterize how everyday risk work is performed by staff, and how safety-netting and follow-up advice are communicated. In WP3 I will design and administer patient/carer questionnaires, and conduct interviews, to assess the extent to which they recalled and understood any advice given; whether it met information needs; and determine outcomes. Data analyses will identify key components that comprise more and less 'successful' advice, and barriers to implementation. In WP4 I will integrate the findings from WP1-3 and recruit clinical leads and staff from NHS111, GP Out-of-hours, Urgent Care/Treatment Centres and General Practice, to focused group discussions in order to identify and prioritise actionable improvement targets. Timelines for delivery Key deliverables are planned for each WP over a four-year period. Anticipated impact and dissemination Evidence-based quality/safety improvement resources will be made available via the FutureNHS platform that will have immediate impact for services and patients/carers and longer term efficiency savings for the NHS. A knowledge mobilisation plan for engagement and dissemination will be developed with, and for, end users.

Lay Abstract: Aims of the research Urgent care services (NHS 111, GP Out-of-hours, and Urgent Care/Treatment Centres) play a vital role in assessing patients when GP surgeries are closed. These services typically deal with non-life-threatening conditions, but also conditions that are potentially life-threatening. We know very little about the risk management work being done by urgent care services; by their staff; and by patients/carers themselves. The proposed project aims to fill this knowledge gap and to inform quality and safety improvements. Background to the research Patient risk management is very important in the urgent care context because initial assessments are often done by telephone which can make it difficult to rule out serious illness. Even when patients are seen, staff are unlikely to know them, or necessarily have direct access to their records. In a national analysis of patient safety incidents, urgent care services were responsible for the highest incident rates; with communication failures, with and about patients, most common in these settings including failing to tell patients what to do if their condition worsens (inadequate safety-netting) or not making appropriate onward referrals (follow-up). Design and methods used I will address the following questions: 1. What structural and organisational resources are available in urgent care services to keep patients safe? I will recruit leaders of 40 organisations providing urgent care services across England for a focused telephone survey in order to document and map the range of resources (tools/technologies) in place to keep patients safe. 2. What patient risk management work is performed by staff, and how? I will recruit six services as case studies and spend a four-week period in each, making observations, interviewing 30 staff, recording 180 staff/patient/carer encounters, and reviewing patient record entries. This will allow me to explore the nature and context of risk management work such as delivering safety-netting advice to patients/carers. 3. To what extent is safety-netting and follow-up advice recalled and understood by patients/carers? I will ask 125 patients/carers whose encounters I recorded, whether they recalled and understood any safety-netting/follow-up advice given, and what happened next, in a telephone questionnaire 10-14 days later. The advice recalled will be compared with the advice given. I will then interview 30 patients/carers to understand more about their experiences of using that particular service, including their motivation, and any information sought beforehand. I will explore advice 'successes', as well as potential 'failures', and ideas for improvement. 4. How can patient risk management in urgent care services be optimised? I will recruit 54 staff from NHS 111, GP Out-of-hours, Urgent Care/Treatment Centres, and GP surgeries to participate in eight focused group discussions. I will share the project findings and ask them how they think quality and safety might be improved. Patient/service user and public involvement My project plan has been influenced by conversations with service users, staff, and service leaders, over the last two years. All agree that patient risk management is a crucial area for improvement and that my aims are achievable. A diverse Service User Group will be involved from start to finish, and two members will help steer the research in my Project Advisory Group. Experts from National Voices, the leading coalition of health and social care charities in England, will also provide strategic advice and input throughout. Dissemination During the research I will provide accessible updates on a project webpage, publish in academic journals and present at conferences. I will work with arts practitioners to help engage the public. I will share quality and safety improvement resources with services, meet with key national decision-makers, and hold a meeting to share the overall findings with relevant stakeholders.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: GENERIC HEALTH RELEVANCE