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Discussion
Summary
GPESs in this study recognised a broad range of skills/attributes associated with being a safe GP. Importantly, many of these were judged to be trainable. Not surprisingly, technical/clinical skills were considered important and the most trainable. Least trainable were attributes that would constitute professional values; yet these are crucial to the effective performance of any clinical practitioner, the learning culture in the practice and therefore patient safety. Interestingly, leadership was considered the least important skill/attribute to being a safe GP, which contrasts sharply with the views of hospital doctors. This may reflect a difference in the way that GPs understand and interpret the concept of leadership in respect of safety, as compared to hospital doctors. For GPs, safety may reside much more in individual practice and care, rather than in the leadership of a team and they may conflate 'leadership' with 'management'. In contrast, hospital doctors often have more clearly defined leadership roles as part of clinical teams at the frontline and also as part of clinical directorates at managerial level. This may make leadership in respect to safety a more recognised construct within secondary care.
The additional novel skills/attributes proposed by respondents further suggest that there are important, albeit subtle differences in the perceived necessary safety skill-set between primary and secondary care doctors. For example, the fundamental feature of general practice in coordinating the effective provision of holistic, long-term patient care may be reflected in the additional item suggested 'taking ownership/accountability'. This is in contrast to care in the hospital sector where the majority of patient contacts and follow-up are on a relatively short-term basis, with patients ultimately discharged back to the care of their GP. In a similar vein, that GPs are often the patients' first port of call for medical advice (and the onus that this places on GPs) may be reflected in the additional item suggested 'intuition – listening to that worrying little inner voice'. Interestingly, 'awareness of patient' was ranked relatively low by GPESs in both importance and perceived trainability. It is possible that this item is not fully understood. GPES and trainees are focused on 'patient-centred' consulting and determining the patient's agenda, which is what is required to pass the RCGP membership examination. The proposed alternative terms 'patient-focused' and 'patient advocacy' reflect this specific context. In a similar vein, 'negotiation skills' (as a subset of teamwork and communication) was suggested as an additional item, perhaps emphasising this critical GP skill in negotiating a management plan with patients (as their advocates), and with other healthcare professionals, as 'gatekeepers' to secondary care.
Comparison With Existing Literature
To the best of our knowledge, this is the first national survey to explore GPES' views regarding the key skills and attributes necessary to being a safe GP. The views of GPs regarding what constitutes 'patient safety' have been previously explored, but the specific individual skills and attributes necessary to be a safe GP were largely overlooked when compared to team and systems level priorities. Most of our study findings compare favourably with existing competency frameworks, but provide further insight into the potential prioritisation of competencies and what is trainable, as perceived by GPES from a patient safety perspective. For example, training in some safety-critical skills such as team-working and communication is widely available and researched. However, perhaps an added dimension is required to emphasise how these skill-sets interact and impact on the safety of the immediate workplace and the wider NHS. From this perspective there is now growing interest in educating the NHS workforce in human factors science. A possible educational gap, therefore, is the need to move beyond a limited focus on the importance of 'non-technical skills' to patient safety to an appreciation of a more holistic understanding of the role and consequences of human-system interactions in the clinical workplace. Developing educational interventions for patient safety that focus on raising awareness of the workplace as a complex socio-technical system will be necessary.
Strengths and Limitations
The survey response rate of 50% was moderate, but comparable to other internet-based surveys in healthcare. The large number of respondents was sufficient for analysis and inference. We did not capture demographic data in an attempt to reduce the questionnaire completion time and because we judged that, although important, this information was not particularly critical to the study purpose and interpretation of findings. We were therefore unable to compare the characteristics of responders and non-responders so the possibility of response bias cannot be excluded. Our findings may not therefore be generalisable from a GP educator perspective, or representative of the non-training GP community. Moreover, we acknowledge that this particular group of GPs may not be considered 'experts' and therefore the possibility of 'unconscious incompetence' exists, with GPES having differing interpretations of safety and a potential lack of knowledge/insight of safety systems and their role in individual errors when compared to patient safety 'experts'. Related to this point is the technical limitation that using the CVI as a numerical cut-off for survey items may have resulted in items being discarded based on respondent consensus, whereas in fact safety experts would have scored them differently and potentially retained them. We acknowledge that there is inherent subjectivity in methods that rely on human judgement. Indeed, the additional items suggested by respondents may indicate a gap in the question set and/or interpretational issues on the part of the participants. Nonetheless we believe this study adds to our knowledge and understanding of this under-researched topic, with GPES well-placed to identify the safety attributes of a safe GP. All GPES must be deemed safe consulters prior to being accepted as educational supervisors, and patient safety competences both at individual (through medical appraisal) and system (practice) level are assessed at re-accreditation visits. Moreover, the GPES are all trained to assess and make judgements on trainees' ability to practice (including safely) and can be called to account for these judgements.
Implications for Research and Practice
These findings provide a basic educational platform on how to go about improving patient safety in primary care through targeted training of GPs in those safety skills/attributes which were perceived as a higher priority and judged to be trainable by experienced and informed frontline educators and clinicians. Importantly, this can help develop educational programmes in priority safety skills at different levels of training and career progression for GPs. Additionally, we may be able to agree a skill-set on which to base the development and alignment of assessment tools for testing the safety competencies of GPs, particularly those in training. Given increasing calls for primary care clinicians to engage in and lead in safety improvement efforts our findings suggest a need to encourage GPs into more visible leadership positions and also emphasise how GPs are leaders in their own practices, although many may not explicitly recognise this. This is particularly prudent given the renewed moves towards primary care-led commissioning in England and health and social care integration in Scotland. Finally, this study also gives weight to the argument for extending GP specialty training to enable the acquisition of skills in patient safety, leadership and quality improvement in parallel to core clinical competencies - necessary for delivering safe, effective care for the 21 century. Future research should further explore GPs' views on the concept of leadership as a safety skill in primary care. Repeating this study to explore the views of GP trainees and the wider primary care team could also provide invaluable insight into potential differences in views and may help to shape targeted training interventions for the whole primary care team in the future.
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