Early warning scores: a system designed in a hospital ward is unlikely to work in general practice

paediatric emergency medicine consultantAll data on the application of safety systems is useful, and Clark and colleagues' work on the National Paediatric Early Warning System (PEWS) cited by Salisbury is an important addition to the literature. 1 2 It's important to highlight, however, that the wholescale lifting of a system designed in a hospital ward straight into the community was never going to be successful.Time and time again the system safety literature has told us interventions are context, and sometimes patient, specific.It was never the intention of the PEWS programme board to do this.As part of the SPOT (System Wide Paediatric Observation Tracking) programme we had always intended to create a standardised approach in inpatients, then start aligning this with processes in emergency departments (this work will be released in 2025), and then move towards pre-hospital and primary care.The hope is to have a tool that is additive to the clinical gestalt of the primary care clinician (which Salisbury points out is probably the most important part of the diagnostic process) and, rather than create a new score, we have something that aids communication with other healthcare professionals using a common and standardised language.Clark and colleagues' paper supports what we already knew.A score designed to pick up a deteriorating patient on the ward is not going to pick up a potentially unwell patient in a general practice with anywhere near the specificity to be credible in practice.The National PEWS programme board (which does include GP representation) fully supports Salisbury's comments on the subtleties of illness recognition in primary care.Whatever "system" is rolled out to align with the inpatient charts will be very cognisant of this.