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CHAPTER3 Consulting withpatients
Telephone consulting and homevisits
To cope with i demand for GP appointments, the past 20y have seen the
proportion of GP consultations taking place over the telephone i from 3%
to 12%; simultaneously, the proportion of consultations taking place in patients’ own homes has d from 9% to 3.5%.
Emergency telephone consultations Nearly all requests for emer-
gency care are made by telephone. General rules:
• Train surgery sta to handle distressed callers, recognize serious
problems, and act appropriately when such calls are received
• Appear helpful from the outset. Keep calm and friendly— even if
provoked; worried callers often appear abrupt or demanding
• Record the time of the call, date, patient’s name, address the patient is
at and a contact telephone number, brief details of the problem, and
action taken (even if calls are being recorded)
• Collect only information you need to decide whether a visit/ urgent surgery
appointment is necessary. If a visit is necessary, collect enough information
to decide how quickly the patient should be seen and whether extra
equipment or help is needed. If a visit is not necessary, decide whether
other actions, such as an urgent surgery appointment, are required
• If giving advice, make it simple and in language the patient can
understand. Repeat to make sure it has been understood. Consider
asking patients/ carers to repeat what you have told them. Always tell
callers to ring back if symptoms change or they have further worries
• If a visit is indicated, ensure the address is correct and ask for directions
if you are not sure where to go. Try to give a rough arrival time
• In some cases (e.g. major trauma, large GI bleeds, MI, stroke, burns,
overdoses), call for an emergency ambulance at once
• If a call seems inappropriate, consider the reason for it, e.g. depression
might provoke recurrent calls for minor ailments
• If in doubt— see the patient.
Routine telephone consultations May take various dierent forms:
• Telephone triage systems to lter requests for surgery appointments
• Telephone clinics where patients are free to call with their problems
• Telephone message books
• Bookable telephone slots in surgery time
The telephone is a useful way to answer simple queries without wasting
surgery time. Examples include:
• Consultations for minor, self- limiting conditions or conditions not
requiring an examination
• Follow- up of surgery consultations, e.g. to give results, or oer
management advice or a prescription following investigations
The biggest drawbacks of telephone consultations are:
• Inability to examine the patient
• Lack of visual cues to aid communication— be alert for verbal cues (e.g.
lowering of the voice, hesitations, signs of distress). Ask about ideas/
concerns, and invite the patient to ask questions
0 Before giving advice, ensure you have sucient information upon which
to base your judgement. If examination is needed, see the patient.
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TELEPHONE CONSULTING AND HOMEVISITS
Remote video consultations A large number of both private and
NHS GP services now routinely use video consultation platforms (such
as Skype) to deliver GP consultations. Feedback from both patients and
healthcare practitioners has been positive. From the GP perspective, consultations take place in much the same way as standard telephone consultations but the doctor is able to see the patient, can perform rudimentary
visual examination, and is also able to pick up visual cues from the patient.
Home visiting Home visits may be routine checks for housebound
patients or emergency visits for patients temporarily unable to get to the
surgery. Home visits done in working hours are usually done by practices
under their GMS/ PMS contract but, in some areas, home- visiting services
are provided by the PCO and practices are able to ‘opt out’.
Routine visits Conducted like ordinary surgery consultations. Seeing patients in their own home may give valuable extra information.
Emergencyvisits
• Try to stick to the problem you have been called about; take a concise
history and examine as appropriate
• Make a decision on management, and explain it to the patient and any
carers in clear and concise terms they can understand. Repeat advice
several times ± write it down
• Record history, examination, management suggested, and advice given
• Always invite the patient/ carers to call you again should symptoms
change, the situation deteriorate, or further worries arise
• For inappropriate calls, take time to educate the patient and/ or carers
about self- management and use of emergency GP visiting services;
always consider hidden reasons for seemingly unnecessary visits
Beingprepared
• Ensure you have a reliable car with a full tank of fuel
• Have a good street map and in- car electronic navigation system
• Carry a mobile phone and large, strong torch in the car
• Check your drug box is fully stocked and all items are in date
• Check all equipment carried is operational and carry spare batteries
• Carry a list of emergency telephone numbers and know which
pharmacies have extended opening hours
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Safety andsecurity
• In all cases, ensure someone else knows where you are going, when
to expect you back, and what to do if you do not return on time
• If going to a call you are worried about, either take someone with you
to sit in the car or call the police to meet you there before going in
• If you are uncomfortable, make sure you can get out. Note the
layout of the property, and make sure you have a clear exit route to
the door
• Set up your mobile phone to call the police or your base at a single
touch. Consider carrying an attack alarm
• If possible, have separate bags for drugs and consultation equipment;
leave the drug box locked out of sight in the boot of the car when
visiting
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CHAPTER3 Consulting withpatients
Referrals and electronicmedia
Referral letters Good communication is essential when referring patients
to other doctors/ agencies. Electronic pre- lled word processing templates
may add some information automatically, but ensure all referral letters include:
• Address of the referrer (including telephone number, if possible), name
and address of registered GP if not the referrer, and date of referral
• Name, address, telephone number, and date of birth of the patient (and
any other identiers available, e.g. hospital or NHS number)
• Name of the person to whom the patient is being referred (or
department if not a named individual)
• Presenting condition— history, examination, investigations already
performed with results, treatments already tried with outcomes
• Relevant past medical history and family history
• Current medication, and any intolerances/ allergies known
• Reason for referral (what you want the recipient of the letter to do),
e.g. to investigate symptoms, to reassure parents
• Any other relevant information, e.g. social circumstances
• Signature and/ or name in legible format of referrer + GMC/ Nursing
and Midwifery Council number
• Ensure a copy of the referral is stored on the patient’s electronic record
Referral rates E p. 57
Referral management systems E p. 57
NHS e- Referral Service (eRS) Since October 2018, Trusts will only
accept e- referrals from GPs. Once a referral is made, patients can book an
appointment at a time and venue of their choice either in the GP surgery at
the point of referral, or later on the telephone or online.
Use ofe- mail inthe GPsurgery
Dissemination of information E- mail is widely used in the UK to disseminate
(cascade) information to GPs, e.g. NICE, DH, MHRA, PCOs.
Communication with doctors/ other healthcare providers Many communications between doctors occur by e- mail both within practices and also
between practices/ other healthcare providers (e.g. consultant advice by
email). 0 E- mail transfer between non- NHS e- mail accounts should never
be considered secure or condential.
Communication with patients ~80% of the UK population now has access to
e- mail. Cyber- savvy patients increasingly want to be able to communicate with
healthcare professionals by e- mail, but it has been used relatively little for communication with patients due to concerns over quality of e- mail content, time
lag, condentiality, and liability. The NHS eConsult system is likely to increase
electronic communication between GPs and patients. The eConsult system
uses standard questionnaires and templates to exclude urgent conditions unsuitable for eConsult and collect important information for the consulting GP.
Guidelines fore- mail consultations withpatients
• Establish turnaround time; do not use e- mail for urgent matters
• Warn users that e- mail is not secure and that they cannot assume
condentiality just because they are communicating with a doctor;
advise patients not to use a work or multi- user e- mail account
• Retain copies of e- mail communications with patients
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REFERRALS AND ELECTRONICMEDIA
• Instruct patients to put their name and date of birth in the message,
and the category of transaction in the subject line of the message for
ltering:e.g. prescription, appointment, medical advice
• Congure an automatic reply to acknowledge receipt of messages
• Send a new message to inform the patient of completion of the request;
ensure that others are not copied into the reply
• Avoid giving person- specic information or conrming information given
by the patient— it may not be the patient
• Never write anything that you would not be happy to see printed on a
newspaper’s front page
• Append a standard block of text to the end of messages which contains
the GP’s name, contact information, and reminders about security and
the importance of contacting the practice by telephone for emergencies
• Explain to patients that their messages should be concise
• Remind patients when they do not adhere to the guidelines
Social media Internet- based websites/ tools allowing users to create/
share content between networks of people, e.g. Facebook, LinkedIn,
Twitter, YouTube. Social media are used successfully by doctors to:
• Establish wider/ more diverse social and professional networks
• Engage the public and colleagues in debates
• Facilitate public access to accurate health information
• Improve patient access to services
Risks ofsocial mediause
• Loss of personal privacy
• Potential breaches of condentiality
• Online behaviour that might be perceived as unprofessional, oensive,
or inappropriate by others
• Risks of posts being reported by the media or sent to employers
Guidance on social media use The BMA, GMC, and RCGP have all produced
guidelines for doctors on the use of social media. Key points:
• Social media blurs boundaries between public/ professional lives
• Adopt conservative privacy settings where available, but be aware that
not all information can be protected on the web
• Ethical and legal duties to protect patient condentiality apply equally on
the Internet as to other media
• It is inappropriate to post informal, personal, or derogatory comments
about patients or colleagues on public Internet forums
• Doctors who post online should declare any conicts of interest
• Do not accept Facebook friend requests from current/ former patients
• Defamation law can apply to any comments posted on the web made in
either a personal or professional capacity
• Be conscious of online image and its impact on professional standing
Further information
BMA Social media guidance for doctors. M www.bma.org.uk
GMC Doctor’s use of social media. M www.gmc- uk.org
RCGP Social media highway code. M www.rcgp.org.uk/ social- media
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CHAPTER3 Consulting withpatients
The doctor’sbag
• The GP’s bag must be lockable and not be left unattended during home
visits. If left in the car, keep the bag locked and out of sight— preferably
in the boot. Consider having a separate bag for drugs and consultation
equipment and only get the drug bag out of the boot of the car if it is
needed. Keep the bag away from extremes of temperature.
Consider including the following in your doctor’s bag. Exact contents will
vary according to location and circumstances:
Diagnosticequipment
• Stethoscope
• Sphygmomanometer
• Thermometer
• Gloves, lubricating jelly, and tissues
• Torc h
• Otoscope
• Ophthalmoscope
• Tongue depressors
• Peak ow meter
• Pulse oximeter
• Fluorescein sticks
Administrativeequipment
• Mobile telephone ± charger
• Laptop computer with access to
full patient record
• Prescription pad
• List of useful telephone numbers
• BNF/ MIMS
• Envelopes/ notepaper
• Electronic navigation aid ± map
• Pathology/ X- ray forms (if electronic forms are not used)
• Controlled drugs record book (if controlled drugs are carried)
• Quick reference text, e.g. Oxford Handbook of General Practice
Otherequipment
• Airway ± Laerdal mask
• Oxygen cylinder and mask with
reservoir bag
• Automated external debrillator
• Nebulizer
• Spacer device
• IV cannula
• IV giving set and uids
• Needles/ syringes
• Bandages
• Urine dipsticks
• Capillary blood glucose tester
and appropriate test strips
• Tourniquet, vacutainer (or
syringe), and needles
• Patella hammer
• Swabs
• Specimen containers
• Vaginal speculum ± sponge
forceps
• Fetal stethoscope/ Doppler
• Obstetric calculator
• Peak ow chart/ wheel
• Note book
• Temporary resident records
• List of local chemists and extended
opening times
• Small amount of change for parking, etc.
• Gauze swabs
• Adhesive plasters
• Scissors
• Skin closure strips
• Suturing equipment/ skin glue
• Urinary catheter and bag
• Antiseptic sachets
• Dressing pack
• Sharps box
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THE DOCTOR’SBAG
Drugs for the doctor’s bag Consider:
Injectables
• Adrenaline (epinephrine)
• Naloxone
• Benzylpenicillin injection
• Cefotaxime injection
• Lorazepam/ diazepam
• NSAID, e.g. diclofenac
• Local anaesthetic, e.g. lidocaine
• Opioid analgesic, e.g. morphine,
oxycodone
• Thrombolytic therapy (if >½h from nearest acute hospital and trained)
Oraldrugs
• Antacid
• Antibiotics (adult tablets and
paediatric sachets), e.g. amoxicillin+
erythromycin/ clarithromycin +
trimethoprim/ nitrofurantoin
• Antihistamine
Otherdrugs
• GTN spray • Glycerol suppositories
• Bronchodilator for nebulizer • Rectal diazepam
• Salbutamol inhaler + spacer • Diclofenac suppositories
• GlucoGel® glucose gel • Domperidone suppositories
Drugs administered from a doctor’s bag Should be in a suitable container and
properly labelled with:
• Patient’s name • Relevant warnings
• Drug name • Name and address of the prescriber
• Drug dosage • Date
• Quantity of tablets • Warning ‘Keep out of reach of children’
• Instructions for use
• Antiemetic, e.g. domperidone,
prochlorperazine
• Antihistamine, e.g. chlorphenamine
• Hydrocortisone injection
• Diuretic, e.g. furosemide
• Syntometrine
• Glucagon ± IV glucose
• Major tranquillizer, e.g.
haloperidol, chlorpromazine
• Rehydration tablets/ sachets
• Aspirin
• Lorazepam
• Paracetamol tablets +
suspension
• Prednisolone tablets (soluble)
• NSAID, e.g. ibuprofen
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• Check drugs at least 2×/ y to see they are still in date and usable; commercial databases (e.g. M www.doctorsbaguk.com) that store data about
drugs in the GP’s bag can be useful to alert you when drugs go out of date.
• Record origin, batch number, and expiry date of all drugs administered
to patients or dispensed to them to take themselves.
Furtherinformation
Drugs and Therapeutics Bulletin:
• Drugs for the doctor’s bag 1— adults (May 2015)
• Drugs for the doctor’s bag 2— children ( June 2015)
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CHAPTER3 Consulting withpatients
Evidence- informed decision- making
Evidence- based medicine (EBM) is ‘the conscientious, explicit and
judicious use of current best evidence in making decisions about the care of
the individual patient. It means integrating individual clinical expertise with the
best available external clinical evidence from systematic research.’ (Sackett
etal., 2018)
The 5 steps ofEBM
1. Convert clinical information needs into answerable questions
2. Track down the best evidence with which to answer them (Box 3.1)
3. Critically appraise that evidence for its validity/ usefulness
4. Apply the results of this appraisal in clinical practice
5. Evaluate your clinical performance, e.g. through audit (E p. 54)
Box 3.1 Useful sources ofbest evidence forGPs
• NICE (E p. 25) M www.nice.org.uk
• Cochrane Database of high- quality systematic reviews to inform
healthcare decision- making M www.cochranelibrary.com
• PubMed Central (PMC) Free to use, searchable database of biomedical
and life sciences journal literature M www.ncbi.nlm.nih.gov/ pmc
• Google Scholar Freely accessible web search engine that indexes
scholarly literature across an array of publishing formats and disciplines
Critical appraisal is the process of assessing and interpreting evidence
by systematically considering its validity, results, and relevance. It is essential
to avoid misinterpretation and misuse of evidence in practice.
Table 3.1 explains grading of evidence from most to least reliable; Table 3.2
is a glossary of common EBM/ critical appraisal terms. Critical Appraisal
Skills Programme (CASP) checklists are available to download from
Mwww.casp- uk.net. Before integrating evidence into practice consider:
• Are the results of the study valid and applicable to my patient?
• What are the results?
• Will they help me in caring for my patients?
Table3.1 Classication and grading ofevidence:most l least reliable
Grade Evidence
A Ia Meta- analysis of randomized controlled trials
B IIa At least 1 well- designed controlled study without
C IV Expert committee reports or opinions and/ or clinical
Denition:evidence obtained from. . .
level
Ib At least 1 randomized controlled trial
randomization, e.g. case– controlled study; cohort study
IIb At least 1 other type of well- designed quasi- experimental study
III Well- designed, non- experimental descriptive studies, such as
comparative studies, correlation studies, and case studies
experience of respected authorities
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EVIDENCE-INFORMED DECISION-MAKING
Table3.2 Glossary ofterms used inEBM and critical appraisal
Term Explanation
Systematic
review and
meta- analysis
Randomized
controlled trial
(RCT)
Case– control
study
Cohort study Identies 2 groups (cohorts) of patients:1 that received the
Cross- sectional
study
Cost– benet
analysis
Bias Can take many forms but describes any systematic errors that
Condence
interval (CI)
Control and
experimental
event rates
Absolute risk
i or d
Relative risk or
risk ratio (RR)
Relative risk d
(RRR)
Number
needed to treat
or harm (NNT/
NNH)
Odds ratio
(OR)
Negative predictive value E p. 145
Positive predictive value E p. 145
Appraisal and synthesis of individual study reports using a rigorous
and reproducible methodology for searching for and selecting
studies included, thereby minimizing bias. Meta- anal ysis is systemic
review using quantitative methods to summarize results
Subjects are randomly assigned to an intervention or control
group (no intervention, placebo or alternative intervention).
Groups are compared to detect any dierences in outcome
Identies a group with an outcome of interest (cases) and another
without (controls), and looks for history of a particular exposure
exposure of interest, and 1 that did not. Then follows the
cohorts forward looking for the outcome of interest
Observation of a population at a set time or over a dened
period of time
Assesses whether cost of an intervention is worth the benet by
measuring both in the same (usually monetary) units
may distort outcome or interpretation of trial evidence
Quanties uncertainty. Usually reported as 95% CI, which is the
range of values between which it is 95% sure that the true value lies
Rate at which events occur in a control group (CER) or
experimental group (EER). CER/ EER=event rate ÷ total
number in the group, e.g. if 10 out of 100 have an event in the
control group, CER=0.1. May be expressed as a percentage
(e.g. 10%) or proportion (e.g. 0.1)
Absolute arithmetic dierence in rates of outcomes between
experimental and control participants in a trial (= CER − EER)
Ratio of risk in the treated group (EER) to risk in the control group
(CER). RR=EER/ CER. Used in RCTs and cohort studies. If RR=1
there is no dierence between the two groups for that measure
Dierence between the EER and CER (EER − CER) divided by
the CER. Usually expressed as a percentage
Measure of the dierence between active intervention and control
in terms of benet or harm. Equal to 1 ÷ absolute risk reduction
(or increase). For NNT, an NNT of 1 indicates 100% eecti veness;
the closer the NNT is to 1, the more eective the intervention. For
NNH, the higher the value, the safer the intervention
Odds of an event are the number of events divided by the
number of non- events. OR is the ratio of the odds in the
experimental divided by the odds in the control group. Often
expressed as a percentage
Sensitivity E p. 145
Specicity E p. 145
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Further information
Sackett SE, etal. (2018). Evidence- Based Medicine:How to Practice and
Teach EBM, 5th edition. Elsevier:Churchill Livingstone.
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CHAPTER3 Consulting withpatients
Guidelines, protocols, and integrated
carepathways
Clinical guidelines Dened as ‘user- friendly statements that bring together
the best external evidence and other knowledge necessary for decision making
about a specic health problem’. Over recent years there has been a dramatic
i in publication of guidelines and protocols. They aim to d harmful or expensive variations in clinical practice, improve healthcare outcomes and encourage rapid dissemination of useful innovations. Good clinical guidelines
have 3 properties— they:
• Dene practice questions and identify all their decision options and
outcomes
• Identify, appraise, and summarize best evidence about prevention,
diagnosis, prognosis, therapy, harm, and cost- eectiveness
• Identify the decision points at which the evidence needs to be integrated
with individual clinical experience and clinical circumstances in deciding a
course of action
Advantages and disadvantages ofguidelines
Advantages
• Provide guidance for busy clinicians— a consistent basis for
decision- making
• Practical framework for common problems and chronic disease
• Summarize the available research evidence
• Can be used as a basis for continuing medical education
• Justication for expenditure— can aid cost- eective use of limited
resources
• Facilitate the audit cycle
Disadvantages
• Poor quality guidelines can reinforce poor practice
• Lack of relevance of the guidelines to the clinical setting— much of the
‘evidence’ used to develop guidelines comes from secondary care and
may not reect the situation in primary care
• Tendency to uniformity— can stie innovation
• Resistance to change— new methods may not be considered until a
new guideline is produced
• Increased risk of litigation
• Cost— guidelines are time consuming to develop and update
• Lack of ownership— guidelines developed by others may not feel
relevant
• Diculties in implementation— guidelines that are not user- friendly
and well disseminated will not be used
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GUIDELINES, PROTOCOLS, AND INTEGRATED CAREPATHWAYS
Before starting to use a guideline Always ask:
‘Is this guideline valid, important and applicable in my practice?’
If theanswer is yes then consider:
• What barriers exist to implementation?
• Can they be overcome?
• Can you enlist collaboration of key colleagues?
• Can you meet the educational and administrative conditions that are
likely to determine the success or failure of implementing the strategy?
Protocol The term reserved for guidelines at the more rigid end of the
spectrum. These are very specic guidelines which are expected to be followed in detail, with little scope for variation, e.g. resuscitation protocols.
Integrated care pathway (ICP) ICPs amalgamate all the anticipated
elements of care and treatment of the multidisciplinary team, for a particular patient group in order to achieve agreed outcomes. Any deviation
from the plan is documented as variance— the analysis of which provides
information for the review of current practice. ICPs aim to:
• Facilitate introduction of guidelines and systemic audit into clinical
practice
• Improve multidisciplinary communication and care planning
• Reach or exceed existing standards
• Decrease unwanted practice variation
• Improve clinician– patient communication and patient satisfaction
• Identify research and development questions
• Cross the interface between primary, secondary, and social care
Grading/ classication of evidence Table 3.1, E p. 70
Further information
eGuidelines (free registration required) M www.eguidelines.co.uk
National Guidelines Clearing House (US) M www.guideline.gov
NICE M www.nice.org.uk
Scottish Intercollegiate Guidelines Network M www.sign.ac.uk
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