Chapter 10
Illustrative patient pathway to self care

You will understand the theory of this guide to promoting and supporting self care if you see it applied. The next four chapters give you examples of patient pathways in self care as applied in a typical general practice. They describe the roles that everyone in the team can play and resources you’ll need – for people with sore throat, back pain, asthma, and cough and colds. There are more examples of patient pathways on the www.wipp.nhs.uk website.

Illustrative patient pathway to self care: sore throat

This chapter gives you an example of a general practice team’s approach to the self care of sore throat.

Section 1 Self care for sore throats

The start

We start with the patient’s perspective. You could:

work through the detailed scenario observing the sort of issues and discussion that the fictional practice team progress through here
discuss how your team would respond to the patient story given here
take an example case of a patient with sore throat from your own practice (anonymising the patient’s identity in the team’s discussion as appropriate).

If you do not know enough about the management of sore throat for completing the problem based learning, learn more about the range of self care support options and read through the clinical summary about sore throat in the second section of this chapter, before you start the problem based learning exercise.

Patient’s story 10.1

‘I recently had a really bad sore throat. As I only usually have sore throats for 2–3 days, sometimes followed by a cold, I just treated this as any normal sore throat and took paracetamol as usual.

A week later and I still had a sore throat, especially in the mornings, so I decided it might be time to visit the GP. I had thought of going a couple of times but know that there’s not much a GP can do for a sore throat or cold and it is often advertised not to attend your GP surgery if you just have a cold.

I decided to go the pharmacy first to see if they could recommend anything that would clear up my sore throat so that I didn’t need to see the doctor. They sold me some medicine but it did not help my sore throat much. The next day I rang for an appointment to see the doctor. I was very impressed that I got an appointment at very short notice. I was aware, though, that by this time I had started to feel a whole lot better but as I had an appointment I thought that it was still worth going.’

Note: the patient in this scenario had tried awaiting resolution of her symptoms, and self care for relief of symptoms, and to some extent was tolerating the symptoms.

Your project team

Consider Tool 11 on team building

You might want a team to discuss alternative self care support options for sore throat as in this example to include:

practice nurses
reception staff
practice manager
GPs
patient and/or carer
pharmacist
pharmacy assistant.

You could use a checklist as in Table 10.1 (see p. 130) to record who is involved and in what way.

Team discussion considering the patient story 10.1

Consider Tools 1, 3, 4, 5, 6 or 8 for your teamwork and discussions

In this scenario, discussion between the fictional practice team members reveals:

patients making an urgent appointment are usually seen by the GPs after the routine surgery. If a GP locum or new GP registrar is in the practice many of the urgent appointments will be with this doctor. The practice nurses are too booked up with patients with long term conditions to provide any help
the GP’s view is that many of the patients attending for urgent appointments are irritating – unless they have a serious medical complaint. The GP gives patients inadequate explanations about their condition because of the pressure of time
the reception staff often feel squeezed between patients who are anxious about their symptoms, and the desire to reduce the burden of extra patients for the GPs. Receptionists would like more guidance to prioritise those patients who need to see a doctor urgently
management is inconsistent. Some doctors give antibiotics for sore throats frequently, others hardly ever. None feel that they can give enough time to explain how the patient can manage next time, or how patients can decide when to consult with a sore throat. They are unsure how they would do this anyway
patients and carers continue to attend with sore throats because there is no consistent policy. They feel unsure how to take care of themselves and how long it is reasonable to wait before consulting a GP or nurse about their sore throat. They often feel that they were right to see the doctor last time because they received a prescription
the pharmacist usually delegates advice about sore throats to the pharmacy assistants. No consistent policy has been agreed in the pharmacy. Neither have the GPs and local pharmacists agreed a policy for the treatment of sore throats and the pharmacists are unaware of which patients the GPs feel should be seen. The pharmacy assistant feels that she is expected by her employer and the customer to sell something to relieve the symptoms.

What you do next might include:

Consider any of Tools 2, 3, 4, 5, 6, 7, 8, 9 or 10 for your action planning

arrange a meeting between members of the primary care team and the pharmacist team to agree a common approach to supporting self care for sore throats
nominate one of the practice nurses as the lead clinician because of her special training and skills in health promotion. (Or arrange for one of the practice nurses to receive such training before taking on the lead.) She might combine this specific task (of education about sore throats) with other prioritised health education tasks such as smoking, obesity and exercise
examine the time that the practice nurse has available. A shortage of time will prompt an audit of tasks performed. Analysis suggests that up to 40% of the work currently performed by the practice nurse could safely be delegated to a less qualified health professional. The team decide to use an appropriately trained health care assistant. You might train suitable volunteers from the existing members of staff to the requisite standard, or employ someone already trained
patient and carer representatives on the team help to draft and test posters and new information in the practice leaflet about the availability of advice about self care to people with sore throat, as an example.
reception staff and pharmacy assistantswill use information (see Box 10.1, p. 131) to advise patients on self care and whether they need an appointment at the surgery. Patients who are not happy with this, or who are on medication, will be referred to the nurse or doctor for telephone advice in the first instance
the receptionists decide to give out to patients the flow chart on self care for sore throats, published by NHS Direct.1 The practice manager will scan this into the computer so that it can easily be printed out, and check once a year that it is an upto - date version
the GPs and practice nurses agree to use the Prodigy patient leaflet on sore throats.2 It can be printed out for patients who attend
the pharmacist would prefer to use the patient information leaflet from the Scottish Intercollegiate Guidelines Network (as it does not denigrate the use of lozenges, etc that might affect sales) and will train the pharmacist assistants on its use.3 The pharmacy already has a supply of the leaflet on reducing antibiotic use (Antibiotics: don’t wear me out) that customers can collect from a display4
discussion about the cost of supporting self care leads to a proposal that the pharmacist and practicemanager will approach the PCT. In other areas, PCTs have financed a minor ailments scheme where care is transferred from general practice to pharmacies, and patients normally exempt from prescription charges can receive OTC medicines free of charge
the doctors and nurses agree to meet with the practice or community pharmacist to examine the evidence about the treatment of sore throats with antibiotics and to draw up an agreement so that patients receive consistent management. They will allow for patients to opt for symptomatic treatments that give them temporary reduction in the discomfort of sore throat, even if there is no or limited evidence of any particular treatment providing a ‘cure’. The practice pharmacist might source the evidence, in addition to that presented in this chapter.

What extra resources might this require?

Consider either Tool 8 or 10 for determining resource and skill needs

Time for meetings and for training.
Protected time for the lead practice nurse to monitor and support the introduction of the changes; time for her health promotion activities.
Training for reception staff to use the flow chart and leaflets and direct patients to the pharmacy or practice nurse for advice.
The practice manager will ensure that all computers are set up so that information leaflets can be printed out. A supply of ready printed leaflets will be kept in the reception area and the lead receptionist or her deputy will ensure that they are replenished.
Additional staffing hours may be needed initially – achieved by modifying the workload of existing staff, extending the hours of existing staff or employing additional staff. An additional health care assistant may be the most cost effective approach.
Schemes for transfer of management of minor ailments funded by PCTs have allocated funding for a pharmacy facilitator for setting up the scheme. The PCT needs to fund the cost of the medicine supplied plus a consultation fee for the pharmacist.
The pharmacy may need extra time, but many of the consultations in minor ailments schemes are basically transfers from dispensing of a prescription that the patient would have received from a doctor. There should be an area to preserve the confidentiality of consultations between the pharmacist and patients, and assistance with the paperwork created by the minor ailments scheme.
Supplies of leaflets and posters about the minor ailments scheme.

part 2

Chapter 10 Illustrative patient pathway to self care