Chapter 13
Illustrative patient pathway
to self care: cough and colds

This chapter gives you an example of a practice team’s approach to the self care of cough and colds.

Section 1 Self care for cough and colds

The start

We start with a 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 a cough and cold 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 coughs and colds for completing the problem based learning, learn more about the range of self care support options and read through the clinical summary about cough and colds in the second section of this chapter, before you start the problem based learning exercise.

Patient’s story 13.1

‘Tom is three years old and had only started at nursery a few weeks ago. He was hot, irritable and off his food for a couple of days over the weekend. He was coughing all the next night and kept waking up crying and asking for a drink, so I took him to the doctor. I was annoyed with the doctor who didn’t seem to think Tom was ill at all and got us out of his room as quickly as he could. Mind you, Tom did seem much better than he had done in the night and was pulling all the drawers in the desk open and climbing on the couch. The doctor just listened to his chest and said to go on with the drinks and the paracetamol.

I left it a couple of days and he was no better, so I took Tom back to see one of the other doctors. I had to wait ages to see that doctor and Tom embarrassed me by behaving badly. I told the doctor how ill he was at night, cough, cough, cough, until he was almost sick, even if he did perk up in the day. He just felt round Tom’s neck, and then gave up examining him when Tom screamed and fought. The doctor wrote a prescription out for antibiotics. I wasn’t sure, then, whether Tom really needed them. The doctor hadn’t even listened to his chest again. Then after three days, Tom got diarrhoea, although he seemed better in himself. This time when I rang the practice, the receptionist suggested I talked to the health visitor. She was really sympathetic. She said she would ask the doctor and ring me back. When she did, she said to stop the antibiotics as they probably wouldn’t make any difference to his cold, and told me lots of useful things to try with him. She said that I could always ring NHS Direct any time if I was worried about any of his symptoms or ask the pharmacist for advice. That made me feel more comfortable about managing his cough.’

Note: the young patient and mother in this scenario had tried awaiting resolution of Tom’s symptoms, relief of his symptoms with paracetamol and to some extent tolerating the symptoms.

The project team

Consider Tool 11 on team building

You might want a team to discuss alternative self care support options for cough and colds as in this example to include:

reception staff
practice manager
GPs
practice nurses
pharmacist
health visitor
patient representative.

You could use a checklist as in Table 13.1 to record who is involved and in what way.

Team discussion considering the patient story 13.1

Consider Tools 1, 3, 4, 5, 6, 8 or 10 for your teamwork and discussions

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

the pharmacist is not sure when the practice want adults or children referred to them. He usually refers people with green mucus, but has read that this does not always mean they need antibiotics. He has also read that cough medicines do not do much to help, but people seem to expect them
the doctors manage colds and coughs inconsistently. The youngest doctor says he never gives antibiotics, the older ones say they usually do if the patient seems to expect it, or if they attend more than once. None of them spend much time explaining how patients might care for themselves, as the pressure of time when patients are seen urgently is too great
the practice nurses are too busy seeing people with long term conditions in their chronic disease clinics to see any patients attending urgently with cough and colds, and feel that they are not competent to give advice or examine chests
the health visitor feels that she is the expert here for advising parents. She has had training and lots of experience of advising mothers on childhood illness management. However, she is usually only in the practice on the day of the baby clinic and would find it difficult to liaise with the rest of the practice team on a more regular basis
receptionists would like more guidance to prioritise those patients who need to see a doctor urgently
the pharmacist usually delegates advice about cough and colds 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 cough, and the pharmacists are unaware of which patients the GPs feel should be seen
the practice manager is concerned about thenumber of ‘urgent extra’ patients who have to be fitted into the appointments scheme. If these numbers could be reduced, more appointments bookable in advance could be released
the patient representative feels that patients are made to feel a nuisance if they attend with cough and colds. He suggests that they should be able to talk to one of the doctors on the phone and receive antibiotics without being seen. The doctors are completely against this idea as, despite what they do in practice, they all agree antibiotics should not be used unless a secondary infection is suspected.

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 for the members of the project team to look at ways that patients can be educated about prevention and following self care plans in relation to cough and colds as an example
the practice manager and practice nurses agree to look at the workload. They need to decide if any of the work in chronic disease clinics can be done by other staff, or if more practice nurse time is needed, or if more training is required to extend their roles, or if a nurse practitioner could be trained or employed
receptionists will receive training on using the NHS Direct algorithms,1 to help them become more confident in advising patients on the most appropriate course of action – for example those ringing in with coughs or colds
the patient representative will arrange for a patient advice leaflet and some posters to be piloted. The health visitor offers to obtain (or write) some leaflets for cough and colds, applicable to various age groups
the doctors and nurses agree to meet with the practice or community pharmacist to examine the evidence about the treatment of cough and colds with antibiotics and other medication, and to draw up a policy so that patients receive consistent management from the GPs and local pharmacists. They will need to allow for patients to opt for symptomatic treatments that give thema temporary reduction in the discomfort of sore throat, even if there is no or limited evidence of any particular treatment providing a ‘cure’
the pharmacist will give patients a leaflet about overuse of antibiotics, and the practice will print out the patient information leaflet on Prodigy if the patient attends the practice.2 The pharmacist might source the evidence, in addition to that presented in this chapter3
the patient representative and practice manager will arrange some talks to the patient group. The GP agrees to talk about antibiotic use, and the health visitor and pharmacist will talk about self care
doctors will use the patient information leaflets on Prodigy,4,5 and the practice manager will ensure that all computers can print out patient information leaflets on the printers in the consulting rooms
the practice manager and doctors discuss setting aside longer specific times for doctors to receive phone calls from patients, but this proves difficult and a decision is postponed until the ‘extra urgent’ patient demand is curtailed by other activity. The doctors feel that a nurse practitioner would be a better use of resources, to answer telephone queries about minor illnesses or undertake telephone triage, but might prove difficult to recruit
the practice will approach the PCT for help with finding a nurse practitioner.

part 2