Month: January 2019

The five questions: what are they, and do they matter?

capture

In the most recent annual report from the Chief Medical Officer for Scotland, Dr Calderwood discusses the need to move towards a shared approach to clinical decision-making. Are we not already doing this? The evidence says not.

NHS surveys tell us that patients value highly the opportunities to discuss their care, the options open to them, and being involved in the decisions that shape their management. A survey undertaken by the Citizens’ Panel showed that while 92% of patients felt comfortable about asking their doctor about treatment, only 67% did so. Similar percentages were recorded for discussing risks and benefits. Why is there a gap? Patients report that the willingness of doctors, of how busy they appear to be, inhibit these discussions.

three talk

If we are to change our culture further (and it has already changed over the last fifty years) then we need to focus on how we enable these conversations. How often do we interrupt patients when they are talking? As well as restricting their narrative, it limits their expression of what is of concern. It emphasisis the agenda of the clinician and the pressures on their time. This needs to be more than tokenism, we need to really dig deep and learn better ways to do this. Having a good framework in which to conceptualise these conversations is important. One such structure is the three talk model. 

I also think that, as well as listening, and leaving space for debate and questions about management, we can coach patients to ask for better information. Some of this confidence comes from health literacy. Some comes from having the right words, the right questions to ask of clinicians as they leave our primary care consulting rooms and are passed on to secondary care colleagues, to other clinical teams.

This is where the five questions come in. The five questions were drafted by Choosing Wisely UK, which is part of global initiative to improve conversations between patients and their clinicians.  Five boards piloted the use of the five questions, encouraging people to ask clinicians about their management plans. Having the questions written down enables patients to take first steps in these discussions. The questions aren’t going to change the world, but they can empower patients to start these important conversations.

I have displayed these questions in practice leaflets, on the noticeboard in the waiting room, on lanyard cards, on signposting cards and on the practice website. I don’t know how well I would do with answering all of the questions all of the time. However, as well as providing concrete examples for patients, this produces an environment, a culture where patients are expected to discuss their care. This message is as powerful for my colleagiues as it is for patients.

A wise friend of mine, Dr Maria Duffy, commented that these questions appear very clinically orientated. They do not explicitly promote discussions around the social determinants of health. She works in Pollok and is a GP trainer as well as a GP partner. She is part of the Deep End group, practices who look after patients in more deprived areas, where there are higher proportions of patients whose social and economic background has a big influence on their health.

She would add:

  • Is going to the doctor the best way to address my problems?
  • What is there that I might change myself that would help?
  • How much do I expect to achieve by seeking a clinical solution?

While these questions do not focus on a shared approach to clinical decision-making, they encourage patients and clinicians to think outside the clinical box, to imagine other ways of tackling life’s problems.

However, it is not enough to parachute in to our surgery with the cards and the posters. The most important next step for me is to ensure that my colleagues understand the scope of what I am doing, that patients are engaged in the project, and that any practical top tips are spread to other clinical areas.

Letters to patients

As well as being a GP, I have been working in secondary care as a GP with a special interest in Dermatology. Around five years ago, I was feeling very annoyed with one of the practices that refers to the dermatology clinic. Patients were attending for review without having tried the treatment that I had suggested.

The dermatology clinic is usually rammed, and these appointments were adding unnecessary pressure on the clinic, wasting patients time, as well as adding a longer burden of ill-health due to skin disease. Nobody was happy.

I could have written to the practice and had a strop, but the practice involved was struggling to recruit partners or salaried GPs. They were relying on locum cover, and there didn’t seem to be an end in sight. In addition, other patients in other practices didn’t always seem to understand their treatment plans.

An aside here: most patients with chronic dermatological conditions have complex treatment regimens. This could include a pre-washing emollient, a soap substitute, a moisturiser, then a topical treatment, to be titrated up or down, and tapering to other treatments. Very few patients and GPs manage to get this all down at the first attempt.

I started writing my clinic letters direct to the patient with a copy to the GP, with consent. Nobody turned me down. The best responses were from relatives of patients with dementia, where a written care plan was useful for the team of carers. At the clinic, patients were advised to check with their practice for their prescription when they received their copy letter.

I didn’t do this as a proper improvement project, I didn’t measure follow-up outcomes, patient satisfaction, and I didn’t have a ‘spread’ plan. However, the feedback was immediate, and positive. GPs were in favour: they no longer have to contact patients to check up on new prescriptions. Patients were in favour, finding it helpful to have the treatment plan written down in the letter. Relatives were in favour, having a documented plan to follow. The secretary confirms that there is no additional work in doing the letters this way.

After 3 years of doing letters this way, I’m beginning to see other clinicians trying this out. Patients bring their letters to GP consultations, ready to discuss their treatment as more equal partners. I have been asked to advise other clinicians about how to structure their letters.

The biggest and best outcome is patients as equal participants in their treatment, and communication about their health. It is a culture shift, and it is gradual, and I am part of it.

Indication prescribing

I have come across something so simple, so easy to do, and so intuitive, that I can’t believe that I haven’t always done it. It helps patients understand their medication, and enables better conversations about concordance between patient and prescriber.

It is indication prescribing. I have always done this for PRN medications, without even thinking. For example, if I prescribe paracetamol, the prescription says ‘take two tablets four times a day for pain’.

Now, when I add a repeat prescription, I am adding ‘take one daily to treat high blood pressure’ or ‘take one tablet before meals to ease symptoms of irritable bowel syndrome’. So far, it has had good feed-back, it costs nothing, and it moves the responsibility for compliance, concordance, for treatment towards a more patient-centred model.

There will always be the patients who state that they only take four white tablets at breakfast, or one of my more memorable old ladies who used to keep her many medications in a bowl like pan-drops and helped herself to a few each day.

I hope, by making Indication Prescribing the norm in our practice, that these patients will become the outliers. For each medication review by prescribers and the practice pharmacist, an opportunity to make this become the way things are done around here.