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.