September contract calendar
Patients can get the most out of a practice while giving you the contract data you need, says Dr Peter Stott
The new GP contract is not only a new way of paying GPs, it is also a new way of working that forces primary care to perform regular reviews of patients' clinical status. Patients have responsibilities too, for without their willing co-operation, practices will not achieve financial utopia.
So how can we work so that both of us get the best out of the system? The challenge is to find a way of enabling patients to understand how they can make the most efficient combination of blood tests, visits to the practice and repeat prescription requests while still providing us with the data we need. If this can be achieved then the system will be more efficient.
If we don't enlist their support, then people who have several conditions will have to come several times. Those with asthma, diabetes and hypothyroidism for example could end up having three sets of visits. This could result in lots of wasted opportunities – wasted time for patients and wasted energy for the practice. We need to think in terms of the one-stop shop where people get everything done on one visit and patients use primary care more efficiently. Timed medication review may offer one solution.
Most GP computer systems now trigger an alert at predetermined time intervals and a full treatment review is intended at this time. This is a key time for the practice because it can be set to coincide with the need for nGMS data acquisition. There are three levels of review.
Level 1 A technical review of the list of patient's medicines
Level 1 reviews don't need access to the patient's notes and do not usually involve a review of the full repeat prescription list. The patient may be present, but not always. And the reviews don't have to be performed by the doctor. They are equally well done by a nurse or pharmacist and involve things like dose and pack optimisation, resolving quality problems and brand to generic switches.
Level 2 A review of medicines with the patient's full notes
Level 2 reviews are usually performed by the GP, pharmacist or nurse. The patient may or may not be present. Review includes:
lRemoval of unwanted items
lReview as part of an audit (eg PPIs, cox-2s)
lReviews as part of the nGMS (lithium, thyroid, asthma)
Level 3 Face-to-face review of medicines and condition
Level 3 reviews are performed with the patient present and as a full partner in their care. The review should consider their prescribed and OTC medication in the context of the patient's lifestyle and experience. In some circumstances, the carer should also be involved. Things to be addressed include:
lEvaluating therapeutic efficacy of each drug
lIdentifying and meeting unmet needs
lProviding information to enhance concordance
Level 2 and level 3 reviews are ideally suited to the purpose of nGMS. People who have several problems can then be managed on one occasion and informed as to the next time a review will be needed – but there is one caveat. For many, blood tests or other investigations will also be needed in order to make informed decisions. This needs to be done before they see the doctor or nurse, so the flowchart looks something like figure 1.
Medication review at Tadworth medical centre
Like many practices, Tadworth has well-developed clinics for asthma, COPD, hypertension, diabetes, cardiovascular problems and stroke, and has a yearly audit programme for patients on lithium and thyroid replacement.
When a repeat prescription request triggers a yearly medication review, a level 2 medication check is performed by the doctor who then orders appropriate tests and indicates if a subsequent clinic visit is needed.
We have designed a specific form for this – the patient care plan (figure 2). This has tick-boxes to make it easy. The completed form is attached to the patient's repeat prescription and the receptionist makes the necessary arrangements with the patient when they come to collect it.
Local pharmacists are also involved because some scripts go direct to them. Our health care assistants ensure data entry is as complete as possible before the patient attends. This reduces the clinic time needed for data entry during the consultation itself.
So someone who has asthma and hypothyroidism would receive an invitation to see the practice nurse for a blood test and asthma check. Someone with diabetes and asthma would be asked to have a fasting blood test and then to attend the diabetes clinic and the asthma clinic. Someone with hypertension who had been seen within the last three months would simply have their computer medication record updated.
Where time constraints prove insuperable, most patients will be happy to come back later; and next year more time will be allowed. The respiratory checks for asthma and COPD can be quite time-consuming and tend to require a rather different approach from other nGMS areas, particularly for complex cases where two visits may be necessary.
But as a general principle the whole process is designed so that wherever possible we offer a one-stop-shop approach to patient care. This minimises the need for patients to consult opportunistically. We run our clinics at times when the weekly workload is lowest. So we get the patients to come in when it suits us, not when it suits them.
The system is not foolproof and needs considerable professional input, at least in the first year until patients know what to expect. The doctors have to spend more time scrutinising repeat prescriptions and designing care plans. We have appointed a practice pharmacist to deal with the initiation and maintenance of the systems, and there needs to be a lot of discussion and staff training. Nevertheless, we hope the investment will pay for itself in the longer run.
Medication review is a specific quality area in nGMS and there are points available for doing it. Our system makes it work even more in our favour; and the points earned pay for the salaries involved. There may even be a small profit with which to pay for waiting room improvements!
Task-Force on Medicines Partnership and the National Collaborative Medicines Management Services Programme 2002. Room for review – a guide to medication review: the agenda for patients, practitioner and managers. Medicines Partnership,
1 Lambeth High Street,
London SE1 7JN
Peter Stott is a GP in Tadworth, Surrey