Having a plan – a short guide for patients

Following on from my blog on making the most of remote consultations, I realised would be helpful to talk about the outcome patients should expect from a remote consultation. This blog is based on my clinical experience, on feedback from patients, carers and relatives, and on my ongoing experience of helping look after my mother who is at the end of her life.

There are some simple things that that everyone should come away with at the end of a consultation. If these areas have not been covered the consultation is incomplete. Don’t accept this.

Consultation information:

At the end of the consultation you must:

  1. Have agreed a plan (even if this is ‘watch and wait’, or a referral on)
  2. Have written information on what has been discussed
  3. Know the signs of improvement or the signs of deterioration to look for
  4. Know when & who to contact if things change
  5. Know who to contact in an emergency

At the end of the consultation:

At the end of the consultation you should know:

  1. That your concerns have been listened to
  2. That the agreed actions will be taken
  3. That you can seek a second opinion if needed
  4. That the consultation will be communicated to all involved in the patient’s care

You should also receive:

Written information on the consultation. This may be in the form of notes, a care plan or visit summary & copies of ALL communication between clinicians.

‘No decision about me without me.’

‘If you’re not provided your records (as you should be) , you may wish to keep a record of your consultations yourself and / or record them. As a clinician I encourage this.’ – Steve Turner RGN; RMN; Ba(Hons); P.G. Dip. Ed

In my next blog I’ll look at communication and documentation. What form should this take? Covering all options including: online access to records, patient held notes, visit summaries, asessment letters, patient notebooks. How can we ensure patients & all involved have this information in real time?

Previous blogs in this series:

A guide for patients on remote clinical consultations

Giving a history – guide for patients


Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamSocialCare #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If you have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Author: Steve Turner

Date: 11.06.2020

Version: Draft 1e. Changes – typos corrected, added subject of next blog.

Sharing your medical history with clinicians

It is often assumed that the person carrying out a consultation has access to your medical records and your full medical history. Sometimes telephone consultations are carried out with a clinician who doesn’t know (or have access to) your medical history.

This is quite common. As we get older and are likely to have more than one medical problem (‘multimorbidity’ in jargon), and services are frequently delivered by different specialists from a variety of different professions (‘sub-specialisation‘ in jargon).

If we have a medical condition that has been ongoing for many years and is well controlled, we may forget to tell the clinician. You may forget to mention something like asthma for example, because it hasn’t been problematic for a while. It’s really important not to miss these areas, as the safety and effectiveness of your treatment plan depends on it.

It may help, before the consultation, to write a list of:

  • Previous illnesses, including mental health problems*, sleep problems and mood variations (‘no health without mental health’)
  • Previous hospital admissions & operations
  • All your long term conditions (the chart below shows an acronym ‘MJTHREADS’ used by clinicians). Alternatively it may be helpful to think of a ‘systems review’ in terms of a ‘body scan’, starting with the head.
  • All health related people (including complementary therapists, & support groups ) that you see.

In addition some (or all) of the following details will be relevant. Think about:

  • Your preferences and beliefs about treatments, including resuscitation & end of life care (often called advanced decisions or advance care plans)
  • Who cares for you or who you care for. People don’t always realise (or tell clinicians) that they are caring for others
  • Your job or lack of a job , or how you occupy your time
  • Financial worries
  • Your social circumstances – who do you live with? -do you have close family & friends? -do you feel isolated? -live in a remote location? – do you feel vulnerable? – your hobbies?
  • How you feel about your own safety – have you ever felt like harming yourself?
  • Past (or recent / ongoing) trauma and abuse
  • Your spiritual beliefs
  • Recent travel abroad
  • Your ethnicity
  • Your diet and any recent changes
  • Recent weight loss or weight gain
  • How much exercise you take
  • Your sleep pattern and any recent changes
  • Your family history
  • Other areas (listed here in no specific order) such as childhood history, pregnancy history, risk taking history or sexual history

*In response to feedback on this blog from patients, it’s important to note that there may be some details related to mental health that patients do not want to share with all clinicians.

The above list may look daunting, and is obviously not all needed in all consultations, however it’s worth reviewing. I have come across people who were waiting to be asked some of the above questions, and wanted to tell someone something important, who told me they only opened up because they were asked.

This blog links to the blog for patients on making the most of telephone consultations. It’s a ‘rolling blog’. I will be updating it based on feedback, and incorporating all coimments and suggestions.

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If you have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 01.05.2020

Author: Steve Turner

Version: Draft 1c 07.06.2020

Revision history: Asterisked note on patients’ preferneces for data sharing inclided.

Making the most of remote consultations – a guide for patients (*rolling blog)

It is now very common for clinicians to carry out consultations with patients over the ‘phone or on the internet.

If you have time to prepare for the consulation here are some suggestions. This is part of our patient led clinical education work. The aim being to help all patients / users of health and care services lead on their own care.

In some cases, you may be talking to someone who has never met you, so preparation is key.

Here is some general advice:

Preparation

  1. Write it all down beforehand if you can, as it’s difficult to remember otherwise.
  2. Take some observations if you are able. Temperature blood pressure heart rate other measurements, including your feelings, mood and areas such as sleep & appetite. If the problem is something visible (like a rash for example) send pictures & monitor changes over time.
  3. Tell them how you are different from your norm.
  4. Tell your story of why you are calling, in your own words.
  5. Be honest and remember mental health and physical health are equally important. Inseparable in fact.
  6. Ask if you don’t understand anything.
  7. Don’t be afraid to check that the clinician has followed what you are saying.

It’s important that you are allowed time at the outset to tell your story in your own words, to be able to share your ideas, your concerns and what you are expecting for the consultation. If you are speaking to someone who doesn’t have access to your medical history, they will also go through this with you in detail.

This checklist will help you prepare for the consultation and lead to an agreed plan for what to do next. Think particularly about what you would like to have happen. This is a question you may well be asked.

A screenshot of a cell phone

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Your clinician will also need to refer to your medical history. If they have this to hand they may check that it’s up to date with you. Often they may not have this information and will have to go through your history with you. This is vital in order to ensure you come up with an appropriate and safe plan for your care. Click here for a second short blog on giving a history.

Medicines and treatments (of any kind)

Consultations often involve medicines and treatments. Because of this it’s important that you share details of all medicines and related substances you take, not just those that are prescribed. This includes herbal medicines, over the counter medicines, supplements and anything borrowed or bought over the internet. It’s vital to be honest, as interactions can be very serious, sometimes fatal. Your clinician will not think badly of you if, for example, you don’t take a prescribed medicine or are trying something else. Statistics show that at least 50% of people don’t take their medicines as prescribed. That’s 50% of the whole population with mental or physical illnesses, not just a specific group of people.

Remember a medicine isn’t always the answer, share with the clinician details of non-medicine related treatments and approaches you take, and how well this works.

This chart shows the information you need to share. Very importantly this includes details of any allergies or sensitivities and how these affected you.

What happens next – The plan

Finally, many consultations do not result in a medicine, or specific treatment, being prescribed. Some may result in a medicine or treatment being stopped, changed or reduced. Sometimes it’s a case of ‘watch and wait’. The most important thing is that both the patient and clinicians have agreed on plan, know how to monitor progress and what to do if things change.

What’s important is that:

  1. You have agreed a plan
  2. You know what tests are needed (if any) and they are arranged
  3. You know what referrals have been made and when to expect to have these consultations
  4. You know the signs of improvement or the signs of deteriorations to look for
  5. You have information on the problem and access to more in a format you prefer
  6. You know when & who to contact if things deteriorate
  7. You know the signs to look out for and when to call 999
  8. Everyone involved in your care shares this information

Summarised in the chart below:

*This is a rolling blog. I welcome all suggestions for amendments, deletions and additions from everyone. Please email steve@carerightnow.co.uk

I am grateful to my friends and colleagues who helped me put together this information.

Steve Turner is a nurse prescriber and clinical educator & Associate Lecturer at Plymouth University. Steve shares health information from the Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19  and on the web site www.patientled.education

Click here for the Care Right Now CIC web site

If have any questions about coordinating care for a loved one, you can contact Steve by email: steve@carerightnow.co.uk

Published: 20.04.2020

Author: Steve Turner

Version: 1

Revision History: 27.04.2020 – added a note about taking and sending pictures (‘Preparation’ point 2.)

Life in Lockdown: Coronavirus (StAustell Voice 15.04.2020)

I was working up to retirement when Coronavirus hit us. I work on clinical education and service development. I have lived in the St Austell area for 18 years. Some of my work, such as supporting Pharmacies in the North West, was already carried out from home.  Most of my teaching work has now stopped so I have applied to return to #NHS. While I’m waiting to hear back, I’m sharing health information from my Twitter account @MedicineGovSte using hashtags: #TeamPatient #TeamNHS #TeamCOVID19 .

I am also helping coordinate mum’s care. Mum is 90. She lives 300 miles away & is very frail & poorly. Normally my brother & I would go straight to her when she needs us. So this is a really worrying time. Mum has fantastic carers; community support and a great GP. Because mum has multiple long-term conditions and is seen by several different health and care teams, I am finding that the coordination I do for her is vital to ensure that she receives the best care, nothing is duplicated, she receives her medicines and has the right equipment in the home. If any local families have any questions about coordinating care for a loved one please let me know. I’m happy to share some tips. steve@carerightnow.co.uk

I’ve also started a serives of blogs based on our patient led clinical education work. The first one is on telephone consultations: click here to see it.

More than ever now, we love to spend time in our garden. We’re planting vegetables and the garden’s looking better than ever.

Take care #StAustell

Steve Turner is a registered general and mental health nurse prescriber and Managing Director of Care Right Now CIC. http://www.carerightnow.co.uk

First published in the StAustell Voice

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Steve is Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University  and a former NICE Medicines and Prescribing Programme Associate.

@MedicineGovSte

LinkedIn profile.

info@carerightnow.co.uk

Author: Steve Turner

First published: 16.04.2020 Revised: 27.04.3030

Version:1c


‘Are my medicines really necessary?’

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‘Are my medicines really necessary’ is one of the most frequent questions from our patient led clinical education sessions.

In this blog Steve Turner, Head of Medicines & Prescribing @MedicineGov,  reflects on the need to combine research and guidleines with the patient’s actual experience, when deciding on medicines.

 

My experiences and learning

I was speaking about the use of medicines at a conference when I mentioned that medicines are ‘over prescribed’. Although nobody questioned and challenged me on this I was troubled by my use of this expression. By saying medicines are prescribed too frequently it seems to me this can be interpreted as a bad reflection on the prescribers.

As I mentally mulled this over (I’m not a quick thinker) I came to the conclusion that a beter expression may be ‘medicines are overused’. After all it’s us (the patients) who go to our Doctors, Pharmacists and Nurses and us who accept their prescriptions. Therefore if we agree that people can rely too heavily on medicines, and there’s wealth of evidence for this, then we need to sort this out together.

My social enterprise company’s Patent Led Clinical Education work came about because a large section of the population are prescribed multiple medicines, with potential for interactions and increased side-effects.

It’s widely accepted that 50% of the population don’t take their medicines as prescribed. Add to this the sometimes overlooked fact that people also use alternatives including over the counter medicines, herbal medicines , suplements, illicit drugs, self-medicate with alcohol, buy medicines over the internet, or borrow medicines from other people.


‘The human and financial costs of over use of medicines are immense. ‘


In our patient led clinical education sessions we have learned that many people don’t know what their individual medicines are for, and we see how many medicines are prescribed purely to counteract the side-effect of another medicine can pile up.


‘So far, nobody who has attended one of our sessions has expressed a wish to take more medicines, and those who did express a view all said that they didn’t want to take medicines if they didn’t have to.’


So what can we do together?

This blog aims to help us make sense of the vast amount of guidance available and describing why ‘trusted information’ is important in making decisions about medicines, and why this is only helpful it it’s linked to the patient’s actual experience.

So much information, so many policies & guidance?

There’s an overwhelming amount of information and guidance on medicines, coming out on a daily basis. Even clinicians struggle to keep up and need help.

Two things are important in trying to make sense of this information overload.

  1. Making sure that the information you are looking at is from a ‘trusted’ source, (by this I mean ones that your prescriber is expected to use). see http://www.medsinfo.guru
  2. Linking this to patient experiences and support from others who have the same conditions.

 

  1. ‘Trusted’ information

The National Centre for Heath and Care Education [NICE] in England produces guidance, standards, indicators and evidence services covering health and social care. It’s not just about medicines. There’s a massive amount of trusted information on their web site, which covers:

  • Conditions and diseases
  • Health protection
  • Lifestyle and wellbeing
  • Population groups
  • Service delivery, organisation and staffing

To get a feel for this one place to start is the NICE Pathways, where you can browse the topics, pick one and have the information presented in a diagram, where you can click on the headings for more information.

In some areas has been a move away from producing guidelines on a single illness or condition to a more holistic person based approach. This better reflects the complexities of real life, where it would often be a luxury to have just one illness with no complicating factors. NICE guidance on medicines optimisation, multi-morbidity clinical assessment and management, and patient experience in adult NHS services are good examples.

In addition NICE produces a document on Key Therapeutic Topics as part of the NICE Medicines and Prescribing Programme. This document is reviewed and refreshed annually. Click here for the topic list.

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2. Patient experiences

Medicines (for adults) are tested and approved before that can be prescribed, and their safety is monitored, especially in the early stages, or if there are concerns (black traingle drugs). However drug trials are most often carried out on relatively small groups of poeple, usually from a limited range of ethnic groups, who who do not necessarily represent the population as a whole. For example, these ‘controlled trials’ usually exclude people with multiple illnesses, heavy drinkers or smokers, older people, and people with other illensses such as addiction or mental ill health.

Controlled drugs trials are not carried out on children.

In addition the effect of medicines, including side-effects fall into two categories. Firstly, those that can be predicted (pharmaco dynamic effects – that the effect of the drug on the body). Secondly, those that vary according to the bodily make up of the patient (called pharmacokinetic effects – the effect of the body on the drug).

It’s only when you combine the guidance with the specific circumstances of the patient, including the ethnicity and physical make up and lifestyle of the patient that a decision on a medicine can be made effectively. For this to work, the patient must be part of this decision, and be allowed to lead on their own care. Our work shows this:

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Testimonials on our patient led clinical education work.


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