At our partners' away day last year, it emerged that there was widespread unease about the management of sore throats in the practice. Everyone felt swamped with unnecessary consultations (always as urgent extras) for self-limiting sore throats. Our antibiotic prescribing seemed high and there appeared to be a real determination to deal with the problem.
Vital to our agreement on a protocol was the recent BMJ paper1 showing that delayed prescription for this complaint did seem to reduce consultation rates, while also leaving patients empowered and satisfied.
I was the most profligate prescriber and did not manage to avoid the chairman's eye at the critical moment. Thus I was charged with producing a protocol, a patient information leaflet and notices for the waiting rooms.
|Clockwise from top left: Surgery poster, patient information leaflet, College Surgery sore throat protocol|
There was a fair degree of discussion and haggling before we could agree a protocol. We all had our pet regimens. This was a very common clinical problem, but one that we hardly ever thought worth discussing. It turned out that there was a lot of literature to read, e.g. the value of throat swabs and the sensitivity of monospot tests, if decisions were to be based on fact.
It mattered that we all had our say and that we did not feel dragooned into using a protocol that had been 'parachuted' into our individual practices from outside. Some of us doubted whether we could influence 12,500 patients with such entrenched views, without causing major upset.
Did the protocol work?
Yes, it did and it still does. The home PC-generated notices are read in the waiting room and people are often apologetic when they come in with a sore throat.
Delaying the prescription or just giving advice seems to satisfy most people. We have not seen an increase in quinsy or tonsillitis and there has been a significant decrease in consultations for self-limiting viral sore throats.
The national Path of least resistance campaign2 to reduce antibiotic usage has followed on well from this protocol. We can be confident that even in a larger practice such as ours, there is no risk of one doctor being played off against another, or one doctor being singled out as a 'soft touch'.
Importance of ownership
Why are doctors bad at following protocols? Partly it is because we are pragmatists: a protocol has to be seen to work before we accept it. We also have a resistance to being told what to do: we need to own it. But above all, a protocol has to work at 6.30 on a Friday night when there are still four extras and you're on call for the weekend.
There are many other common conditions that might lend themselves to practice protocols, such as urinary tract infection, thrush and sinusitis. Clearly, it is wasteful to ignore national guidelines, but there is real value in local discussion and ownership.
This process has demonstrated several features that a practice protocol needs if it is not to be pushed to the back of the desk and ignored:
- Everyone must agree that it is relevant to have one
- Everyone must be consulted and listened to
- Basic research must be done to base decisions on fact
- The protocol must be concise, with room for individual quirks
- One person must be charged with seeing the process through within a realistic time limit
- Little P, Williamson I, Warner G et al. Open randomised trial of prescribing strategies in managing sore throats. Br Med J 1997; 314: 722-7.
- Standing Medical Advisory Committee Subgroup on Antimicrobial Resistance. The path of least resistance. London: DoH, 1998.