March 22, 2023

This video offers advice on how to develop safety nets and follow up plans.

Hi there i’m dr martin benfield i’m a gp trainer and this video looks to the final section of the consultation the follow-up plan and safety net so in consultation models uh they appear as separate entities at the end of the consultation in reality they kind of merge into the whole management plan discussion uh the follow-up plan being when the next review is

Going to happen and the safety net being the the information you want the patient to remember in think in case things get worse or don’t improve as planned to some extent the follow-up plans and safety net can overlap quite a lot we’ll look at the follow-up plans first there’s a slightly simpler than the safety net while you’re discussing your management start

Thinking about what kind of follow-up you’re going to need when you start in general practice it’s good practice to have full arts for many of your consultations it’s safer and also you get to learn from what happened next after you gave the advice you did patient there is some balance between having a very attentive doctor and a burden of unnecessary appointments

The follow-up plan needs to include how the next contact is happening when it’s going to happen and who is arranging it the how can be face-to-face phone call doctor text message it could be patient initiated e-consult letter uh calling receptionist the when could be fixed two weeks four weeks at a time when you’re expecting the intervention to have worked or the

Blood tests result to be back uh or it could be more flexible triggered by an event such as the blood test result coming back and then the follow-up happens uh the who is arranging often gets missed by the doctor seems obvious to them sometimes but not so much to patients are you booking it right now is there is is the patient going out to reception to book it

Right now is the doctor going to contact at a certain point is the patient needing to contact at a certain point when deciding on the follow-up plan have a think about what you’re actually achieving have you given enough time for the intervention to have worked has the blood test happened yet if nothing’s going to change until the blood test result comes back

Then the follow-up has to be after that point similarly if you know the results of the test is coming back say within 48 hours you don’t really want the patient waiting another two weeks to then find out what’s going to happen next as a result of that test you ideally get that done sooner what difference are you expecting the blood test to make if you expect it

To confirm everything that was discussed already and the patient to carry on the plan then a simple fallout’s needed if however you’re expecting a whole new discussion to happen as a result that test then a proper appointment is going to be required for that as you become more experienced you’ll be able to reduce down the number of follow-ups and to start shifting

The responsibility over to the patient to have more control over when they want the follow-up to be your management plans are like to have more steps in it for the patient to follow and then to contact you as required when the patient is given instructions on if and when to contact that’s when the safety net and the follow-up plan start to merge into one there

Are more considerations than you might first think with the safety net as we talked about in previous videos people can only remember a certain amount of information they’ve been given they tend to remember the first thing last things things were repeated and things that were emphasized is important so although the safety net maybe has fairly small proportion of

The whole discussion it actually ends up being a fairly large section of the remembered information you could give massive masses of examples of symptoms and reasons and what to do but persons i need to remember a certain amount so your safety net needs to be understood it needs to cover all the important areas but it needs to be concise enough that the person

Can realistically remember it safetynet will consist of symptoms to look out for it’s going to look for reasons why this is important that needs a time scale for those symptoms and it needs to be clear what to do if they occur shouldn’t be covering any new information here in terms of symptoms or reasons if you’ve been doing a transparent consultation during the

History taking there could have been opportunities to explain why you’re explaining called require or pneumonia or cancer symptoms and then during the differential diagnosis chat there should have been times where you explained why or why not it was or wasn’t the serious condition so when you then bring this up in the safety net discussion should be the third time

This topic is covered and it should never ever be the first time a decision for you to make for the safety net is how specific to make the symptoms it can range from very non-specific to very specific a non-specific example would be if anything gets worse in any way whereas specific would be if you develop a fever you start feeling more ill in yourself or you

Start feeling short of breath if you’re non-specific then you obviously you’ve got a wider net to catch as many symptoms as possible by being specific you are alerting the patient specifically to those symptoms to look out for if you’re concerned by one specific condition then you’re unable to be more specific on the symptoms if you’re less sure of what might

Happen next for example the patients presented with non-specific abdominal pain then you need gonna need to be a lot broader with your safety net the non-specific way may fall down if the patient develops a symptom and didn’t realize that that was important so often a mix needs to be chosen if you get worse in any way for example feverish you feel more ill in

Yourself or you get short of breath um so we can also explain our safety net and why it’s important to increase the recall although there are no signs of pneumonia at the moment it would be really important that you contact us at any time if your symptoms worsen in any way for example you feel more ill your fevers return or you start feeling short of breath

You can also link in the expectations answers from your data gathering in this section as well it makes it works quite nicely doing that i would definitely want to start antibiotics if or i would want to organize a chest x-ray if in the example we’ve been doing so far uh you probably want to explain your findings why do you think it’s not pneumonia at the moment

Describe the natural history of the condition that you think it is and then the safety net merges with those expectations answers you had a fever and then this chesty cough started so i had no doubt at all you’ve got an infection the fever’s gone now so i think your body’s on top of the infection and when i listen to your lungs they sounded completely clear your

Pulse was normal and your oxygen levels were normal so i think it was a viral bronchitis in the tubes rather than a bacterial pneumonia deep in the lungs themselves the fever should not return you shouldn’t feel worse at any time from now onwards but on average these coughs last for about three weeks i would definitely want to start antibiotics if there was any

Evidence at any time you’re worsening for example the fever returned you started feeling more ill in yourself for some reason or you started feeling short of breath so would you be able to contact me immediately if that happens we might also organize a chest x-ray at that point if it was uncertain what was going on the next aspect is to build in uh timings again

This can be non-specific like any time or specific in x number of days in our example we use the anytime option because we were looking at a serious condition that could worsen at any time i don’t want them calling up in a week’s time when actually their symptoms got better the next they’ve got sorry got worse the next day so we could add in both options i would

Expect you to start feeling better and be significantly better than you are now by two weeks time and i would expect all your symptoms to be fully resolved in four weeks please contact me if that doesn’t happen the anytime option really good for worsening conditions that might need immediate action whereas the specific times are better for the symptoms that may

Not have got worse but they haven’t improved as expected when the natural history says it should have improved by or when the medication should have started working by and at that point obviously we’d then be looking at either stepping up treatment plan or reassessing the differential diagnosis the last factor to build in is how the patient contacts you may need

To add it and add in an emergency contact uh for out of hours although there are no signs of pneumonia at the moment it will be really important that you contact at any time if you worsen in any way call the surgery if it’s during working hours if it’s evenings or weekends uh call 111 or go direct the emergency department if at any time you suddenly feel really

Ill remember from previous videos to always add that check question at the end of any any chunks of information does that all make sense the other thing to remember is to break up long monologues with a check question and that enables the patient to be engaged is more likely and more like to remember what’s happening and you’re able to check that they understood

The chunks uh have you ever had to call 111 before or if you became very unwell do you have someone that could drive you to the hospital or uh do you have any questions about any of those symptoms to look for uh as a bit of an aside uh something that can get missed with the safety net uh follow-up discussions is medication side effects so common side effects

Are also often described to patients but very rarely what to actually do about it so have a thing can they be ignored if mild is there anything they could do about them at what point would this patient having a side effect need to trigger them to contact you right for the final part of this video what i’d like to do is for you to have a think about a standard

New dyspepsia consultation um mild very mild symptoms no red flags and you’re going to give a ppi you’re going to give omeprazole for two weeks i’d like to have a think about your safety net and follow-up plan that you’re going to describe to the patient what symptoms would trigger an urgent review what symptoms were triggering not so urgent review what would the

Patient do in both of these situations what is going to happen if symptoms don’t fully resolve how is the patient going to contact you in that situation if treatment works but the symptoms returned what instructions are you going to give then do your range of fixed follow-up appointment in another certain number of weeks and how are you going to arrange that so

If you can pause this video have a think even better write down what your safety net plan would be and then listen to my version that’s coming up in a second okay so here’s my version uh if at any time anything really bad happens such as severe pain you vomit blood you pass those black sticky stools we talked about that could suggest bleeding and if that happens

You’ve got to go straight to the emergency department if during the next two weeks you notice your symptoms start to worsen or new symptoms develop then please contact me because i’d want to see you within a couple of days if that started happening you can send an e-consult with my name on it or you could call reception and they’ll send a message through to me and

I can give you a call back in that situation so i think we probably need to reassess the diagnosis and we probably need to arrange some tests i suspect does that all make sense i’m going to book you a follow-up appointment for three weeks time a phone call if that’s okay and what i’d like to do is check your symptoms fully resolve that they didn’t start coming back

Again and we can also discuss a bit more about what we might be able to do to try and stop this happening again and if your symptoms ever did start to return what we could do then okay so if you can take a few minutes to write out your safety net uh speech to this patient uh then say it out loud see how it sounds does it make sense is there too much information

And then after writing out decide where to add your check questions in so you know you don’t want more than a couple of sentences in a row stop adding in some check sentences that you can use that will break up the monologue when revising topics i would strongly advise you to do this exercise every time this will obviously help your real life consultations it

Will also aid your akt revision because you could use this to start building in your different the next few steps in the treatment ladder and you can use that to help remember what each step is on the say the nice guidelines for topic it’s clearly going to help you with rca preparation as well so good luck everybody

Transcribed from video
Safety net and follow up plans By GP Consultation Skills MB