BRADFORD & AIREDALE CCG TRUST

ashcroft surgery,
bradford

Newlands Way, Eccleshill, Bradford, BD10 0JE, West Yorkshire, UK

Useful Numbers

  • CALL 111 –  open 24 hours for help with medical problems of short duration and sudden onset
  • ANY LOCAL PHARMACIST for good advice about medicines, minor illness
  • DISTRICT NURSES: 01274 256 131 for wounds, dressings, elderly people
  • HEALTH VISITORS: 01274 221 223 for advice about babies and children
  • MIDWIVES: 01274 623 952 if you’re pregnant
  • National Coronavirus Support Line 0333 880 6619

Scanning & Letters Protocol

Downloads

  • – – –

ASHCROFT LEADS

  • Doctor:   Dr Ramesh Mehay 
  • Nurse: – 
  • Admin:  Victoria O’Shea & Sallie Parker & Read Coder Manjit Singh

DATE REVIEWED:

20th June 2019

DATE OF NEXT REVIEW:

June 2020

The Issue & Why we have developed this system

The volume of posts is so high that in amongst the masses of “noisy” posts there will always be a few letters that have important medical things requiring action. Therefore, we need a system to sieve out the noise so that doctors focus their attention on letters that require their input.     Otherwise, these letters that require input are at high risk of become drowned by the others with the subsequent real and high chance of action being missed.  

In order to minimise that risk, we have decided that only those letters that require an action need to go to the doctor.       In this way, by sieving out the ‘wheat’ from the ‘chaff’ enables the doctor to focus on the stuff that matters.   Clearly, this process will enhance patient safety through enabling doctors to slow down and concentrate on those letters that truly need their input.

The Policy/Protocol

When letters arrives in the surgery, it will either be electronic (from NHS mail) or a paper letter received in the post.  

  1. If it is a paper letter, it will need to be scanned and attached to the patient record by the scanning and letters’ team within 5 days of arrival.
  2. If it is an electronic letter, it will need attaching to the patient record within 5 days of arrival.  
  3. The scanning team will then read that letter and decide on their action.
  4. That action might be…
      • to file a letter  
      • do some sort of admin action before filing the letter
      • to send it to the doctor
      • to send it to the nurse
      • to send it to the in-house pharmacist 
      • full guidance on all of this is provided below.
  5. ONE GOLDEN RULE: If a scanning team member not comfortable with actioning a particular letter, they will forward it onto the appropriate health professional e.g. a doctor, a pharmacist
  6. Finally, Code the letter using either the Read-Code or SNOWMED system (code yourself if you have been trained, alternatively send to Read-Coder).

The SRAC Mnemonic

The following SARAC mnemonic will help you remember the process:   

  1. Scan 
  2. Attach (to the patient record)
  3. Read
  4. Action
  5. Code
Doctors & Other Health Staff: you should read and action your letters within 5 working days.
 

Basic Guidance on Handling Letters in SystmOne

Dear scanning team, we need to prevent different scanners from doing different things.  So please read this section carefully.    Try not to assign letters as “outpatient letter” or “clinic letter” or “discharge letter”.  Please put it under specialty type like “Dermatology letter”, “Cardiology letter”, “Psychiatry letter”.   GPs need to find and read these letters quickly when a patient is with them in the consultation.   For example, if a patient is under say 3 specialists and all the letters are coded as “clinic letter”, can you see how incredibly difficult it would be for the doctor to find just a specific Cardiology one?   They would have to open all the letters one by one until it popped up.   So, the way you code and assign it is key to helping us find things easily.  

So, pay careful attention to what you code under the two bits of the letter – SENDER and TYPE.   This is what I suggest…

  • Do not select BRI or St Lukes
  • Instead, select specific department  eg Dermatology, Gynae, Respiratory etc.
  • Same rule applies to discharge letters, do not select BRI or St  Lukes but select department.
  • WHY?   Because knowing which department a letter has come from is more important than the building!
  • So always choose specialty departlment like Cardiology, Gastroenterology, Vascular, Elderly Medicine and so on

So, options under SENDER should be (and this may need tidying up in S1)

  • A&E
  • Breast Services – use for screening, clinic
  • Mental Health
  • Elderly Medicine
  • General Surgery
  • Respiratory
  • Cardiac – including Acute Coronary Unit (ACU)
  • Diabetes
  • Endocrinology
  • Dietician
  • Physiotherapist
  • Orthopaedics
  • MSK
  • Dermatolology
  • Plastics
  • Maxillo-facial (nor Oral)
  • Dental
  • Medical Admissions -use for MAU (Medical Admissions Unit) or AMU (Acute Medical Unit)
  • Oncology
  • Optician
  • Ophthalmology
  • Orthopaedics – use this for trauma/fractures
  • Pain Management
  • ENT
  • Rheumatology
  • Sexual Health
  • Stroke Services – including TIA
  • Paediatrics
  • Obstetrics
  • Gynaecology
  • Urology

Choose from one of the following and NOTHING ELSE

  • Discharge report  (not summary)
  • OOH/NHS 111 report
  • A&E
  • Ophthalmic Services – use only for GOS/Opticians Reports
  • Clinic letter  (default) – use this for most things – surgical procedures, stroke services, elderly medicine, breast services, paediatric assessment unit etc.
  • 24h BP
  • 24h ECG
  • X-ray
  • Ultrasound Scan
  • MRI
  • CT
  • Gastroscopy – use this one instead of Endoscopy (both are the same)
  • Colonoscopy
  • Cystoscopy
  • Spirometry
  • Retinal Screen
  • Doppler
  • Venogram
  • Other Test Report

Some Basic Training on Letters

  • When you look at the ‘anatomy’ of most letter, the important bits are usually at the beginning and the end.   The middle is often just some blurb about what went on.  
  • But the beginning tells you what the things was all about.
  • The end bit will provide a summary of conclusions and things to do (if any).  
  • Therefore, when reading a letter, read at your normal pace, but slow down your reading speed a little for the beginning and end bits.

When reading medical letters, there are really only 2 questions to ask yourself…

  1. Does this letter have an action?   By action, I mean a task – like doing a referral, or a new medication adding, or some bloods or x-ray being requested.  (Actually, that’s about it).
  2. Does this letter have items that needs Coding?
  • If answer to both is NO >>> File Letter
  • If action but no Coding >>> See if you can do the action (otherwise refer it on to doctor, nurse, pharmacist etc).
  • If no action but needs Coding –> Code and then File.
  • If yes to both – do both!   But do the action first because we must not miss doing the important bit.
A lot of letters now have a section “FOR THE GP” – under which specialist departments will specify exactly what they would like the GP to do.

Speeding up

  • DNA letters
  • Clinic review letters where nothing needs doing.

Slowing down

  • Cancer letters, 
  • Medication changes from clinics
  • Discharge summaries 
  • Letters from opticians

Some admin people get scared about reading and actioning ‘clinical’ letters.  This is understandable because they feel they have little clinical training.   But don’t worry… we are not asking you to make doctor decisions.   Most letters that are written in plain english and spell out exactly what needs to be done if anything.   All we are asking you to do is to make sure those actions happen.  

For example, if a letter says “please can you change the dose of his medication to…” then you know that can go to the pharmacist.   If it says “please can you refer to the audiology team”, you know that can go to a doctor to do the referral.   If it says “The patient remains stable on xxx and I have therefore discharged her back to your care”, you know the patient is stable and is being discharged and nothing needs doing.    Can you see how it does not require a doctor to understand most of these letters?   Most can be actioned and sorted by a member of our Scanning & Letters team.

It’s all quite easy really.   And if you come across a complicated letter or a difficult one – just send it to the GP.  It’s okay to do that and none of us will get cross (promise).

  • Most letters will require no action.  They are for providing information only.
  • Medication actions – some will say ‘can you change the dose’, or ‘switch the patient to a new drug’ or ‘start/continue a new drug’
    >>> send to our in-house pharmacist.
  • Referral actions – if a letter says ‘please can you refer this patient to…’
    >>> send letter to doctor.
  • Blood tests – if a letter says ‘please can you arrange for a Full Blood Count (for example)’
    >>> ring patient and make appt with the health care assistant for a blood test.
  • X-rays and Scans – if letter says ‘can you arrange for a CXR/Scan’
    >>> send letter to doctor.

And that’s mostly it.

  • Let’s say you get a letter than needs a change in medication dose AND a referral to (say) a cardiac specialist.
        • Once the letter has been scanned, you can easily send it to two or more people.
        • In this case, send an e-copy of the letter to the doctor to do the cardiac specialist referral form.   
        • Send a second e-copy of the letter to the in-house pharmacist to make the medication dose change.
        • Oh, and don’t forget to either do any Coding yourself or send to the Read Coder.
  • Let’s take another example – a letter requires the GP practice to do a blood test and refer the patient to physio
        • Send an e-copy of the letter to the doctor to do the physio referral
        • Ring the patient and book them in to do the blood test with the health care assistant.
        • And of course, again, always send the letter for Coding. 

If there is a letter that you don’t understand or are simply not sure about or even feel out of your depth, then simply scan and send it to a doctor. We won’t mind because what you are otherwise doing for us is brilliant anyway.

Practicalities

  • All partners, salaried GPs and GP trainees can be allocated letters.
  • All other GPs (including locum GPs), should not be allocated letters unless confirmed by the Practice Manager.
  • If a staff member is not working for 5 or more consecutive working days, please do not allocate any letters until they are back at work.
  • Let them have their induction first.  Let’s not overload them straight away.    
  • Start allocating after 2 weeks.
  • Email them with “We have now started sending clinical letters to you in SystmOne.  Please look at your electronic letters inbox in SystmOne every day.   Letters need to be actioned within 5 days.   If you are unsure how to proceed, please discuss with your GP Trainer or another regular GP in the practice to help ‘train you up’.”
  • All letters should be scanned onto the system and allocated to a doctor within 5 working days of their arrival
  • If there are any problems adhering to this time-frame, this should be raised with the Practice Manager
  • What we don’t want is for there to be any unnecessary clinical risk taken caused by a delay in processing clinical letters.  
  • The Practice Manager will hopefully find a solution to get the backlog cleared so that the 5 working day limit can continue.

Actions for Specific Letters

Most of the letters you read will require no action.   Most of these letters will simply be giving information.   Information giving letters that require no action can be ‘Coded and Filed’.

  • ‘the patient has been discharged back to your care’ + there is no GP action
  • DNA (Did Not Attend) letters – file – unless the letter asks you to chase it up OR the DNA is for a child <18.  For children DNAs – see below.
  • National Screening letters
  • Outpatient letter with ‘no changes’
  • Physio & Occ Health report – file if no action.
  • SALT (Speech and Language Therapy) letters – file if no action
  • OOH (Out of Hours letters) – file unless it says “FOR GP ACTION”
  • Endoscopy reports that are NORMAL
  • All discharge letters & TTOs
  • Letters which say “can you prescribe’, or ‘can you change the dose’ or ‘can you switch xxx to yyy’.
  • Rheumatology letters that mention methotrexate or denosumab
    >>>  pharmacist will need to make double sure the patient understand these drugs & the importance of blood monitoring.
  • ‘please can you refer this patient to xxx’
  • ‘please can you review this patient’
  • ‘please can you provide more information on…’
  • ‘please can you inform the patient….’
  • If a letter says ‘please do the following blood tests’
    >>>call patient to book appt for the blood test with the health care assistant.   
    >>>No need to send a task or anything. 
    >>>Just book them in and put in a reason “needs blood tests as per letter dated xxxx”
  • If there are regular bloods to be done
    >>> send letter and task to nurse (e.g. needs monthly bloods for rheumatology drug monitoring)
    >>>hopefully the nurse will put onto a scheduled task system.
  1. Print off the letter. 
  2. Add it to the blue board for the on-call doctor to review and do.
  3. As a safety net, add to the on-call doctors emergency appointment list.  
  4. Talk to emergency doctor if needs be to highlight it to them.
  • For most adults >>> FILE
  • Exception to the rule is Mental health: if the patient is under the psychiatry team and has not attended 2 or more appointments
    >>>forward to doctor with message “patient under psychiatry, not attending 2 or more appointments”
  • If the patient is a child
      • If the patient is on the “Child Safeguarding” register
        >>> send to doctor with message “DNA appointment, child on safeguarding register”
      • If the patient is NOT on safeguarding register and has DNA’d 2 or more appointments
        >>> send to doctor  with message  “DNAd 2 or more appointments with xxx”
  • If the letter says “FOR GP ACTION”: send to GP
  • If it doesnt say this >>> file
  • All MARAC letters need to be sent to the doctor on-call.
  • No exceptions.
  • Put reason “MARAC”
  • Do not send to doctors.
  • Print a “PRISON COVER LETTER” (on our website click STAFF AREA > SECURE STAFF AREA > enter password > click ADMIN FILES)
  • Attach a HOME  VISIT summary with the last 10 consultations.
  • If the letter is about a cancer, look in the medical record and see if it has been coded.  If it has NOT – then Code it.
  • If it is a new cancer diagnosis, ring the patient and make an appointment for them to see a GP within 2 weeks and add to record “patient newly diagnosed with cancer.  made 2 w review appointment.”
  • Add them to our cancer register.
  • If the chronic condition has been recently diagnosed
    >>> always send a task to the Practice Nurse lead if there is one.    
  • This applies ti diabetes, asthma, COPD, epilepsy, learning disabilities, stroke, hypertension, heart attacks (also called myocardial infarction), and heart failure.

Lead Nurses are

  • Heart –
  • Respiratory (Asthma/COPD) –
  • Diabetes
  • Dementia
  • Rheumatoid Drugs
  • Fractures
  • Osteoporosis
  • Child Protection Cases
  • Adult Protection Cases
  • Falls Assessment – refer to the District Nursing Team.

Nursing team will add patient to register and set recall for 12m.

A letter which detail a fracture of any kind – what you do depends on the age of the patient.

  • Under age 50 >>> Code & File
  • 50 and over
    >>> send letter to our in-house pharmacist
    >>> who will then work out whether this is a fragility fracture, do a FRAX score and any other work up as part of the Osteoporosis protocol.
  • Notes for the pharmacist
    >>>give patient Osteoporosis PIL, and order Bone Densitometry (DEXA) scan. 
    >>>When report back, start Ca/vitD/Bisphosphonates if report says so.  \
    >>>Education Patient.  Lifestyle advice.  
    >>>Refer to falls risk assessment if patient unstable on feet (i.e. via District Nurses).
  • DEXA scans are basically scans which measure how strong your bones are.
  • In older life, people often become OSTEOPOROTIC  (in other words, they have weak bones).
  • But younger people can get this too, especially if they are on things like steroids or suffer from conditions like anorexia.
  • The T and Z scores tell you how bad it is.
  • Do not confuse this with OSTEOARTHRITIS (which is wearing of the joints).
  • So, if you get a DEXA scan – if normal = FILE.   
  • If DEXA scan says “YOUR PATIENT IS OSTEOPOROTIC” >>> send to the pharmacist, who will decide what needs doing or not.
  • Dementia goes to Lynne.
  • She puts on a recall.   Arranges bloods if none done.
  • Does monthly audits of who needs recalls and letters sent.
  • Does not get involved in Care Plan arrangements.
  • If the letter asks for a referral to an Ophthalmology service, first of all see if it says whether they want it urgently.  If it doesn’t say ‘urgent’, ‘as soon as possible’ or ‘for an early appointment’, then it is pretty safe to assume it is routine.
  • If it is routine and the patient is 16 and over, then there is a template letter in S1 (called ‘opticians letter’).  Print off this covering letter and send with the GOS/Opticians letter to SOAP (Shipley Ophthalmic Assessment Project at Windhill Green Medical Centre).  No need for GP to sign.  But remember, the patient must be 16 or over.
  • If patient <16, and again, it is for nothing urgent (i.e. routine), send covering letter with the optician’s letter to the Hospital Eye Service (HES) and BRI.
  • Remember, if the letter indicates anything towards an urgent ophthalmic assessment >>> send it to the doctor and RED FLAG the item.
  • Minor Eye Surgery problems such as blocked tear ducts, cyst removal, and skin anomalies >>> send to Windhill Green’s Eye Surgery Service.
  • Many of these letters will often say… ‘ As part of the HFEA regulations I have to ask you whether or not you know of any reason why this couple should not be considered for fertility investigations or treatment.’.
  • No need to send to the doctor.   
  • Print template letter and send.   We have a template letter to send back in reply to the specialist (which basically says, they can come and look for this information themselves if they have sought the patient’s consent – rather than us doing it – the obligation is on them, not us).

Clinical Terminology

This is a test (done in hospital) where they inject a dye into the blood vessels to see if any (like the heart or leg arteries) are obstructed.  For instance, a coronary angiogram checks the coronaries (blood vessels which supply the heart).  If they are, all sorts of things can be done to widen them like stenting (inserting a bit of tubing to keep them open).

In asthma, the lungs become tight – but this tightness is reversible (especially with inhalers).  Please remember, asthma kills – a lot of people forget that.  This is the reason why they should carry inhalers with them all the time.  You can never predict when a life threatening attack is every going to happen – even in the most mildest of asthmatics!

We get particularly worried about brittle asthma – where the asthma goes off so frequently in an individual.  We get worried because one of those attacks could end up being life-threatening!

Atrial fibrillation is a specific condition where the heart pumps erratically and not regularly and steadily like it should do. We get worried because the long in the long run clots can form giving rise to a stroke to a heart attack. So we put these people on blood thinning drugs to stop these clots from forming. Atrial fibrillation gets more common as you get older. Doctors often use the letters AF to refer to it because it is a bit of a mouthful. And it can only be properly diagnosed by doing an ECG heart test (the ones the nurses do with all those wise)

The aorta is the biggest blood vessel in your body.   It runs all the way from your heart, back down the back wall of your chest (the thorax) and down the back of your belly (the abdomen).   It measures about 2.5 cm in diameter.  If it is 5cm or more, we worry about an aneurysm – which is basically weak walls in the aorta – the danger is that they can “burst” at any time and be fatal.   So, they usually need an urgent ultrasound scan to assess whether they have an aneurysm or not.  

  • These are three types of skin cancers.   
  • The first – BCC – is very slow growing, so although it needs treatment, it is not usually a super urgent thing. 
  • The second – SCC – is a worrying cancer and needs urgent treatment because it can spread.
  • The final one – melanoma – is the most deadliest and needs super urgent referral because it spreads quickly and can end a life within 6 months!
  • If the letter is about a cancer, look in the medical record and see if it has been coded.
  • If it has NOT – then Code it.
  • If it is a new cancer diagnosis, ring the patient and make an appointment for them to see a GP within 2 weeks.
  • Add them to our cancer register.

Smokers often get a condition where the lungs get stiff and are not very elastic anymore. That means that air doesn’t go in and out very easily. This is called COPD, short for Chronic Obstructive Pulmonary Disease. Over the years it has had lots of different names. Others include COAD – Chronic Obstructive Airways Disease and some of you will even remember the term emphysema.

Coronary Heart disease (CHD) is anything to do with the heart. For example, a heart attack, which is medically referred to as a Myocardial Infarct or MI for short.  Other examples include angina, or acute coronary syndrome (ACS). Interestingly myocardial infarcts are sometimes referred to as an STEMI and NSTEMI (the ST/NST stands for ST/NonST segment elevation, but you don’t have to worry too much about that).

  • DEXA scans are basically scans which measure how strong your bones are.
  • In older life, people often become OSTEOPOROTIC  (in other words, they have weak bones).
  • But younger people can get this too, especially if they are on things like steroids or suffer from conditions like anorexia.
  • The T and Z scores tell you how bad it is.
  • Do not confuse this with OSTEOARTHRITIS (which is wearing of the joints).
  • So, if you get a DEXA scan – if normal = FILE.   If “YOUR PATIENT IS OSTEOPOROTIC” >>> send to the pharmacist, who will decide what needs doing or not.

Diabetes is a condition where the body cannot control the sugar levels in the blood very well. But it is important for the body to control the level of sugar running around in your body at any one time – too much or too little can be dangerous. In normal people it is the hormone insulin which controls the amount of sugar running around. In diabetics this insulin system doesn’t work very well. 

In some diabetics just simply controlling the amount of sugar they get from food is enough – so they go on a diabetic low sugar diet. Others need tablets like metformin but others will need something stronger like Insulin in the form of injections. In general, those that are controlled by insulin injections are called Type 1 diabetics. All the other types are called Type 2.   Although sometimes, it is not as clear as that.

This is basically surgery on the sinuses.

Heart failure sounds worse than what it is. Basically it means that the heart is not pumping as well as it should and that means blood doesn’t flow around the body very well and ends up making people short of breath the ankle swelling and so on. It has lots of different names because there are different types of heart failure. Most doctors use the word Congestive Heart Failure (CHF for short) or Congestive Cardiac Failure (CCF). Another type is LVF – which is short for Left Ventricular Failure. Different people have different degrees of heart failure and we doctors use something called the NYHA classification to work out how bad it is. NYHA stands for New York Heart Association.  A lot of elderly people have Heart Failure.  It is not uncommon, although it is troublesome because it causes significant shortness of breath and swollen painful ankles.

This is a term used by doctors to describe something picked up by chance.  It does not say how serious that thing that has been picked up is.

This terminology is often used by doctors when talking about back problems.  L1, 2, 3 and S4 and S5 are different levels of the spine.  Each building block of the spine has a corresponding number.

A term used by urologists to describe symptoms in men and women when peeing.

When a clot goes to the brain, it stops blood getting through and a part of the brain dies. This is called a stroke. Depending what area of the brain is shut off, the patient will often have varying degrees of speech difficulty and be paralysed down one side of the body. If the clot is dissolved quickly, then once the blood is restored to the brain, sometimes there is no damage and the brain fully recovers.  That’s why it is important to get all suspected strokes to hospital within 4 hours.

So, if a patient has stroke-like symptoms that fully recover within 24 hours, it is not a stroke but something called a TIA or Transient Ischemic Attack. If they have symptoms that are more permanent then it is likely the person has had a proper stroke. In summary, a TIA is like a mini-stroke where it recovers. And a stroke is the proper full blown thing. 

TIAs are also worrying because although the person fully recovers, they can indicate a full-blown stroke might be on its way if nothing is done. By the way, a stroke is often referred to by medics as a cerebral vascular accident or CVA for short.

A fancy name for a simple faint; not serious.

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