I RAT patients

“Is WWHAM out of date” was a question posed by the GPhC and the RPS at their recent workshop. It was an appropriate question to ask when its use might have identified two of the situational research (mystery shopper) situations in the recent Which report.  I think most of us coughed and answered “of course we WWHAM”, while I tried desperately to remember it.

I RAT my patients and as a part of that process WWHAM has its role. I would support the medicines counter assistants (MCA), as long as their WWHAM was part of my overall RAT approach. It is fairly simple and just a switching around of the Advice, Treat, Refer pneumonic that was used within minor ailment and similar schemes.

So here is my approach:

R – means refer. This is the identification of Red Flag situations. The Red Flag situations apply just as well to the medicines counter assistants as to the pharmacists. I have, in the past, taken little red stickers into pharmacies to put by specified P medicines, because I want to speak to all patients before this medicine is sold.

The MCA refers to the pharmacist all patients that have specific symptoms, take other medicines, have co-morbidities, ask for specific medicines and other factors such as age, which takes the patient out of their level of expertise and passes them on to the pharmacist.

The pharmacist will refer to another clinician when the patient presents with specific red flag symptoms or factors in their condition. In this case the red flags might suggest a more serious complaint that requires investigation, or a more severe presentation that requires treatment that I have no access to.

This is important to me – I decide whether the patient is mine – or someone else’s.

A – means advice. I like to offer patients advice first, a leaflet or something that would help them understand their condition. I have often given a leaflet saying “read this, it’s you” – try it – it is great to watch someone’s eyes light up as they flick the paper and answer – “you’re right this is me”. There are often several things to approach first – diet, exercise, smoking, lifestyle are often important. Then things that the patient can do to relieve or reduce the symptoms and this is an important parallel approach.

T – means treatment. I tend to down-play treatment – at least be honest about what can be achieved. I remember teaching – “there is only one thing you know about chronic pain – that it’s chronic” and that medicines seldom do more than reduce pain scores by 2 points. So it’s not so much that treatments cure conditions (although some do), but more about treatments allowing you to get through conditions or cope better with them. The realism here often works better than setting up medicines as a miracle cure

I still have two requests:

I do wish that materials produced by companies to support their products would be structured to help me RAT patients

I do wish that the government would introduce a ‘community pharmacy prescriber’ status or NHS England a series of PGDs that allows me to continue to treat patients who really can’t afford to pay for their medicines.


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