This tool is provided as a guide. If in any doubt or you are concerned that an alternative pathway would be more appropriate please discuss with the on call clinician.
Non-urgent advice: Important
Start all conversations by asking for the patient’s name and date of birth the patient must be opened in SystmOne each and every time, and an outcome recorded for the contact.
Think continuity of care every time
Is this an ongoing problem that the patient has consulted for before – without any acute changes?
Is this something that has been going on for longer than 2 weeks and not getting any worse?
- Offer next available routine appointment with usual clinician, or
- add to appropriate waiting list and inform patient we will contact them within 2 weeks
Useful Resources
From May 2023, there has been an imposed change to the contract for primary care services in England. This requires that we must take steps to to ensure that a patient who contacts the contractor is provided with an appropriate response.
These appropriate responses are defined as being any one of the following
- invite the patient for an appointment, (in person, telephone or video), at a time which is appropriate and reasonable having regard to all the circumstances
- provide appropriate advice or care to the patient by another method
- invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves
- request further information (which could be via an e-consultation)
- to convey when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances
The appropriate response must not jeopardise the patients health, be based on the clinical needs of the patient and take into account their preferences where appropriate.
There is no requirement to provide any appointment on demand from a patient.
Social Prescribing Link Worker can explore solutions around non-medical issues that underpin health conditions
Patients suitable for referral include those
- who are high service users (GP and hospital)
- with poorly-managed long-term health conditions
- with a low level of confidence to manage their own health (“activation”)
- with mild-moderate mental health issues (eg stress/anxiety/low mood)
- who would benefit from coaching to help with behavioural change
- who are socially isolated/lonely/disconnected
- looking for support, guidance & motivation to make lifestyle changes
111 advise the patient to contact 111 (online or call)
1Day same day (or following day if late afternoon)
999 instruct patient to call 999
ED advise patient to attend the Emergency Department
Econ request patient to submit more information via e-consult, photos must be good quality
EyeCas advise patient to attend Eye Casualty
FCP first contact physiotherapist (here or via Connect)
Follow-up next available appointment (non-urgent) with patients usual clinician
Nurse next available practice nurse (check appropriate nurse for the need)
Pharm signpost or refer to community pharmacy
PP next available practice pharmacist appointment or wait list
PT next available practice pharmacy technician appointment
Routine next available (non-urgent) appointment or wait list
UCC advise the patient to attend the urgent care centre
??? discuss with on call clinician
Up to half of Jo’s minor ailment slots may be directly booked by reception, the rest will be pulled from the on call list.
Abscess
Allergies
Athletes foot
Cellulitis and skin infections
Cough, cold and flu like illness (adults)
Diabetic problems
D&V (adults)
Ear pain
Impetigo
Shingles
Sore throat
UTI
Vaginal discharge
Health Coaching is a supported self-management intervention The Coach can support the patient to identify and achieve health-promoting goals set by the patient. This can be achieved by one to one meetings/ consultations on a weekly basis for up to 12 weeks depending on the needs of the patient and their commitment.
Criteria for referral:
-Diabetes, type 1, type 2 patients who are at risk of developing diabetes i.e. impaired glucose regulation.
-Self-managing Respiratory conditions: Including COPD and Bronchiectasis.
-Patients with musculoskeletal problems that can benefit from improved health and well-being invention
Fridge items
If in clear bags place directly in the fridge in the main store room and inform nursing team of the delivery
If in boxes open box and place contents in the fridge in the main storeroom, then inform nurses of the delivery
All other items
Place in main office and inform the intended recipient
Notification of birth received add to incoming correspondence workflow and send task to KB
Baby registered follow usual registration process and create / update task to KB (include in the task mum’s details)
If baby not registered four weeks after receipt of notification of birth, raise as a safeguarding task to NK
KB to add five week due date to task, task to remain open until baby is brought
When task becomes active (turns red) contact mum and book postnatal and baby check appointment (GP only) immediately followed by immunisations (PN), again keep task open until attends
PN to complete task when attends and make arrangements for subsequent vaccinations
If non-attendance PN / GP to attempt to contact mum. If two failed contacts raise as a safeguarding concern.
Bleeding
Severe bleeding that is still bleeding encourage patient to apply direct pressure, raise the affected limb (if arms) and sit on chair
Call for help and first aid kit
Bleeding has now stopped discuss with nurse or on call clinician
Chest pain
If struggling to talk or significant concern call for immediate help
Otherwise add to on call list, ask patient to sit in waiting room and inform on call clinician – do not send patient home to await a call back
Collapsed patient
Press panic button under desk and on S1
Call for help from main office
Check for danger
Check for response can you hear me? open your eyes!
Open airway tilt head back
Check for breathing
If not breathing normally roll patient onto back and start chest compressions, continue chest compressions until help arrives
If breathing normally place in recovery position
Violent or aggressive patient / visitor
Attempt to defuse situation, try to remain calm
Seek support from colleague
Trigger panic alarm under desk and on S1
Consider the need to call 999
Line manager or on call clinician will arrange debrief
Ensure incident is reported on TeamNet
Vomit or body fluids
Vomit bowels, gloves, masks and spill kit is available in the drawer under the reception desk
Inform a member of the nursing team
See also information poster on doors and noticeboards
Coroners
Pass to NL or MR
Complaints, concerns or compliments
Date stamp, place in BSM tray (unless on leave) or hand to MR
Electronic download
The electronic download (including downloading the emails for scanning folder) will be undertaken once each working day
Downloaded documents will be screened for urgent actions and these highlighted to the appropriate team
Emails
These should be continually monitored during the working day by the identified members of staff
Prescription requests should be moved into the prescription team subfolder within the shared email account for action by the prescription team
Requests for patient review from care homes and other services should be added to the appropriate clinic list (home visit slot for urgent matters, admin task slot for administrative requests or next available ward round for routine matters)
Safeguarding concerns should be forwarded to AVD and a task raised to NK
Safeguarding information requests should be forwarded to BSM, unless it is a request a next day response, in which case this should be added to the on call list as a professional call
Invoices, bills, delivery notes
Date stamp and place in BSM tray
Letters
Will be opened daily and stamped with the date of receipt
Prior to adding to the scanning tray all letters will be reviewed for urgent actions and these escalated to the appropriate team before placing the letter for scanning
Letters that are requests for reports, subject access requests or from solicitors must be processed using the other pathways in this section
Registration documents
Received by email print and put in registration tray
Handed in at reception check patient ID, add ID details to form and then place in registration tray
Once registered, place in scanning tray
Once scanned and linked to patient no further action is needed (can be completed)
Report requests
When received by post or at reception, record receipt in the patient record, date stamp the request and place in the reports tray
If the request is for a copy of the medical record, complete the steps above but put into BSM tray
Solicitors letters
Date stamp and place in BSM tray. If BSM on leave hand to MR
Subject Access Requests
Date stamp and place in BSM tray
Tasks from other S1 units
These will be monitored throughout the working day, with Priority One tasks added to the on call clinician’s admin slot(s)
Tasks will otherwise be forwarded to the most appropriate team (or exceptionally person)
See also incoming correspondence policy on TeamNet
Opening
When the surgery opens at the start of the day the following actions are to be taken by the first receptionist(s) on duty
Logon to the left hand PC at reception (this is needed for the patient call screen)
Ensure that the check in screen is running
Unlock reception drawers and tambour unit (key in main key safe) and return key to key safe
Unlock tray cupboard in main office
Ensure practice mobile phone is turned on and charged
Place on call box and reception box on top of white cupboard towards the back of the main office
Ensure friends and family box is on reception counter with pens and blank cards
Ensure that the correct clinician name plates are on the appropriate clinic room doors
Ensure reception lights are turned on at 8am
Closing
When the surgery closes at the end of the day the following actions must be taken
Return the friends and family box to behind the reception screen
Check that no patients are left in the waiting area, toilets and consulting rooms
Return on call box and reception tray from main office to reception tambour unit
Return all items from reception area to the appropriate drawer or tambour unit
Lock reception drawers and tambour unit, return keys to key safe
Ensure that the signs above both prescription request boxes have been changed
Ensure the practice mobile phone has been turned off and secured
Print off the appointment lists (detailed view and single sided) for the following working day and place in top drawer on far left back of reception
Remove the current days appointment list print out and place in confidential waste
Ensure that all computers are turned off unless S1 update is planned for that night
Remove all cups from desks and consulting rooms, load and start dishwasher
Do not take home anything that shouldn’t leave the practice; in particular patient information (including notepads)
All policies can be found on TeamNet
Adult and Child Pathways
Immediate concerns for safety
999 or take to ED if patient or caller reports suicidal and intending to act, self harm with significant injury, patient missing
Crisis team if patient known to service
New depression or anxiety
Signpost to Talking Therapies
1Day or Routine depending on the amount of distress and impact on patients day to day activities
Ongoing symptoms and / or needing medication review
Follow-up with usual clinician if no worsening concerns in past 2 weeks
1Day if sudden worsening of symptoms or new significant distress
Routine otherwise
Ensure has sufficient medication to continue until at least 2 days after the planned review
Referral to social prescribers if social isolation may be a factor
Immediate concern for safety
999 or take to ED if patient or caller reports suicidal and intending to act, self harm with significant injury, patient missing
Crisis team if patient known to service
New concerns
Signpost to Behavioural and Emotional Mental Health pathway – can self refer
1Day or Routine otherwise
Ongoing concerns
Signpost to CAMHS / BEMH if already under those services
Routine unless acute worsening of symptoms
Abdominal Pain
999 or ED if sudden severe abdominal pain with any of the following: vomiting blood, sweating, clammy, dizziness, fainting, male aged >66 or female aged >70
Follow-up if long standing and not acutely worsening
1Day or UCC if new
Routine if bloating is the only symptom
Abscess
E-con if well in self and able to send a high quality photo
1Day or UCC otherwise
Abortion see termination of pregnancy
Acne
Pharm if new
E-con or Routine if has tried OTC products for 3 months consistently
Follow-up if ongoing concern
PP if reaction to medication
Addison’s disease
Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder of the adrenal glands.
999 if patient states is in crisis
??? if patient report unwell but not in crisis
Alcohol misuse
In most cases signpost to Recovery Network Nottingham https://www.nottinghamrecoverynetwork.com/ or call 0800 066 5362
Advise must not stop drinking abruptly.
??? or 1Day if currently shaking or unsteady
Allergies (including hay fever)
999 if face / mouth swelling, wheezing, tightness in chest or throat, trouble breathing or talking
1Day or ??? if affecting asthma control
Pharm if new and not tried anything for more than 1 week
1Day if symptoms very troubling or no response after at least six weeks of OTC treatment
Follow-up if ongoing concern and not worsening
Anal pain and bleeding
999 or ED if severe bleeding, severe anal or abdominal pain and and of the following: dizzy, lightheaded, reduced consciousness, coffee ground vomiting, shortness of breath or poo is black or dark red
1Day if new bleeding or fever symptoms
Pharm if new pain with or without piles
Arthritis and joint pains
999 or ED sudden onset of single joint pain (without any injury) that is red, hot, swollen and patient feels unwell
1Day sudden onset of multiple joint pain within the past week or worsening
FCP patient suspects they have arthritis
MOSAIC or Routine ongoing issue without sudden worsening
1Day or Routine worsening pain
Follow-up if asked to call for joint injection
Asthma
Nurse wanting / needing routine review (may need further supply of inhalers in the meantime)
Nurse (same week) asthma worsening over weeks or months
1Day or ??? asthma worsening over days to weeks
999 unable to talk in full sentences
Routine (within 1 week) suspected asthma same week appointment
Nurse or PP or PT issues with inhaler(s)
Athlete’s foot
Nurse (same day) or ??? diabetic or HIV+ patient
Pharm otherwise almost always
Routine treatment failures (has been using appropriately for at least six weeks) continue treatment in the meantime
Autism
Suspected (in child) self referral to Behavioural and Emotional Mental Health service.
NB there is no requirements for this referral to come from a GP, parents, children, schools and social workers are all able to access this service.
Back pain
999 or ED new or worsening symptoms: If pain, tingling, numbness or weakness in both legs, numbness or tingling around the buttock or genitals, difficultly passing urine, loss of bladder or bowel control or pain started after a serious accident
Pharm if tot taking OTC analgesia
FCP or MOSAIC if taking OTC analgesia and pain not improving, pain stopping daily activities, worsening pain, or struggling to cope
1Day if high temperature, fevers, weight loss, lump or swelling, change in shape of back, pain worse at night, pain between shoulders rather than lower back
Follow-up if ongoing back pain, unless sudden change in symptoms
In all cases unless sending to ED or booking a same day appointment send back pain safety net text
Bacterial Vaginosis (BV)
Patient suspects may have advise self taken swabs and then will get text message with result
Bad breath
Signpost to NHS Choices website and dentist
Balanitis (swelling to the head of the penis)
1Day if child, diabetic or unable to pass urine
Routine (same week) otherwise
Adults can also be signposted to GU Medicine
Bed bugs
Pharm
Bedwetting in children
Urine sample if sudden new bedwetting in previously continent child
Health visitor otherwise
Bells palsy
999 if new one sided face droop, unable to lift up both arms and keep them there or difficulty speaking
1Day otherwise
Animal and human bites
ED if large or deep wounds, unable to stop the bleeding or wounds to face, head or genitals
Nurse (same day) or UCC otherwise
Black eye(s)
ED if change in vision, change in pupil shape, head injury with bruising around both eyes or unable to move eye
ED or 1Day (if unable to travel and can be seen same morning) if taking warfarin or blood thinners (not aspirin or clopidogrel)
Routine (same week) if not settling after two weeks, or other bruising
Blisters
Pharm most cases
UCC if new large blisters from rubbing shoes causing walking problems
E-cons if worried about infection but otherwise well
1Day or Nurse (same day) if worried about infection and unwell with fever or nausea
Blood pressure
New high blood pressure
ED if systolic >180 or diastolic >120 and chest pain, shortness of breath, change in vision. See also stroke
Routine if blood pressure lower than the above and no symptoms – ask the patient to take two blood pressure readings a day until the appointment (and bring them with them)
??? otherwise
New low blood pressure
ED if loss of consciousness, confusion, unable to walk or stand, chest pain, shortness of breath, bleeding that is new and can not be controlled
1Day or UCC if brief new fainting and now fully recovered and aged <60
1Day if has symptoms
Ongoing blood pressure management
Follow plan in the journal, otherwise Routine (same week)
Bloating see abdo pain
Boils see abscesses
Buttock pain see back pain
Breast pain or lumps
If of childbearing age consider pregnancy test
1Day if high temperature, fevers, redness, heat or swelling to part or all of the breast, hard lump that doesn’t move, nipple discharge, change in breast shape, part of the skin looks like orange peel (dimpled), a nipple has sunk inwards or a new rash around the nipple
Routine if pain only that is not improving with OTC painkillers
Broken bones (suspected)
999 if unable to be moved
UCC if injury to foot, lower leg, knee, fingers, hand or wrist signpost to
ED if injury above the knee or at / above the elbow
Bunions
Nurse (within 1 day) if new and diabetic same or next day practice nurse appointment
Otherwise self referral to podiatry
Burns and scalds
ED if chemical and electrical burns, burns larger than the persons hand, white or charred skin (any size)
ED if face, neck, hands, feet, over (or around) joints or genitals
Nurse (within 1 day) if more than 48 hours since injury or ?infected
UCC otherwise
Carbon monoxide poisoning
If you think a gas appliance is leaking carbon monoxide, call the free National Gas Helpline immediately on 0800 111 999.
111 if patient suspects carbon monoxide poisoning
ED if altered consciousness, drowsy, finding it hard to breath or newly confused
Carpal tunnel syndrome see wrist pain
Cataracts
Optician if suspected
E-cons or message to usual clinician if known and worsening (for direct referral to opthalmology)
Cellulitis (skin or wound infection)
999 or ED if suspected infection and any of the following a very high temperature, or you feel hot and shivery, a fast heartbeat or fast breathing, purple patches on your skin, feeling dizzy or faint, confusion or disorientation, cold, clammy or pale skin, unresponsiveness or loss of consciousness
1Day otherwise
Cervical screening (smear)
Nurse if has received invite letter or been recalled by ourselves
Details of when people will be invited available at https://www.nhs.uk/conditions/cervical-screening/when-youll-be-invited/
Chest infection see cough
Chest pain
999 if pain spreads to arms, back, neck or jaw, makes chest feel tight or heavy, also started with shortness of breath, sweating and feeling or being sick, lasts more than 15 minutes
Follow-up if known to have chest pain and no worsening or change in symptoms in the past two weeks
1Day for all other cases
Chicken pox
Signpost to NHS website https://www.nhs.uk/conditions/chickenpox/
??? if pregnant patient or household contact
1Day if unwell or unsure about diagnosis
Cold sores
Cold sore are common and usually clear in 10 days with or without treatment
Pharm in most cases
1Day if HIV+, diabetic, if very large or not starting to settle after 10 days
Colic
Colic is when a baby cries a lot but there’s no obvious cause. It’s a common problem that should get better by around 3 or 4 months of age.
999 or ED if baby has a weak or high-pitched cry, or baby’s cry does not sound like their normal cry
1Day if worried about baby’s crying, baby has colic and nothing seems to be working, or parent(s) finding it hard to cope
Routine (within 1 week) if baby is not growing or putting on weight as expected, or baby still has symptoms after 4 months of age
Cough, cold, chest infection and flu like illness (adult)
Most settle without anything other than OTC remedies within three weeks; most people start to feel better within one to two weeks.
Pharm for the majority of cases, offer link to NHS website https://www.nhs.uk/conditions/common-cold/
1Day if any of the following apply; not settling after 3 weeks, symptoms suddenly worsening, very high temperature and hot / shivery, shortness of breath or chest pain, serious LTC (diabetes, heart, lung or kidney disease, chemotherapy or HIV+)
UCC if normally fit and well and the above criteria do not apply
1Day or ED if coughed up a few small spots, flecks or streaks of blood, or noticed blood in your phlegm or handkerchief
ED or 999 (if unable to be taken) if coughing up more than just a few spots or streaks of blood, or any of the following – coughing up blood and finding it hard to breathe, have a very fast heartbeat or have pain in your chest or upper back
Cough, cold, chest infection, croup and flu like illness (child)
999 or ED if any of the following:
Skin: pale, mottled, ashen, blue, or reduced turgor
Activity: no response to social cues, does not wake or does not stay awake, weak, high pitched or continuous cry
Breathing: grunting, breathing very quickly, drawing skin in between ribs, centre of chest or front of neck when not crying
Other: temperature over 38C if under 3 months, rash that does not fade when pressure applied with a glass, bulging fontanelle, neck stiffness, fitting at the time of the call
1Day or UCC depending on capacity to see safely
Head injury and concussion
Follow-up if already seen for this and no worsening concerns in the past 2 weeks
1Day if new or worsening concerns and injury more than 2 weeks ago, or worsening symptoms in a patient already seen for this injury by one of our team
UCC if any wounds to face or scalp
ED if major wounds or continued bleeding to face or scalp, knocked out but have now woken up, vomited since the injury, a headache that does not go away with painkillers, a change in behaviour (like being more irritable or losing interest in things around you (especially in children under 5)), crying more than usual (especially in babies and young children), problems with memory, drinking alcohol or taking drugs just before the injury, a blood clotting disorder (like haemophilia) or medicine to thin blood, had brain surgery in the past
999 if unconscious, difficulty staying awake or keeping their eyes open, a fit (seizure), fallen from a height more than 1 metre or 5 stairs, problems with their vision or hearing, a black eye without direct injury to the eye, clear fluid coming from their ears or nose, bleeding from their ears or bruising behind their ears, numbness or weakness in part of their body, problems with walking, balance, understanding, speaking or writing, hit their head at speed, such as in a car crash, being hit by a car or bike or a diving accident, or a head wound with something inside it or a dent to the head
Conjunctivitis
Most cases settle within a week with regular eye hygiene (wiping with water that has been boiled and then cooled)
111 if pain in the eye(s), sensitivity to light, changes to vision that do not clear with blinking, very red eyes
1Day if baby aged <28 days, wears contact lenses, symptoms not settled after two weeks
Constipation
Pharm for most new cases, unless <1 year old or >65 years old
Follow-up if already being treated for this and no sudden worsening in the past week
1Day if new and young child, or any age if abdominal pain or vomiting, or if blood on toileting
Corns or callouses see bunions
Cradle cap
Cradle cap is a harmless skin condition that’s common in babies. It usually goes away on its own in 6 to 12 months, but there are things you can try to make it better.
Signpost to NHS conditions website https://www.nhs.uk/conditions/cradle-cap/
Pharm for most cases
Routine (within three days) if not getting better after a few weeks of treatment, cradle cap all over body, crusts bleed or leak fluid, or the affected areas look swollen
Cuts and grazes
UCC or Nurse (same day) if new wound and patient concerned
Nurse (same day), UCC or 1Day if thinks wound infected
ED cannot stop the bleeding, the blood comes out in spurts and is bright red and hard to control, loss of feeling near the wound or have trouble moving it, bad cuts on face or the palm of hand, the wound is very large or deep, or there’s something stuck in the cut, such as a shard of glass – do not try to take it out yourself
Cystitis see Urinary Tract Infection (UTI)
Cysts and skin lumps
Routine within 1 week if sudden onset and growing, or new change (within the past month) of a known skin lump
Routine otherwise
Dandruff
Pharm for almost all cases
Routine if not settling and worsening after at least one month of OTC treatment, itching affecting sleep, spreading on to face
1Day if new redness, weeping or bleeding from the scalp, or if fever symptoms and no other illness
Dental problems, including new swelling inside the mouth
ED only if finding it hard to breathe, a swollen or painful eye, or suddenly start having problems with eyesight, have a lot of swelling in mouth or thinks they have taken too many paracetamol
Signpost to dentist, list of dentists available at https://www.nhs.uk/service-search/find-a-dentist
Do not offer appointment in primary care even if care home resident
Delaying periods
Signpost to pharmacist
Routine (needs to start medication 3 days before period would be due, if no BMI recorded will need to use machine first)
Diabetes
Nurse or follow-up for most ongoing concerns
1Day or ??? if newly raised blood sugars, ketones detected at home, abdominal pain, fast or deep breathing, feeling newly tired or vomiting
ED if newly confused, unable to stand or reduced consciousness
Diarrhoea and vomiting (adults)
Signpost to NHS conditions website https://www.nhs.uk/conditions/diarrhoea-and-vomiting/
Pharm if concerned about dehydration or needing medication to stop diarrhoea for a few hours
111 or 1Day if concern about dehydration remains after OTC medicines, blood in diarrhoea, more than seven days of diarrhoea or two days of vomiting
999 or ED if vomit blood or vomit that looks like ground coffee, green or yellow-green vomit, might have swallowed something poisonous, a stiff neck and pain when looking at bright lights, or a sudden, severe headache or stomach ache
Diarrhoea and vomiting (children)
999 or ED if any of the following:
Skin: pale, mottled, ashen, blue, or reduced turgor
Activity: no response to social cues, does not wake or does not stay awake, weak, high pitched or continuous cry
Breathing: grunting, breathing very quickly, drawing skin in between ribs, centre of chest or front of neck when not crying
Other: temperature over 38C if under 3 months, rash that does not fade when pressure applied with a glass, bulging fontanelle, neck stiffness, fitting at the time of the call
Otherwise see adults above
Dizziness
ED if unable to stand, new weakness in arm or leg, one side of face drooping, difficulty speaking, chest pain, continual vomiting or if new dizziness after a head injury
Routine (within the week) or 1Day if not coping with symptoms
Follow-up if ongoing concern previously seen here and no worsening concerns in the past week
Double vision
Signpost to optician in most cases
ED if following head injury
1Day or 111 if eye pain or severe headache
Deep Vein Thrombosis (DVT)
1Day (same day) if patient concerned may have a DVT
ED if no capacity to see during the same day or worried about DVT and breathlessness and / or chest pain
Dyslexia
Signpost to school or education provider if in education
Signpost to private or occupational health provider if an adult
Signpost to NHS conditions website https://www.nhs.uk/conditions/dyslexia/
Do not book in to primary care as this is an occupational / educational matter and not medical
Emergency contraception
If wiling to pay for EC Pharm
Otherwise 1 Day
Ear pain, infection (adult)
Pharm new onset and affecting one ear only
1Day or UCC if generally unwell, a very high temperature or feeling hot and shivery, swelling around the ear, fluid coming from the ear, hearing loss or a change in hearing, something stuck in the ear
Routine (within the week) if not settling after 3 days, recurrent ear infection, treatment failureEarwax only advise two weeks of olive oil drops into affected ear(s) twice a day (must lay on side when doing this) and then if not settling Nurse
Ear pain, infection (child)
1Day or UCC if generally unwell, a very high temperature or feeling hot and shivery, swelling around the ear, fluid coming from the ear, hearing loss or a change in hearing, something stuck in the ear or affecting both ears and child aged under 2
Routine (within the week) if not settling after 3 days, recurrent ear infection, treatment failure
Early menopause (suspected)
Econ or routine
Eczema
Pharm if mild and new onset (or Signpost to OTC emollients), otherwise RoutineEcon if causing problems and can send a good photo
1Day or UCC if new cracking and bleeding, discharge, hot, swollen, or feeling unwell
Follow-up if ongoing concern and not worsening in the past two weeks
Elbow and arm pain see Arthritis (suspected), but also consider Chest Pain
Eye problems
Floaters and flashes
Signpost to same day optician appointment or EyeCas if sudden onset, the number of floaters or flashes suddenly increases, a dark “curtain” or shadow moving across vision, new blurred vision, new eye pain, or onset after eye surgery or an eye injuryInjury
ED if chemical injury (keep rinsing eye with water while waiting for 999), a sharp object has pierced the eye, injury from fast flying object (ie grinding), any changes to vision after injury, headaches, temperatures, sensitivity to light, nausea or vomiting, unable to move eye or keep it open, blood or pus.
Fainting
999 if still unwell and any of the following have not fully recovered or have difficulty with speech or movement, chest pain or a pounding, fluttering or irregular heartbeat (heart palpitations), seriously hurt themselves, are shaking or jerking because of a seizure or fit, fainted while exercising, fainted while lying down
Nurse (within 2 days) if new faint for ECG and Lying and Standing BP (discuss with on call as may need FBC as well)
Follow-up if ongoing issue and not worsening
Falls
Signpost or refer to Falls Team (via CityCare) if agred >60 and worried about falling or >1 recent falls without injury or feeling unwell
1Day if felt unwell before or after fall
Routine otherwise
Fever (child)
999 or ED if any of the following:
Skin: pale, mottled, ashen, blue, or reduced turgor
Activity: no response to social cues, does not wake or does not stay awake, weak, high pitched or continuous cry
Breathing: grunting, breathing very quickly, drawing skin in between ribs, centre of chest or front of neck when not crying
Other: temperature over 38C if under 3 months, rash that does not fade when pressure applied with a glass, bulging fontanelle, neck stiffness, fitting at the time of the call
1Day or UCC depending on capacity to see safely
Fatigue (tiredness)
Signpost to https://www.nhs.uk/live-well/sleep-and-tiredness/why-am-i-tired-all-the-time/ if not otherwise unwell and has not already looked at self help
ED if sudden onset of severe fatigue with difficulty standing or confusion
Signpost to pregnancy test if female aged between 16 an 50
Signpost to Nottingham Talking Therapies if reports new / worsening anxiety, depression or stress
Routine if symptoms present for >4 weeks
PP if symptoms started since starting a new medication
Flu like illness see cough
Food allergy see allergy
Food poisoning see diarrhoea and vomiting
Foot pain see arthritis
Foreskin problems
ED if foreskin is pulled back and can not be returned to its usual position over the end of the penis
1Day or ??? if difficulty or pain passing urine
Signpost to NHS Conditions website https://www.nhs.uk/conditions/phimosis/
Routine otherwise
Fungal nail infection
Signpost to podiatry of diabetic
Pharm for most other cases
Routine only if treatment failure (at least 3 months of continual use)
Gallstones see abdominal pain
Ganglion cyst see cysts and skin lumps
Gastritis see abdominal pain
Genital herpes see herpes
Goitre (swelling to the front of the neck)
999 if finding it hard to breath
Routine otherwise
Gout see arthritis and joint pain
Gum disease see dental
Hair dye reactions
Signpost to NHS conditions website https://www.nhs.uk/conditions/hair-dye-reactions/
Hair loss
Routine
Hand, foot and mouth disease
Signpost to NHS conditions website https://www.nhs.uk/conditions/hand-foot-mouth-disease/
Pharm usually
1Day if high temperature or hot and shivery, high level of parental concern, reduced urination, or patient is pregnant
Routine otherwise if not settling after 7 to 10 days
Hay fever see allergy
Head lice and nits
Pharm
Headaches
Follow-up if long standing, no acute worsening in the past 2 weeks, on medication and known to a clinician
1Day or Routine (same week) if long standing but worsening symptoms
999 if headache not easing with OTC medication after an injury, very sudden onset very painful headache, sudden problems speaking or remembering things, loss of vision, feeling drowsy or confused, a very high temperature, a rash that does not fade with pressure, loss of balance or difficulty walking
1Day or ??? if new headache and not controlled with OTC medication
Hearing loss or concern
Child
Signpost to self refer to Ropewalk https://www.nuh.nhs.uk/audiology/
Adult
1Day or Routine (same week) if sudden hearing loss over past week, pain or discharge
Nurse hearing check appointment
Heart burn and acid reflux
Pharm if not taking anything
Routine if lifestyle changes and pharmacy medicines are not helping, heartburn most days for 3 weeks or more, or food getting stuck in throat, frequently being sick, or losing weight for no reason
Heat Rash
Pharm
Heavy periods
Signpost to self assessment tool online https://www.nhs.uk/conditions/heavy-periods/
1Day if dizziness or shortness of breath
Follow-up if ongoing and known to a clinician
Econ or Routine otherwise
Hernia
ED if painful, unable to push back in, unable to open bowels, unable to pass wind and / or vomiting
Econ or Follow up if otherwise changing known hernia
Routine otherwise
Herpes
Signpost to GU Medicine if first episode
Issue repeat Acyclovir if on repeats (even if >1 year since last supply)
1Day or Econ if not first episode and Acyclovir not available on repeats or additional concern from patient
See also cold sores
High blood pressure see blood pressure
Hip pain (adults) see arthritis and joint pain
Hip pain (children)
ED if your sudden pain in hip, thigh or knee or cannot put any weight on 1 leg
1Day if new limping child, pain is getting worse or has not improved, or high temperature or feel hot and shivery
Routine (same week) if pain settled but has returned or not settling after 2 weeks and no alternative plan in place
Hives see heat rash and allergies
HRT (Hormone Replacement Therapy)
PP prescription supply issues
Routine if new concern
Follow-up if already on treatment
Hypertension see blood pressure
Impetigo
1Day or UCC
Incontinence see urinary incontinence
Indigestion see heart burn and acid reflux
Infected piercing
Econ with good quality photo
1Day otherwise
UCC if no capacity
Ingrown hair
Pharm
Econ or Routine if ingrown hair or area around it is very painful, hot or swollen
Ingrown toenail
Signpost to podiatry
Econ or Routine if painful and swollen +/- pus, or diabetic
Insect bites
Pharm for most cases (very rarely infected in the first 72 hours)
Econ if not settling with antihistamines or concern about infection
UCC or 1Day if feeling unwell or previous cellulitis in the past year
Iron deficiency anaemia
Econ if new concern
Follow-up if ongoing
Jaundice
Follow-up if ongoing problem and seen by us before
111 or 1Day if new or worsening
Joint pain see arthritis and joint pain
Jaw pain
Signpost to dentist if unable to eat
Routine if recurrent pain, affecting sleep or quality of life
Kidney infection see UTI
Kidney stones see abdominal pain
Knee pain see arthritis and joint pain
Leg cramps
Signpost to NHS conditions website https://www.nhs.uk/conditions/leg-cramps/
Routine if leg cramps disturbing sleep, numbness or swelling in leg(s) or cramps last longer than 10 minutes
Leg ulcer(s)
Refer to district nurse if housebound
Nurse otherwise
Lips (sore, cracked or painful)
Pharm
Loss or change in sense of smell
Signpost to NHS conditions website https://www.nhs.uk/conditions/lost-or-changed-sense-smell/
Pharm
Routine if not settling after three weeks
Low blood pressure see blood pressure
Lumps
Signpost to NHS conditions website https://www.nhs.uk/conditions/lumps/
Routine if not settling after two weeks
1Day if very sudden increase in size, pain or new onset of fever
Mastitis see breast pain
Memory concerns
1Day if sudden (within the past week) onset or significant social issues / risks
Routine
Menopause
Signpost to pregnancy test if last period late and previous periods reasonable regular
Routine bloods if concerned about menopause, aged <50, not on contraception and not previously investigated within the past year (FBC, UE, TFT, HbA1c, FSH) and then routine
Follow up if issue with ongoing symptoms or medication
Routine otherwise
Metallic taste
Signpost to dentist if not settling
Migraine see headache
Miscarriage see vaginal bleeding
Moles
Routine (same week) if changes shape or looks uneven, changes colour, gets darker or has more than 2 colours, starts itching, crusting, flaking or bleeding or gets larger or more raised from the skin
Econ if able to send close and clear photo or if long standing without any changes
Mouth (oral) thrush
Pharm
Mouth ulcers
Signpost to NHS conditions website https://www.nhs.uk/conditions/mouth-ulcers/
Pharm
Signpost to dentist if lasts longer than 3 weeks, keeps coming back, grows bigger than usual or is near the back of throat, bleeds or becomes more painful and red
Nail problems
Signpost to nail cutting service (paid) if unable to cut own nails
Signpost to podiatry for ingrowing nail concerns
Econ or Routine if nail change
1Day or UCC if new pain, redness, swelling around nail
Nappy rash
Pharm
Signpost to health visitor
1Day if high temperature, baby seems very uncomfortable
Nausea
999 if sudden onset of nausea with chest pain that feels tight or heavy, pain that spreads to your arms, back, neck or jaw and / or shortness of breath
Otherwise see diarrhoea and vomiting
Neck pain
??? if with new headache or fever, or new pins / needles or weakness in arm(s) or leg(s)
UCC if pain started between 6 and 48 hours after road traffic collision
FCP if new neck pain not settling after 2 weeks, OTC painkillers not effective
Night sweats
Routine (same week) if first presentation
Follow-up if already seen for this
Nipple discharge
Routine (same week) if new
Nosebleeds
Signpost to NHS conditions website https://www.nhs.uk/conditions/nosebleed/
ED if your nosebleed lasts longer than 10 to 15 minutes despite direct pressure, excessive bleeding, swallow blood and vomiting, bleeding starts after blow to the head, feeling weak or dizzy, difficuilty breathing
1Day if taking blood thinners (not aspirin or clopidogrel), feeling of heart racing, pale skin or shortness of breath
Routine if child under 2 years, or regular nosebleeds
Obesity
Signpost to NHS conditions website https://www.nhs.uk/conditions/obesity/
Signpost to Doris – results to HCA, can then be referred to Tier 2, weight watchers or health and wellbeing coaches
Routine if considering referral for gastric surgery
Obstructive sleep apnoea
Routine if new
Signpost to CPAP clinic if issues with machine or change in symptoms
Overdose
999 or ED if unusual behaviour, not fully awake, vomiting, fitting, chest pain or breathing difficulties
Otherwise discuss with on call
TOXBASE: Username: GP8461 Password: 8PCLE8
Palpitations
999 or ED if currently has palpitations with any of these symptoms: chest pain, shortness of breath, feeling faint or fainting
UCC or 1Day if new onset and causing significant concern or previous heart problems
Follow-up if seen for this previously and not worsening in the past two weeks
Routine (same week) otherwise
Piles (haemorrhoids)
Signpost to NHS conditions website https://www.nhs.uk/conditions/piles-haemorrhoids/
Pharm
Routine if symptoms of piles and they’re getting worse or there’s no improvement after 7 days of treatment, recurrent symptoms, there is a change around the anus
1Day or 111 if piles and temperature is very high or feeling hot and shivery and generally unwell, pus leaking from piles
Pins and needles
Signpost to NHS conditions website https://www.nhs.uk/conditions/
Routine if constant or keeps coming back
1Day or 111 if affecting face (also consider Stroke / FAST test)
??? if chest pain
Pneumonia see cough
Poisoning
999 if more than one person affected patients must not make their own way to ED
Otherwise see Overdose
Post menopausal bleeding
Routine
Prostate concerns
If requesting PSA test, can be booked directly for blood test provided patient is aged >50, no symptoms suggestive of prostate disease and no PSA test in the previous year.Should refrain from sexual activity and vigorous exercise, such as cycling, in the 2 days before the test as they can affect the PSA level and encourage to read the information available online herehttps://www.gov.uk/government/publications/prostate-specific-antigen-testing-description-in-brief/psa-testing-and-prostate-cancer-advice-for-men-without-symptoms-of-prostate-disease-aged-50-and-overIf has symptoms see UTI (as acute infection should be excluded first)
Pubic lice
Signpost to GU Med
999 or ED if any of the following: a stiff neck, bothered by light, seems confused, a high temperature, difficulty breathing (you may notice grunting noises or their tummy sucking under their ribs), breathlessness, or they’re breathing very fast, a rash that looks like small bruises or bleeding under the skin and does not fade when you press a glass against it, their skin, lips or tongue look pale, blue, grey or blotchyFollow-up if previously seen and not settling1Day or Econ for most other cases FCP PharmRoutine if not resolving with >2 weeks OTC treatment, or affecting scalp PharmRoutine if D&V or stomach ache lasting more than 2 weeks, weight lossRashes in babies and children
Repetitive strain injury (RSI)
Ringworm
Worms
Refugee support
Routine with HCA for 30 minute health check if registered within the past month
Signpost to https://www.nottsrefugeeforum.org.uk/ or call 0115 960 1230
Scabies
Pharm
Econ
Routine if still itching 4 weeks after treatment
Scarlet fever
1Day
Sciatica see back pain
Sexually transmitted infections (STI or STD)
Signpost to GU Med
Shingles
1Day if elderly, pregnant, diabetic or HIV+ and symptoms started within the previous 3 days
Econ or 111 otherwise
Shoulder pain see arthritis and joint pain
Sinusitis (sinus infection)
Signpost to NHS Conditions website https://www.nhs.uk/conditions/sinusitis-sinus-infection/
Pharm if not tried OTC and symptoms for less than 2 weeks
Routine (same week) if not settling, severe symptoms, or recurrent symptoms
Skin cysts and tags
Routine
Do not book directly on to minor ops waiting list until seen or agreed by AVD or BSM
Sleep apnoea see obstructive sleep apnoea
Smear see cervical screening
Stop smoking
Signpost to StubIt
Sore throat
999 if difficulty swallowing or breathing, new drooling, making a high-pitched sound as they breathe (stridor) or have severe symptoms and are getting worse quickly
Pharm if otherwise well and not tried OTC painkillers
1Day if child under 7 or high degree of parental concern, diabetic or fever symptoms
Econ if able to send photo of tonsils
Spirometry
Two appointments with EW or HP, 20 to 30 minutes apart.
Must avoid using salbutamol or other reliever inhalers for 4 hours before the appointment
Avoid smoking for 24 hours before the appointment (minimum 4 hours)
Avoid alcohol, strenuous activity and large meals for 4 hours before the test
Sprains and strains
UCC if new
FCP or MOSAIC otherwise
Steroid injections
Follow-up if there is a documented plan in the notes for the injection, can also be booked if has had previously (more than 3-4 months previous). Will need a double appointment.
Stings see bites
Stomach ache see abdominal pain and / or diarrhoea and vomiting
Stroke
999 if new one sided face droop, arm weakness, slurred or garbled speech
??? if the above new symptoms have been present for >24 hours
1Day if the above new symptoms have occurred in the past 2 weeks and now fully resolved
Sun burn
UCC if skin is blistered, high temperature or shivering, dizzy, nausea, headache and muscle cramps, child under 2
Pharm otherwise
Tennis elbow see arthritis and joint pains
Tension headache see headaches
Tired all the time see fatigue
Termination of pregnancy
Signpost to BPAS https://www.bpas.org/clinics/bpas-nottingham-city/ or 03457 30 40 30 if aged >16
??? otherwise
Thrush (men and women)
Signpost to NHS conditions website https://www.nhs.uk/conditions/thrush-in-men-and-women/
Routine if aged <16 or >65, first episode, more than 4 episodes in 12 months, OTC treatment failure, pregnant or breast feeding, diabetic or HIV+
If treatment failure or first episode can do self taken swabs rather than book an appointment
Testicle pain
ED if sudden, severe pain in a testicle, testicle pain along with feeling sick, being sick or pain in your tummy, significant pain that has lasted more than an hour or continues when resting
Routine (same week) if aching or discomfort in testicles, a new or changing lump, new swelling, change in shape, change in feeling, a testicle that has become bigger than the other
Signpost to GU Med as an alternative for patients with recent new sexual partner, especially if any new discharge from the penis or pain in the penis
Travel vaccinations
Complete travel information form for each patient travelling, ideally at least 6 weeks before travel.
Trigeminal neuralgia see jaw pain
Underactive thyroid
TFT blood test if concerned and on treatment and >6 weeks since last dose change and >12 weeks since last TFT test
Routine
Unintentional weight loss
Routine (within 1 week)
Urinary incontinence
Signpost or refer to continence clinic
Urinary tract infection
Request urine sample only if aged <12 or >65, recent treatment failure or male.
Pharm if female, aged 16 to 64, no recent infections, otherwise well, and not allergic to nitrofurantoin
Routine (once cultures back) for treatment failures who are otherwise well
1Day, Econ or UCC otherwise
Vaginal discharge
Self taken swabs if new or treatment failure
Signpost to GU Med if new sexual partner in past 3 months
Follow-up if ongoing and seen here previously
Routine otherwise
Vaginal dryness
Pharm
Routine if not settling with OTC products, or other symptoms
Varicose veins
Unlikely to get NHS funding unless painful or at risk of skin breakdown
Econ with good quality photo
Routine
Vertigo see dizziness
Vomiting see diarrhoea and vomiting
Warts and verruca
Pharm or Econ (with photo)
Watering eye(s) see eye problems
Weight loss surgery see obesity
Weight loss, unexpected see unexpected weight loss
Whiplash see neck pain
Wrist pain see arthritis and joint pain
May 2023
Technical change to ensure continued ability to update page contents (future proofing)
Blood pressure, high and low, added
Fatigue, tired all the time, added
Email address corrected
Hernia added
Herpes (genital) added
Refugee support added
August 2023
Admin and reception procedures manual added
Poisoning and overdose added
December 2023
Delaying periods added
Prostate problems updated to explain why it links to UTI
Pins and needles added
Lumps added