Small actions, big impacts

We have developed a suite of tools to improve the quality of prescribing of bisphosphonates for the prevention of osteoporotic fractures:

  • Primary care bisphosphonate flowchart: this flowchart operationalises the numerous, sometimes inconsistent, guidelines relating to the prescribing of bisphosphonates to prevent osteoporotic fractures. The flowchart can be used whenever bisphosphonate prescriptions
  • Primary care osteoporosis management template: the function of this template is to prompt and standardise the recording of key clinical information when managing patients with, or at risk of, osteoporosis.
  • Osteoporosis management audit search and report tool: to assess the use of bisphosphonate holidays and duration of bisphosphonate prescriptions among patients in your practice you can download the search and report tool (the quality of the information within this tool is likely to be improved by first implementing the Primary Care Osteoporosis Management Template)

Quick practice tip: In addition to, or instead of, using the tools provided above, we have found that putting the review date in the dosing instructions helps to prompt appropriate review and speeds up repeat prescription signing

What is the evidence?

We have implemented the above tools in the Academic General Practice. We have reduced the number of prescriptions for bisphosphonates which exceeds 10 years.


View our presentation given at the National Osteoporosis Society Annual Conference, December 2018

We have developed a protocol to improve the processing of new diagnoses of pre-diabetes when receiving incoming HbA1c results: The Pre-diabetes protocol, once opened, enables:

  • Coding of Pre-diabetes as a “Problem”
  • Provides text to copy and later paste into an electronic task to send to the secretarial team prompt mailing of a standardised patient letter and accompanying patient information leaflet
  • Setting up of an automatic diary entry to ensure follow-up blood test monitoring is undertaken.

What is the evidence?

We have implemented the Pre-diabetes protocol in the Academic General Practice and the  number of patients with a Problem code of Pre-diabetes has sharply increased. This ensures that, affected patients are detected by our Pre-diabetes recall/monitoring searches and thus are monitored appropriately.


Having identified, from that our use of high intensity statins was suboptimal, we put in a suite of quality improvement tools to support the intensification of statins:

  • Standardised patient letter to suggest starting statins: this standardised letter draws in the latest cholesterol result and most recent QRISK and provides information on commencing statins. This prevents inviting patients in for review who have no intention of commencing statins, but also enable efficient processing of incoming cholesterol results. 
  • Standardised patient letter to suggest intensifying statins: this standardised letter advises patients of current management recommendations and suggests using a higher dose of statin. This enables efficient up-titration of statins for patients who wish to undertake this, without the need for a face to face appointment. 
  • Statin intensification prompt: using a protocol, those patients on low-intensity statins are flagged to clinicians when their records are brought up, suggesting intensification of statins.

What is the evidence? 

We have implemented the above tools in the Academic General Practice, with the prompts and letters going out during May 2018. As the data shows, we have significantly reduced the proportion of statins prescribed which are low-intensity. 


We identified the risk of some vulnerable children and families slipping through the net or multiple small concerns not being added together. To support child safeguarding processes in the practice we developed:

  • Child safeguarding template: this template standardises the recording of key child safeguarding information and review due dates for e.g. looked after child health assessments.
  • Parent/guardian protocol: we developed a protocol which brings up a template upon opening a consultation with any patient under 18 years old, to record who has attended with them and who has parental responsibility.
  • Child safeguarding search and report tools: to quickly establish which children are subject to child protection procedures and who has raised cause for concern, the search and report tools have been developed (the quality of the information presented by the search and report tools is optimised by using the child safeguarding template).

Quick practice tip: In addition to, or instead of, using the tools provided above, we use a separate spreadsheet to record the details of children with child safeguarding concerns, so it is clear if a child leaves the practices.

What is the evidence?

We have implemented these tools in the Academic General Practice and, while it took a bit of time to clean up the records initially, we now know if we are missing e.g. the most up to date looked after child health assessment report and can be proactive at chasing this. Our records are much more complete, contemporaneous and accurate now.

When can this be used? We have now used this approach for drug groups which are either time limited or could be. For example, anticoagulants may only be required for a few months or life long, same goes for dual antiplatelet prescribing. Repeat prescription signing is quicker and easier and the risk of inadvertently long prescriptions is reduced if a stop/review date (or the term “lifelong”) is inserted in the dosing instructions. Where prescribers miss a stop date, this helps to alert pharmacists and patients so acts as a safety net.

We have used this approach for bisphosphonates, anti-depressants, antibiotics, tamoxifen/anastrazole and anticoagulants.

What is the evidence? 

Having audited prophylactic nitrofurantoin for UTI and dual antiplatelet prescribing, we reduced/eliminated unintended prolonged courses of these (potentially) time limited drugs. Other evidence exists for example:

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