Context A large, urban GP surgery with approximately 25,000 patients and 27 doctors, including 9 trainees.

Problem Paediatric constipation is a common problem, and NICE guidance is clear in the suggested approach to constipation in children. However, with such a large number of patients and doctors, the approach to investigation, management and referral was variable within the practice. We set out to improve the approach to paediatric constipation across the practice, in the hope that this would improve outcomes including number of referrals to secondary care, and number of A&E attendances.

Assessment of problem and analysis of its causes We looked at patients under 18 years old who had a Read code of “constipation” between April 2014 and April 2015. We compared their management to the NICE quality standards for constipation in children and young people, particularly the treatment used, follow up, and referral to secondary care. Overall the approach was variable, and less than half of the patients were treated in line with the quality standards.

Intervention We introduced a pop-up box for the EMIS IT system to pop up after a Read code of “constipation” in patients under 18 years of age with a brief summary of suggested management. We presented our assessment and the guidelines for the management of constipation at the weekly practice meeting.

Study design This was a retrospective cohort study. We assessed the treatment, follow up and referral of children with constipation before and after the intervention against the NICE quality standards.

Strategy for change We presented our assessment and the guidelines for the management of constipation at the weekly practice meeting, to all doctors, practice nurses and most administrative staff.

Measurement of improvement We compared the management of patients before and after the intervention to look for an improvement in care. We used the same EMIS search criteria of patients under 18 years old with a Read code of “constipation”.

Effects of changes Although there was an improvement in the management of these patients in terms of treatment used, follow up and referral to secondary care, there was still variation between different members of the team.

Lessons learnt If we were to do this again, we could try to address this variation and focus on those team members resistant to change, to ensure consistency in the approach to constipation management across the practice.

Message for others Paediatric constipation is a common problem both in general practice and secondary care. There is clear guidance on the management, but it is not always followed. Simple changes such as ours can improve care for patients, but trying to change the clinical decisions of doctors established in their practices can be difficult.