Medicines Chapter of the NSF for Older People

Report of Medicines and Health consultation - July 2007

Hilda Smith, Lay member, National Partnership Forum for Older People

Introduction
Arising from a decision taken at the April 2007 National Partnership Forum for Older People, and in the context of the Medicines Chapter of the NSF for Older People, Hilda Smith arranged for an experienced external facilitator to work with a range of interests to assist in producing this report. They included the NPHS Pharmacy, community nursing, workforce planning, Community Health Council, the Disability Rights Commission, two members of the Partnership Forum for Older People and third sector Mental Service Users and the Welsh Food Alliance.

Summary

There seems a real need to emphasise that changes should be based on the actual problems experienced by older people. Of particular interest was that a number of participants had personal interest in older people, as well as a professional interest in the issues raised. In terms of promoting future inquiry this could mean that there is a wealth of good will, knowledge and experience to be tapped that we do not currently use effectively.

Mike Cole, the Senior Workforce Development Manager, Workforce Development Unit, National Leadership and Innovations Agency facilitated a robust process. He stimulated a wide-ranging debate on the amount of ill health faced by older people as they struggle to maintain equilibrium and the medication that many take to make this possible.

Mike provided a scenario and posed three questions to help identify strategic and other issues. What should be expected? What would make it better? What would make it significantly better for this family and others?  The issues identified below are not meant to be exhaustive, but provide encouragement to read the seminar report at Annex One and contribute to this report.

Some issues for consideration

Effective communication between healthcare staff and citizens is one crucial aspect of enabling the ‘full public engagement’ recommended in the 2002 Welsh Wanless Review (2)

Patients / carers need to be able to hear, understand and remember what is said in a consultation as part of a continuing process of co-production. This was one of the recommendations of the Bristol (Kennedy) inquiry. (30)

In the future review of the NSF Medicines chapter detailed consideration should be given to achieving ‘full public engagement’ and the preparatory work required to meet this goal (4)

Access to good information, advice and community pharmacy services, particularly for those living in rural and semi rural areas were noted as a source of concern, especially for those living alone and without extended family support (5).

A clear understanding of the importance of social care services and how they directly impact upon healthcare, including medication, should not be ignored (6)

Most old people are quite able to self medicate, but may need advice in understanding their medication. (8)

Are service users and carers aware of, and able to use CHC, employer based and complaints procedures of professional health and social care regulators? (10)

It was recognised that workforce planning issues across the organisational boundaries is a big issue. For example, can we influence the adoption, by social care staff, of the standards used by healthcare staff regarding the receipt, storage, and administration of medicines? (11)

With enough safeguards, does it make sense for healthcare support workers to have some role, recognising that staff need a mix of skills? (13) 

Medication is tested on fit health young people, whereas they are being used by large and growing numbers of older people, where medication can have unintended, dramatic results, as their constitution becomes more frail. What action can government’s take to address this issue? (15) See also (5), (26) and (27).

For vulnerable patients, the crucial importance of access to medical records in ‘out of hours’ and secondary care situations (17)

The need for medicines reconciliation pre and post hospital discharge and the timely and accurate transfer of this information to the appropriate parties and individuals concerned (18)

Many older people would benefit from such home visits. One solution could be peripatetic pharmacists, with secondary care following patients into the community. Overall, does this need acceptance by the Welsh Assembly Government? Are some changes in pharmacist duties, and technician support required? (19)

There is lack of knowledge in the wider community regarding the availability of MURs. After discussion there appeared to be support for the targeting of Medicines Use Reviews (MURs) toward older people especially a couple of weeks post discharge from hospital as a sensible progression (20)

Wider promotion of the National Patient Safety Agency/National Reporting and Learning systems and Yellow Card Reporting to the public was recommended (24)

There are particular issues regarding the interaction of drugs and food, for instance, which in the experience of some service users, GPs do not necessarily offer and nor do pharmacies unless specific requests are made. This lack of advice affects older people in care homes too as care workers are not told how to give various drugs (26)

Should representations be made on these and related workforce planning and development, standard setting and contracting issues to the current Welsh Assembly Government ‘Quality of Food’ consultation and the current interim review of the Assembly / FSA ‘Food and Wellbeing strategy? (27)

How and when can we appropriately influence the Welsh Medicine Chapter in our NSF, from a Welsh service user and public health perspective, bearing in mind that the large amounts of public money involved and that the main policy driver is the English NSF Medicines Chapter? (29)

Medicine handling/administration/review for older people in nursing and residential homes is in large measure dependent upon staff. There is significant inappropriate prescribing. Some forward thinking LHBs are commissioning or employing salaried pharmacists to address this issue. How can the rest learn from the best? (34)

Has any cost benefit analysis been undertaken on the use of anti-depressants and their effects in older people compared with counselling and other remedies. Can this be included in the new Public Health strategy? (35)

An honest and open approach by patient during consultation to avoid waste of money and other factors affecting medication (38)

Ethical issues for prescribing healthcare professionals and the inappropriate marketing techniques used by pharmaceutical companies. What further action is required? (39)

Issue of whether the independent contractor is the most appropriate model from a public health perspective, eg life style changes vs. expensive drugs (41)

Ensuring adequate labelling for visually impaired and blind people - particular request for progress with Braille labelling facilities. There is a legal duty to take all reasonable steps. Can this be addressed with software kit? (42)

Need for older people to be recognised in the new public health strategic framework and not just under long - term conditions / chronic conditions (43)

Fair trading pharmacy to include traceability to ensure a reputable service and accurate ingredients, e.g. recognising the increasing use of the internet for purchases (44)

Finally, the Health, Wellbeing and Local Government Committee of the National Assembly for Wales are holding an Inquiry into Health and Social Care Workforce Planning. We may wish to consider presenting relevant aspects of this report to them before 2^nd November 2007.  Similarly, aspects of this report could be presented to the current Welsh Assembly Government ‘Independent Review of Delayed Transfers of Care’. 

Annex One

12th July 2007 Seminar, 2.30 – 4pm,

Open University in Wales, Cardiff

A. What should be expected?

1. 1.    The Disability Rights Commission representative specifically requested that it be noted that a presumption exists that information is broadly accessable to older people, whereas this is not necessarily the case. What is crucial is the form this takes. Communication about medicines requires in particular consideration of all communication modes, written, verbal, voice recorded, Braille, etc.
   2. Are people too trusting without reading medicine instructions and how to use and not use drugs as part of self care? Effective communication between healthcare staff and citizens is one crucial aspect of enabling the ‘full public engagement’ recommended in the Welsh Wanless Review, so that patients, service users and carers are able to contribute to the co-production of health and improved quality of life. Thus helping to close the gap between available resources and growing demands on healthcare budgets.
   3. Patients/ carers need to be able to hear, understand and remember what is said in a consultation as part of a continuing process of co-production. Beyond the role of professional healthcare registrants, literacy skills and medicines knowledge of front line health and social care support staff is also a key element of making co-production a reality. This will need to be supported by appropriate access to electronic or written records kept, if necessary, by the service user. One of the recommendations of the Bristol (Kennedy) inquiry was for patients to receive a written copy of instructions given at a consultation (and /or a taped version).  Has this been implemented?
   4. 4.    Effective communication includes the need for older people and carers to know what the medicines are for, side effects, and what medicines are being prescribed to deal with side effects, and if they are changed why the change was made. This is significant in terms of achieving key objectives for continuing autonomy, dignity, respect and independence – alongside health and wellbeing. In the future review of the NSF Medicines chapter detailed consideration should be given to achieving ‘full public engagement’ and the preparatory work required to meet this goal.
      5. 5.    Access to good information, advice and community pharmacy services, particularly for those living in rural and semi rural areas were noted as a source of concern, especially for those living alone and without extended family support. Others raised the need for advice services easily available at all times and not just surgery hours or limited pharmacy opening hours. At one Health Centre it was especially noted that the community pharmacy was in the same building as the GP ‘out of hours’ service, and was open seven days a week and until 2300 hours on a Sunday.
         6. 6.    A clear understanding of the importance of social care services and how they directly impact upon healthcare, including medication, should not be ignored. Attention was drawn to the low growth in social care budgets and the need to achieve integrated models of care in providing services required. How does the social care workforce fit into this picture and what can we learn from ‘Modernising Adult Services’ in England and more generally learning points from across the UK?
            7. 7.    One view was “we have a 24-hour community nursing service in most areas of Wales and that it is an excellent resource for those elderly people that need nursing support. As a district nurse much of my work was supervising of medication for vulnerable patients in their own homes that needed assistance and I strongly believe that this is a nursing task rather than social services responsibility”. Another was that trained Geriatricians in local Health Centres, as well as hospitals, providing advice as required - would make a difference.
               8. 8.    Most old people are quite able to self medicate, but may need advice in understanding their medication. The most obvious link is with their GP, but GPs often do not have the time for very thorough medication reviews. Practice nurses run clinics for chronic conditions where medication can be discussed, but not automatically so. Attendance at a medication review clinics would be useful. Any issue that the nurse was unable to deal with could be referred to the GP (this is how many of the chronic conditions clinics work). With regard to polypharmacy, does the above provide the depth of advice required?
                  9. Are we blinkered by traditional approaches to health care? Some older people wish to avoid hospitals and medicines, but who is available to champion increased investment in social care services and the evidence base for re-prioritising expenditure to enable more citizen focused service delivery?
                  10. Without disparaging health care and social care staff, what happens if something goes wrong, when staff are otherwise excellent carers? Are service users and carers aware of, and able to use CHC, employer based and complaints procedures of professional health and social care regulators, or do service users have low expectations and are some fearful of recriminations when raising patient safety issues? And it they do use CHC apart from advocacy support – where is the expert advice within CHCs in respect of care issues?
                  11. 11. It was recognised that workforce planning issues across the organisational boundaries is a big issue. What standards of education are required and what delivery systems are in place to make this a reality? For example, can we influence the adoption, by social care staff, of the standards used by healthcare staff regarding the receipt, storage and administration of medicines?
                      12. 12. A generic health and social care worker was discussed. In redesigning the future work force, what progress is being made in identifying clusters of competence acquired by workers spanning social work and nursing to provide services which are ‘fit for purpose’? Have we more boundaries, than barriers? With such roles spanning are range of occupations, what flexibilities are required and how will employers and professional regulators ensure patient safety?
                          13. 13. With enough safeguards, does it make sense for healthcare support workers to have some role, recognising that staff need a mix of skills? 
                              14. 14. Resuscitation and dementia issues were considered.
                                  
                                  B. What would make it better?
                                  15. 15. Medication is tested on fit health young people, whereas they are being used by large and growing numbers of older people, where medication can have unintended, dramatic results, as their constitution becomes more frail. What action can government’s take to address this issue?
                                      
                                      
                                      16. 16. The crucial importance of effective communication between prescribing professionals (in primary and secondary care), the dispensing pharmacist and patients/carers. The use of language and the clear sign posting of information is an important issue for public protection.
                                          17. 17. For vulnerable patients, the crucial importance of access to medical records in ‘out of hours’ and secondary care situations.
                                              18. 18. The need for medicines reconciliation pre and post hospital discharge and the timely and accurate transfer of this information to the appropriate parties and individuals concerned.
                                                  19. 19. Many older people would benefit from such home visits. One solution could be peripatetic pharmacists, with secondary care following patients into the community. Overall, does this need acceptance by the Welsh Assembly Government? Are some changes in pharmacist duties and technician support required?
                                                      20. 20. There is lack of knowledge in the wider community regarding the availability of MURs. After discussion there appeared to be support for the targeting of Medicines Use Reviews (MUR) toward older people especially a couple of weeks post discharge from hospital as a sensible progression.
                                                          21. 21. An extended role for Pharmacists as an important check and balance in the system. This could be made available through a variety of means, including salaried Pharmacy advice services  – with opportunities and time dedicated to the MUR
                                                              22. 22. The medicines training needs of formal and informal carers; and access to pharmaceutical advice e.g. pharmacists linked to NHS Direct, or patient access via 24 hour pharmacy services provided by large supermarkets. To avoid patient / carer confusion is a personal medical card required, listing what is prescribed and why?
                                                                  23. 23. Review training of doctors and other prescribing professionals - with the increasing availability of powerful drugs, the aggressive marketing practices of pharmaceutical companies and the potential growth of Internet prescribing by doctors. 
                                                                      24. Following the Shipman Inquiry, the public can report incidents through the YellowCard Scheme. This can establish a pattern, which can help inform future action. This however does not help the patient when immediate advice is required. Wider promotion of the National Patient Safety Agency/National Reporting and Learning systems and Yellow Card Reporting to the public was recommended.
                                                                      25. We touched on Monitored Dosage Systems but it was only a small part of the agenda, although clearly these devices are important to older people, and the use of tele-devices with alarms, etc. were thought to be useful.
                                                                      26. There are particular issues regarding the interaction of drugs and food, for instance, which in the experience of some service users, GPs do not necessarily offer and nor do pharmacies unless specific requests are made. E.g. how many people taking anti-parkinsonian drugs know that their effect is reduced if the diet contains an amount of red meat? Service users reported being prescribed anti-biotics – where there were no instructions from the GP on how and when to take these and the instructions on the label just states ‘take three times a day at regular intervals’ and where no advice was given regarding whether they should be taken on an empty stomach, with food or after food. This lack of advice affects older people in care homes too as care workers are not told how to give various drugs.
                                                                      27. In respect of diet and connectivity between obesity/malnutrition and medication, reference was made to:
                                                                          1. Mental health patients getting intensive intervention, but gaining weight, and becoming lethargic and the need to trigger other interventions,
                                                                          2. The importance of the ‘food trolley’ versus the ‘medicines trolley’ in any care setting,
                                                                          3. The expensive nature of prescribed nutritional supplements, when appropriate fresh food could be a preferred option in all settings. The influence and marketing pressures from enteral food companies is noted and requires action.
                                                                          4. The significance of exercise for body and mind, rather than diuretic tablets,
                                                                          5. Many old people taking medication for digestion and constipation which can be easily avoided,
                                                                          6. Avoidance of artificial supplements, such as potassium tablets, when bananas could be part of the diet.
                                                                      28. Dementia was considered as a growing medical problem for care in the community. A suggestion was made for a Night Time service to aid carers.
                                                                      29. How and when can we appropriately influence the Welsh Medicine Chapter in our NSF, from a Welsh service user and public health perspective, bearing in mind that the large amounts of public money involved and that the main policy driver is the English NSF Medicines Chapter?
                                                                      30. Given the large amounts of public expenditure involved, how and when can we begin to appropriately influence the English NSF Medicines Chapter from a Welsh service user and public health perspective?
                                                                          
                                                                          C. What would make it significantly better for this family and others?
                                                                      31. Have we a static service model dealing with a changed situation? With increased emphasis upon community care we should be more alert to medication issues, and the need for immediate advice for the patient and carer.
                                                                      32. Would preventative health care have assisted prior to this situation developing?
                                                                          
                                                                          
                                                                      33. With an above average UK number of older people with long-term conditions in Wales, more support is required to support self-care, expert patients and carers.
                                                                          
                                                                          
                                                                      34. Medicine handling/administration/review for older people in nursing and residential homes is in large measure dependent upon staff. There is significant inappropriate prescribing. Some forward thinking LHBs are commissioning or employing salaried pharmacists to address this issue. How can the rest learn from the best?
                                                                      35. A related problem is that may older people are isolated hence lonely and become depressed.  Medication is the first and only method of treatment by GPs.  LHBs don’t seem to be commissioning complementary therapies or CBT/counselling.  Why is this the case? Has any cost benefit analysis been undertaken on the use of anti-depressants and their effects in older people compared with counselling and other remedies. Can this be included in the new Public Health strategy?
                                                                      36. Need for national and local initiatives where groups of people work together. Carers need to know their limitations. Need for immediate access for advice about medication.
                                                                      37. Implications for staff training in terms of the necessary knowledge and understanding required for public protection and self-awareness.
                                                                          
                                                                          
                                                                      38. An honest and open approach by patient during consultation to avoid waste of money and other factors affecting medication.
                                                                          
                                                                          
                                                                      39. Ethical issues for prescribing healthcare professionals and the inappropriate marketing techniques used by pharmaceutical companies. What further action is required? Any potential and actual conflicts of interest need to be addressed if we are to have effective citizen centred service delivery. See the Health Select Committee Report, May 2005.
                                                                          
                                                                          
                                                                      40. The potential huge savings from making best use of LHB prescribing resources, for intermediate care and other purposes, which might not otherwise be affordable – see the recent National Audit Office/ Wales Audit Office reports.
                                                                          
                                                                          
                                                                      41. Led by the Dept of Health, NHS Pharmacy contracts under constant review, as are issues around governance and standards of prescribing. But the governance arrangements in promoting Health Promotion are weak and needs strengthening. Issue of whether the independent contractor is the most appropriate model from a public health perspective, eg life style changes vs. expensive drugs.
                                                                          
                                                                          
                                                                      42. Ensuring adequate labelling for visually impaired and blind - particular request for progress with Braille labelling facilities. There is a legal duty to take all reasonable steps. Can this be addressed with software kit?
                                                                      43. Need for older people to be recognised in the new public health strategic framework and not just under long - term conditions / chronic conditions.
                                                                      44. Fair trading pharmacy to include traceability to ensure a reputable service and accurate ingredients, e.g. recognising the increasing use of the internet for purchases.                 Draft 16th July 2007 Revised 14^th October 2007

                                                                   

                                                                   

                                                                   

                                                                   

                                                                  Should representations be made on these and related workforce planning and development, standard setting and contracting issues to the current Welsh Assembly Government ‘Quality of Food’ consultation and the current interim review of the Assembly / FSA ‘Food and Wellbeing strategy?

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   

                                                                   

                                                               

                                                           

                                                       

                                                   

                                           

                                       

                           

                       

                   

                

                

                

          

       

    

 

Self-managed Care - a co-operative approach

This is the report of a series of pilot schemes commissioned by the Department for Health exploring how co-operative structures can be used to enable groups of care users to pool their resources under direct payments/personal budgets and take control of their care.

Download the full document as a pdf here (270KB)

Message from the Older People’s Commissioner for Wales

'Shaping the Future of Care'

• What do vulnerable people need to maintain dignity and a sense of well-being?
• What are the strengths, weaknesses and future prospects for existing models of delivery?
• What is our shared goal for the future?
• How can we deliver a business model for the future which meets users' needs and aspirations, mobilises the latent resources of communities and offers secure, remunerative and rewarding work for those employed to deliver
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