Northumbria Healthcare NHS Foundation Trust – North Tyneside General Hospital

Multidisciplinary Review of Medication in Nursing Homes – A Clinico-ethical Framework

Northumbria covers one of the largest geographical areas of any health trust in England and provides integrated health and social care to over 500,000 people living in Northumberland and North Tyneside and employs 9000 staff.
Medicines use in care homes is an area of concern. Problems include:

  • Excess medicines (sometimes inappropriate)
  • Lack of structured review of medicines
  • Patients unaware of what treatment they are on and why

It is estimated that between 10% and 71% of elderly patients take medicines that are not suitable or have the potential to cause harm. Some patients experience minor side effects from medicines that have a profound effect on their quality of life.

Case study: 85 year old lady in a care home was bedbound (strokes & dementia) and unable to communicate or make decisions for herself. She was prescribed 11 regular medicines, including medicines to prevent a fracture, and medicines to prevent cardiovascular disease. Each day nursing staff would administer these medicines by lifting her head and pouring the solution into her mouth. This lady was also taking antidepressant, hypnotic and antipsychotic medicines for agitation. On stopping her preventative medicines her agitation resolved and in time her clinicians were able to stop medication for her agitation.

This case study demonstrates that residents are prescribed excess, inappropriate medication and they or their families (advocates) are not given any say in what medicines they are given.

The aim of this project was to develop a patient involvement framework for medication reviews in care homes.

Funding from The Health Foundation Shine 2012 award was used to set up a series of medication reviews in care homes. A team involving psychiatry of old age, pharmacy, care home nurses, general practitioners and the Trust’s patient experience expert led the project. Care home and general practices from North Tyneside were invited to participate. The stages of the reviews were as follows:

  1. 1. Detailed medication review by clinical pharmacist
  2. 2. Multidisciplinary team (MDT) meeting to discuss review
  3. 3. Meeting with resident or representative (e.g. family) to discuss medicines, MDT discussions and patient’s preferences
  4. 4. Proposed changes (e.g. stop or start medicines) take into consideration the MDT and resident (or representative) discussions

As not all residents had the mental capacity to participate in the reviews, the team developed a four level patient involvement framework, with all reviews starting at level one and moving down to level four (least desired option).

  1. 1. Resident involved in review and makes decisions regarding medicines
  2. 2. Resident has no capacity: Family or representative makes decisions on behalf of the patient
  3. 3. Family not actively involved in resident’s care: A letter sent to family outlining the discussions from the MDT. The family are encouraged to contact the pharmacist to discuss or challenge any proposed changes
  4. 4. No family or other representation: Formal advocacy

The residents are followed up periodically following any changes to monitor for any adverse events. The project’s patient experience lead has been interviewing a sample of patients and family members to capture their experiences on being involved in this project. We used a mixture of quantitative data and qualitative data to measure the success.

Quantitative Data
To date we have completely reviewed 105 residents in 5 care homes.

Quantitative data was collected prospectively at the end of the review process. Our primary data sources are GP records, MDT data collection form and care home records. In some cases we have requested hospital notes.

In 105 residents we made 364 interventions with 14 different types of interventions being made. The most common intervention was to stop medicines; 195 medicines (23.6% of all medicines prescribed) in 81 residents (77%). The 105 residents were taking 825 medicines (average of 8 per resident) compared with 630 medicines (average of 6 per resident) following the review; a 23.6% reduction in medicines burden. The main reason for stopping medicines was lack of indication for the treatment; 108 (55.3%) residents. In 16 cases (8.2%), patient safety was the primary reason for stopping the medicine.

Resident Involvement Framework
Figure 3 shows our current resident involvement mapped against the framework. In most cases the residents or their family representative were involved in decisions. We have used advocates for two residents.
Figure 3: Resident Involvement Framework


Qualitative findings
The main themes emerging from care home staff are:

  • Non-compliance, inability to take tablets, residents’ lack of awareness and understanding of current medication.
  • Staff reported varying involvements from family members
  • Suggestions to improve their residents’ experience of medication and medication reviews included regular medication reviews prompted by the medical practice, forgetting the cost implications of liquid medication when a resident requires it, protected medication rounds and prevent wastage of drugs that have not been removed from repeat prescriptions.

Family members valued getting a voice:
“There is no point in people being on things unnecessarily. You don’t need to be on them, why be on them”
“I think we should be notified if something was going to be stopped. [pharmacist] discussed about taking her off a Statin. Erm…. but at the minute I think she is happy and has really good quality of life, I don’t think she should be taken off things without consulting the family…”

General practitioners agreed with involving patients in decisions about medicines:
“I think involving the family is a really good idea……………it is a positive thing to try and involve them”
The project has attracted interest from primary care and locally there is a desire for it to continue post-Shine funding. A number of initaives are underway to ensure this happens:

  1. 1. North Tyneside Clinical Commissioning Group (CCG) were informed of the project and have received regular updates from the Trust’s communications team. We are curently working with the CCG on a business case to expand this review service from April 2014, when funding ends.
  2. 2. Northumberland CCG have met with the project team and negotiations to set up a similar service in Northumberland are ongoing.
  3. 3. Northumberland medical practices have shown interest in this project. One practice has commissioned services from the Trust to run reviews for their care home residents and we are about finalise a commission from a second practice to provide a similar service.

The learning from this project has been used to shape a local service suppporting older patients in their own homes.
This initiative has the potential to be applied to other patients in care homes. We have already shared our findings with a team in another CCG who are planning a similar initiative. We have developed a model of patient involvement that other individuals working with care home residents can use.

Our work has the potential to be transferred to housebound elderly patients who live in their own homes. Many of these patients have the same medicines issues as residents in care homes, taking multiple medicines with little involvement in decisions. We have been sharing our work with a local team of health and social care professionals (North Tyneside High Risk Patient Programme) so that learning from this care home project can be transferred to patients in their own homes.

The novel aspect of this project is the patient involvement framework. Too often patients in later life or those who lack capacity to make decisions do not get a say in what medicines they take or don’t take. This project allows patients or their representatives to make informed decisions by being supported by a team of health care professionals.

An example of this in practice is a case of a 92 year old lady who was prescribed simvastatin tablets at night. She was unsure what this was for. After the indication (prevention of cardiovascular disease) and the risks/ benefits had been explained, she made a decision to stop taking this medicine; a decision that her GP and other health professionals supported.

An important learning point from this project has been not to assume that as a health professional, one knows what is best for one’s frail older patients. Patients (and their families) have a desire to be involved in decisions about them.

We have used shared decision making tools to help supports residents and their families with decisions about starting, changing or stopping medicines.

Cate’s plots:
NHS Right Care:
Health Foundation’s MAGIC programme:
The team have a number of flyers, research posters, data collection tools (including database), patient/family/professional questionnaires that we will be happy to share with anyone wishing to undertake similar work.

Integrated Community Support Team – NHS Lanarkshire

East Kilbride and Strathaven is a locality within the South Partnership of NHS Lanarkshire and South Lanarkshire Council. Population is approximately 90,000 in both urban and rural locations with an over 65 population of approximately 24, 000 and rising annually.

The Integrated Community Support Teams (East Kilbride & Strathaven pilot) started on 14th May 2013. They provide inter agency support, especially for frail older adults, requiring coordinated care in their homes. This includes Social Care, Nursing, Physiotherapy (PT) and Occupational Therapy (OT) with palliative or rehabilitation/re enablement programmes as appropriate. Proactive links have been made with other services e.g. Carers Development Officer, Specialist Health Services and the Acute Health Sector.

Working in partnership is fundamental to achieving progress in each of the priority areas as set out in the 2020 Vision (2011) and the Quality Ambitions in the Quality Strategy (2010). This pilot was initiated in response to the Scottish Government Re Shaping Care programme by the NHS Lanarkshire, South Lanarkshire Council and partners.

The Integrated Community Support Teams Model has demonstrated that partnership working across health and social care and with third sector organisations provides person centred, effective, efficient and safe supports to allow older people to remain at home wherever possible.

Crucial to all of this were the consultations with, not only all the social work, nursing, allied health professionals and medical staff, but with their partners in the 3rd sector and independent providers and absolutely, not least, the people themselves and their families and carers.

The key issues identified were:

  • Join staff into one team and provide 24 hr community nursing, therapy and home care.
  • Make it a neighbourhood model
  • Use existing knowledge, skills and practices.
  • Build in confidence and resilience within the local workforce
  • Retain GPs as the responsible medical officer

The overall aims were:

  • Provide effective, person centred support to enable people to remain safely at home for as long as possible
  • Support the person to return home as soon as possible if admitted to hospital
  • Support older people with complex health and social care needs to have their community care assessments carried out in their own home if possible

All of this required to be delivered within existing organisational and management structures and within separate bases as available accommodation was limited.

Once the model was agreed and with continued consultation with all the staff and partners pilot teams in the East Kilbride and Strathaven locality were implemented. The ICST comprises both health and social care staff. The social care element includes home carers, community support coordinators, occupational therapists (OTs) and social workers. The health element is made up of community staff nurses, clinical support workers, district nurses (DNs), physiotherapists, occupational therapists, generic support workers and administration staff.

Each team provides coordinated support to a geographic locality area. The desire is to focus on a neighbourhood model, building on the assets within a locally defined geographic area which allowed the flexibility to evolve in a dynamic way.

There had been a recent major realignment within Social Work with the introduction of the Supporting Your Independence (SYI) approach. While home care has been the main focus of SYI activity, the approach permeates all social work practice.

Health care staff are co-located in the three Health Centres, with social care staff in the Civic Centre. In view of accommodation restrictions staff were unable to be co-located together however organisational arrangements have been put in place to maximise opportunities for joint working. Hot-desking with access to both NHS and South Lanarkshire Council IT systems have been put in place on all sites to enable integrated practice. Accommodation was made available within Hairmyres Hospital to provide a secure and central base for both health and social care ICST staff working at weekends, evenings and overnight.

A fundamental ambition of the workstream was to offer a 24 hour, 7 day a week Nursing and Home Care service, closing the 8-9 am and 5-6 pm gaps for Nursing services and the overnight gap for scheduled Home Care – a 24 hour emergency response was already in place. Additional Nursing and Home Care staff were recruited to achieve this.

The Managers and staff from Health and Social Work and the Integrated Community Support Teams have shown what can be achieved when agencies are willing to work together with respect and understanding of each others’ roles, responsibilities and professional cultures but with the single aim of improving care for the local population. Allowing practitioners to inform the development of joint processes has proved effective in building confidence and improving communication. The “lead professional” role enables the continuity of care and the coordinated approach which is vital to this team’s aims.

Prior to the commencement of the pilot a number of qualitative and quantitive measures were identified to be measured against and have demonstrated that:

  1. ICSTs have supported the avoidance of admission to hospital and lengths of stay for older people
  2. ICSTs have supported the reduction in delayed discharges from hospital and allowed people to have complex care assessments carried out at home.
  3. 89% of people referred to the teams in the community have remained at home at 30 days
    Integrated practice is now embedded within the teams.
  4. Nursing caseload complexity is greater in East Kilbride than other localities across Lanarkshire
  5. ICST staff have evaluated the pilot positively

The South Partnership view the work carried out in this pilot of ICSTs as having made a valuable contribution towards informing future arrangements for integration of health and social care.

Not least the independent evaluation and continued feedback from our older people, carers and partner organisations e.g. Carers network, Seniors forums , Public Partnership forums etc has been outstandingly positive.

The evaluation has now resulted in the pilot being continued and is rolling out in the next few months to all other South Lanarkshire areas.

Lessons being learned include the essential consultation with all stakeholders, the involvement of staff and stakeholders in developing the service processes and sufficient flexibility to make adjustments as required.

The use of IT by all staff and links with other agencies together has been a major achievement and is continuing to develop. This has been crucial in delivering the continuity e.g. during out of hours periods.

The single access telephone system has been an undoubted bonus to the patients/service users and their carers – 24 hr access to someone who knows or can quickly access information to support them is seen as the fastest “quick win!! This, coupled with a continuous nursing service and associated home care has provided this 24 hr support across the locality.

Plans are in hand to replicate these important elements within the other areas in South Lanarkshire.
Learning Points / Unique Angles

  • The merging of teams and not another “bolt on” team.
  • Staff feel they are all part of the team – not separate services.
  • We used our existing resources in a different way and listened to what patients, service users, carers and staff all had been saying for many years – bring us together and talk to each other!
  • Consultation
  • Use of existing resources- get the right management leadership and staff involvement
  • Look for solutions not barriers- encourage staff and their patients/service users to provide them

Staffordshire and Lancashire Commissioning Support Unit

Staffordshire and Lancashire Commissioning Support Unit

Category: Setting the Stage – Measuring/Reporting and Acting and Setting the Stage – Staff Engagement / Improving Staff Experience

Staffordshire and Lancashire Commissioning Support Unit

Insight and Involvement – Measuring, Reporting and Acting

Organisation – Staffordshire and Lancashire Commissioning Support Unit (SLCSU) is one of the largest the country delivering a range of transformational and transactional services across Shropshire, Telford and Wrekin, Staffordshire Herefordshire and Lancashire. SLCSU employs over 750 people and covers population of over 3.5 million people.

Aim – Our objectives were to provide one single place for all patient experience, clinical and incident intelligence to provide a holistic view of areas for improvement. Triangulation of the three elements of quality to see the bigger picture
To prevent the likelihood of a recurrence of Mid Staffs by allowing all staff to view relevant data in order to take action on the findings
To gain the greatest amount of intelligence from local data by using the national recognised domains of patient experience to record data and to triangulation local and national data to identify themes and trends

To capture clinical feedback via a real-time system with ease of access and ability to view all data in real time.

To provide opportunities for action based on multi stranded quality data
The work has its genesis in the David-Colin-Thome report into Mid Staffs where the need for a single place for patient feedback, clinical feedback and incidents with real time reporting was highlighted as a requirement to prevent recurrence of the issues. There was a clear need to encourage a culture of openness and transparency the staff engagement element of the project was to ensure that practice managers, GPs and others were comfortable sharing incidents, clinical feedback and patient experience feedback. There was a history of practices being very reluctant to share incidents and feedback from patients and this initiative had a clear objective to encourage the entry and sharing of data. The project was extended to include clinical feedback and safety information this creating a safety system this was to ensure that all data could aggregated and themes via standardised data set. The data aggregation was set up in such a way to allow data to be aggregated at a provider level across multiple locations and organisations/CCGs to ensure that a true picture of provider performance could be seen.

Outcomes – The Insight model has been transformed into a quality system by entering clinical feedback from GPs and by reporting incidents in primary care settings. All data comes together and is reported in real time to identify themes and trends across the quality spectrum. This holistic approach has been pioneered by Stoke on Trent CCG and has been rolled out to all 54 GP practices. Work is now underway to rollout to the GP practices in Telford and Wrekin and Shropshire with the other 6 CCGs to follow, this will see 260 practices using the system to improve services for patients and the public.

As a result of the system we have been able to respond to patient experience feedback real time with monitoring visits to our provider wards, we have been able to identify key themes and trends from multiple sources and have put actions in place to resolve. It has changed the organisational culture as staff now appreciate they are part of feeding in formation that aces up a big picture that one group or location can create without collaboration. Patients are now at the heart of what we do as they drive the requirements for change supported by the evidence form clinical feedback and incidents. The clinical and patient feedback has highlighted issue with our community nursing team and has directly led to a clinical review of services. Work has also been undertaken to resolve issues with cancer referrals and delays to the confirmation of appointments

The communications and engagement team at SLCSU has worked with our emergent CCGs and we have developed a systematic approach to public and patient involvement that has its roots in systemic review of cause and effect. This approach is achieved by using an Insight database which collates, aggregates, analyses and reports quality data in real time to CCG staff based on their commissioning portfolio.

Over 9000 records entered to the system, 2000 small changes in practices, 3 major service reviews

400 incidents at primary care

50 changes in practice, 150 in progress and review 100 with no changes required and 100 currently in review

Changes to clinical practice for surgery

Procedures put in place to identify fax errors

Procedures reiterated about shredding confidential information

Changes to clinical practice and follow up on surgical procedures

Issues raised at CQRM about 111 service

Sub group established to discuss prescription issues Changes in practice for clinical staff. More open culture for the implementation of learning.

Out of Hours Prescription payment Kiosks for NHS Trusts

pe1The demand for prescriptions in the UK is ever rising, with more than 1 billion items dispensed in 2013 alone; that’s 1,900 every minute according to a report by the Health and Social Care Information Centre (HSCIC). With demand so high, the NHS has the arduous task of fulfilling this huge supply, and one area they have been unable to deliver prescriptions effectively is outside of the hospital pharmacy’s opening hours.

To combat this problem, Cammax Limited has developed a prescription payment kiosk specifically tailored to meet the needs of the NHS, allowing patients to pay for their prescriptions during out of hours. Not only are the kiosks equipped to accept cash, but they also process debit and credit card payments, a service the NHS has found difficult to provide up until now. The change carrying capacity of the kiosks is very large to fulfil even the busiest of periods to prevent a patient being short-changed.

Previously, A&E departments have issued prescriptions free of charge due to the lack of a payment facility in place, but the new kiosks are enabling thousands of pounds in lost revenue to be captured, providing invaluable incremental income. Not only do the kiosks accept prescription payments, they have been adapted to incorporate payments for a wider range of hospital services such as maternity scans, crutches and walking aids.

The simple to use, self-serve machines operate 24 hours a day providing patients with a quick and convenient way to access their prescriptions. After payment is taken, the machine then issues a receipt that the patient can take to the pharmacy to collect their prescription. The kiosks eliminate the need for staff to take payments therefore freeing up their valuable time to issue medications for example, leading to reduced waiting times. Automated cash handling also provides a safer working environment, due to security risks associated with this.

The Cammax prescription payment kiosks are currently deployed in A&E hospitals throughout the UK. Even low volume kiosks processing 25 transactions per day are generating almost £75,000 in revenue. This capturing of lost revenue enables the kiosks to be purchased by hospitals at very low risk due to the high returns seen almost instantly.

Hywel Dda Shows the Way!

cs_hywelHywel Dda Local Health Board provides healthcare services to a total population of around 372,320 throughout Carmarthenshire, Ceredigion and Pembrokeshire in west Wales. It provides acute, primary, community, mental health and learning disabilities services via general and community hospitals, health centres, GPs, dentists, pharmacists and optometrists and other sites. It employs around 9,000 staff.

Coming into a hospital can be confusing, even more so when you cannot read. On top of this, we knew people were confused with existing signage or were not even bothering to look at signs. Furthermore, there was too much literature and ‘signage clutter’ on the walls that hampered people trying to find their way. We realised how much we take for granted, both when we know our way around somewhere and also our reliance on the written word – how much more difficult was this for people who cannot read?

What did we do?
We held 3 focus groups to start the conversation and develop the concept of using symbols. This generated suggestions including colour zoning the hospital to maximise orientation, positioning signs and use of terminology. We sought specialist advice from the RNIB. We had continued invaluable engagement with users and staff to test, refine, evaluate and agree a final library of symbols. We successfully created a used truly multilingual system (Welsh and English).

Live practical exercises were run with learning disability users and members of the public to test the new symbols followed by a more detailed audit. Symbols were modified as a result and additional ideas have been captured for future improvement.

What impact did it make?
The new way finding and signage system has now been installed at Withybush Hospital and rolled out to Bronglais Hospital. We invited all user groups to return and evaluate the system using an audit tool developed by the learning disability users. We had an external visit to who we gave mock up appointment letters for them to find their way!

cs_hywel1Formal evaluation together with a recent Community Health Council patient environment audit has demonstrated improved accessibility and user satisfaction. Users with poor literacy skills are able to easily use the symbols and successfully way find to departments. We engaged wider public through the local Citizen’s Panels with positive results.

We hope this approach will be replicated across NHS Wales, and indeed further afield. How wonderful would it be if all service users could be certain that wherever they went in the NHS they could find their way by relying on a consistent use of symbols as well as colour zoning? We held a webex to share the learning across NHS Wales and have received requests for information from across Wales, England and as far away as Australia and New Zealand!

This initiative is special because it shows exactly what you can achieve when you work alongside the very people who will benefit from it. If you could see what this means for all the people involved you would be able to feel how important this has been to
them. Watch

A service user noted at the launch “If someone couldn’t understand the picture and writing then the colours would make sure they were in the right area of the hospital”.

cs_hywel2Key Learning Points

  • Always remember you don’t know best! Involve the people who need to use the signs from the very beginning, it is not difficult but be open to challenge. It has not meant things take a lot longer and has provided a much more effective solution to an identified problem for patients.
  • Think about how much symbols are used in the rest of our lives – from park and rides to toilets, why don’t we use them in our hospitals where people are at their most vulnerable?
  • This approach can be effectively adopted across a myriad of problems to find innovative solutions. Accessible communication is essential, it improves the patient experience and does not require many resources to resolve.
  • Above all, enjoy the process and feel a real sense of achievement when you see the new signs up on the wall and the colour zones coming to life.