Medicines are overused – what can we do? (part 1 of 2)

April 10, 2017 By Steve Turner

In this blog Steve Turner, Head of Medicines & Prescribing @MedicineGov, reflects on ways to reduce unnecessary use of medicines. Bringing together the need for more patient education with ways to negotiate the many rules and guidelines which can overwhelm us all.

My experiences and learning

I was speaking about the use of medicines at a conference recently when I mentioned that medicines are ‘over prescribed’. Although nobody questioned and challenged me on this I was troubled by my use of this expression. By saying medicines are prescribed too frequently it seems to me this can be interpreted as a bad reflection on the prescribers.

As I mentally mulled this over (I’m not a quick thinker) I came to the conclusion that the expression should be ‘medicines are overused’. After all it’s us (the patients) who go to our Doctors, Pharmacists and Nurses and us who accept their prescriptions. Therefore if we agree that people can rely too heavily on medicines, and there’s wealth of evidence for this, then we need to sort this out together.

My social enterprise company’s Patent Led Clinical Education work has shown us that a large section of the population is prescribed multiple medicines, with potential for interactions and increased side-effects. In addition it’s widely accepted that 50% of the population don’t take their medicines as prescribed. Add to this the sometimes forgotten fact that many people use alternatives (including street drugs), buy medicines over the internet and even borrow medicines from other people. It’s no wonder we have a problem.

The human and financial costs of over use of medicines are immense. In our education sessions we have learned that many people don’t know what their individual medicines are for, and medicines prescribed purely to counteract the side-effect of another medicine can pile up.

In fact so far nobody who has attended one of our sessions (n=140) expressed a wish to take more medicines, and those who did express a view all said that they didn’t want to take medicines if they didn’t have to.

So what can we do together?

The next section looks at how to make sense of the vast amount of guidance available and describes why ‘trusted information’ is important in making decisions about medicines, including on when not to take them.

Overwhelmed by the information, policies & guidance?

There’s an overwhelming amount of information and guidance on medicines, coming out on a daily basis. Even clinicians struggle to keep up and need help.

Two things are important in trying to make sense of this information overload.

Making sure that the information you are looking at is from a ‘trusted’ source
The need to differentiate between different sources of information e.g. primary research, systematic reviews, evidence summaries and media reports.
Relating information on the use of a single drug or treatment to the real world.

The first two points will be covered in future blogs. Here and in the second blog, I’m concentrating on guidelines and their use.

The National Centre for Heath and Care Education [NICE] in England produces guidance, standards, indicators and evidence services covering health and social care. It’s not just about medicines. There’s a massive amount of trusted information on their web site, which covers:

Conditions and diseases
Health protection
Lifestyle and wellbeing
Population groups
Service delivery, organisation and staffing

To get a feel for this one place to start is the NICE Pathways, where you can browse the topics, pick one and have the information presented in a diagram, where you can click on the headings for more information.

Recently there has been a move away from producing guidelines on a single illness or condition to a more holistic person based approach. This better reflects the complexities of real life, where it would often be a luxury to have just one illness with no complicating factors. NICE guidance on medicines optimisation, multi-morbidity clinical assessment and management, and patient experience in adult NHS services are good examples.

In addition NICE produces a document on Key Therapeutic Topics as part of the NICE Medicines and Prescribing Programme. This is a 128 page document covering 11 topics in all and is reviewed and refreshed annually.

Click here for part two

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov and NICE Medicines and Prescribing Programme Associate

You can follow Steve’s tweets @MedicineGovSte hashtag #MedLearn

Or email steve@carerightnow.co.uk

Version 2

Last updated: 8/12/2017

Changing mindsets and delivering safe care in Cornwall together. #devocornwall

March 20, 2017 By Steve Turner

We want the best health care system in the world, & the most efficient and effective system …

We have an opportunity to do things differently in Cornwall

How do we achieve this?

The challenges in Cornwall

There’s a huge amount going on with health and social care in Cornwall. Including the Sustainability and Transformation Plan [STP]; exposure of abuse and neglect in care homes; concerns over hospital closures, delayed discharges taking up hospital beds, and devolution of services on the way.

Although I have worked in health and care for over 30 years, I struggle to keep up with the issues and understand how services are organised. This isn’t helped by the current polarisation of views.

On the one hand we have a big dose of NHS and Council ‘spin’, excessive bureaucracy and even bullying. On the other hand we have public concern, often expressed around specific issues, and sometimes based on unfounded rumours.

Neither of these positions are helpful, and neither represent the vast majority of people (public, staff and patients) who just want good services delivered by kind people who are open, accountable and transparent.

#devocornwall

We have a great opportunity now with the devolution of health and care services. This will be realised if we all build bridges, and transcend the usual hierarchical boundaries. We all need to listen and learn. Everyone, to coin an overused phrase, needs to step out of their comfort zones.

Why we need to think differently?

Several community hospitals are under threat of closure, leading to anger and dominating the headlines. Less attention is given to identifying and measuring the benefits, and any disadvantages of community hospitals. For example, can they be staffed adequately, bearing in mind this means Doctors, Nurses, Physiotherapists, Radiographers, Dieticians, Speech and Language Therapists, Social Workers etc.? Is home care a viable option for patients and carers? Are there any creative options such as bringing back the old style ‘convalescence’? Is rural isolation and lack of public transport the major issue?

It’s becoming increasingly difficult to book a timely GP consultation. This has led to several inaccurate scare stories in the press about ‘cuts’ to face to face GP contacts. This needs deep thought as there are times when easy access to a GP on the ‘phone, or on-line, may actually be a better option. Access to health information from Community Pharmacies or in NHS run clinics in shopping centres, or better health information and advice available locally, may be more effective approach. Leaving GPs free to spend more time with those who need their help and expertise most.

It’s now widely accepted that the NHS and Social Care is underfunded. Despite this there is still a great deal of duplication and waste in the system. How many times have you been asked to repeat information to Health Professionals which others already have? Do some services overlap, and are there gaps? Do different organisations link seamlessly with other organisations? Are all services accessible to all? Many people have important stories to tell on these areas of inefficiency.

Now’s the time to talk about this, find out what’s planned, and take action together. ‘Patient engagement’ key component of the STP and #devcornwall.

Patients and public need to take the lead on this. It’s not the NHS or Cornwall Council’s plan it’s ours.

Personal views of Steve Turner. MD Care Right Now CIC, a Cornish Company

Version 2

Date: 30/03/2017

This article is adapted from a letter which fist appeared in the St Austell Voice

‘Care means care, Justice in care’ – Guest blog from Mr John Barrass

February 1, 2016 By Steve Turner

Mr John Barrass never imagined he would become a campaigner until his mother became ill. Read his story, featured here in full.

‘CARE MEANS CARE , JUSTICE IN CARE .’

‘THE NURSING HOME SECTOR is in crisis it has been in crisis for the last 20 years.

No rights , No justice , for any of the frail , vulnerable, elderly, it needs a massive political debate of all colours to change it !.

Please have patience to read this DOCUMENT to the end.

Thank you.

John Malcolm Barrass.

29 th October 2015.

THIS DOCUMENT ‘ CARE MEANS CARE ‘ , ‘ JUSTICE IN CARE ‘ .

THIS INVESTIGATION AND THESE RECOMMENDATIONS OF MINE WOULD SEE THE BIGGEST CHANGES AND REFORM SINCE JOHN MAJOR CLOSED LONG TERM WARDS DOWN BACK IN 1989, 26 YEARS AGO !!

WILL YOU READ A HARD STORY TO TELL AN INNOCENT PRISONER , AND THE INVESTIGATION ,WITH RECOMMENDATIONS.
THANK YOU
JOHN MALCOLM BARRASS 4 TH APRIL 2015 .

In this country , if you are old , frail , you are not only vulnerable , you are bottom of the pile , end of your life , so what ,it doesn’t matter.
We have had 20 years or more of appalling care to prove this, had documentaries made , appalling stories told !
Nothing has been done about this.

THE FACTS

Figures from age UK 2012- 13 approx. 50,000 of the vulnerable elderly suffering mistreatment , abuse , neglect ,in nursing homes .

Radio 5 live 22nd Feb 2015, thousands of safeguarding complaints ,elderly , vulnerable ,2013-14, 1 in 5 homes failing key tests .

In the last 5 years 400 small nursing homes closing down, putting the frail elderly vulnerable in larger homes , without enough staff and qualified staff to deal with them , southern cross and many others that charities know about, prove this.

In the next 15 years there are going to be twice the amount of 85 year olds , and 3 times the 65 year olds picking up there pensions.

The system is in CRISIS now .

CQC Chief Inspector Andrea Sutcliffe told BBC Breakfast TV in Oct 2014 ” the standard of care homes in England is not good enough at the moment “.

CQC Chairman David Prior said at the start of the CQC annual accountability at the healthcare select meeting on 16 th Dec 2014 , the CQC are still not fit for purpose “we have not got where we want to be. “

The Parliamentary Healthcare Ombudsman , Dame Julie Mellor has been forced into raising the investigation figures using only the same staff by spending less time than before accessing the cases and more time investigating the cases , still spending less time than before, pushing the investigating figures up from 400 to 2000 .

When you are spending less time doing both what happens to the serious cases as before as my mother’s , and cases like the Titcombe babies case , and the Sam Morrish boy’s case down here in Devon.

But what purpose are the Ombudsman there for they are not there to investigate nursing homes , they are there to investigate government depts. and the NHS hospitals.

The total cost to the taxpayer together is in excess of £400 million .

What are they getting for there money , an antiquated system , falling apart at the seams.

There are many many other revelations I could go on and on about .

That is why charities like the patients association , and many more are inundated with complaints that the Ombudsman are not looking into there cases properly .

Mr Barrass asks “when will this appalling treatment under the name CARE for the vulnerable ,elderly,frail ,in nursing homes in this country end ” .

The answer he believes after investigating the system for 5 years is in this document below. On the 26th May 2005 my mother suffered in the medical terms a dense right sided hemiparesis total anterior circulation, stroke left her aphasic , with a dense right hemiplegia.

A serious stroke needing 24 nursing care , having multiple health problems and multiple health needs.

This is what care she received and how she had to die.

AN INNOCENT PRISONER.
THIS IS A HARD STORY TO TELL.
Imagine what it must be like to be paralysed on one side ,unable to talk or call out for help ,press a buzzer, eat or drink, unable to walk , then imagine being fed and watered via a tube, the only quality of life you have is to see and hear people.
You are told you need a stimulating environment and responsive therapy.
Instead you are placed in a nursing home which is unsuitable for your needs.

Denied a correct chair for your quality of life, you cannot get out of your room for 4 months, then given a standard transit wheelchair deemed to be unsafe, under the health and safety factor ( had to support mums head once for 2 hrs with my own hand whilst wheeling her around in this chair ) , had to use this chair for 8 months, then when given the correct chair, but not enough staff to get out you out of your room on a regular basis.

Imagine being left in a soiled bed for 1 to 3 hrs,(one time left for 1 hr 20 mins the staff preferred to have there tea break first) However your mouth is not swabbed regularly so you develop crusty lumps around your teeth and on your tongue , nearly die in the first month of care , due to a chest infection not dealt with properly and promptly, blood tests not done on time, and then develop the worst case of constipation a hospital Dr has seen in 9 years, because you were not given the correct bowel medication, care home Dr say your family are fixated on this.

ALL THIS HAPPENED IN A NORTH DEVON NURSING HOME ,DEEMED TO BE ONE OF THE BEST IN DEVON.
WHAT MUST ALL THE OTHERS BE LIKE?
ARE YOU SHOCKED AND APPALLED.

On 23 rd October during the early hours of the morning , my mum died in a North Devon Hospital.
The last 6 days of her life saw her experience great suffering beyond anything she had already endured in the 4 years leading up to this time and place

THESE ARE MY MUMS FINAL 6 DAYS.
Her feed tube needed changing ,could and should have been changed one month earlier. Due to this, complications set in .
( which involved a drug , flu vaccination, super public catheter ) .
Mum’s last 6 days not checked by a Doctor , no management on at the weekend, allowed to have a feed tube change on Monday, when clearly condition at weekend needed looking into.
After being administered a Flu Jab one afternoon by the evening she had mucus / saliva running from the corner of her mouth like a water tap switched on, this continued for 4 days, then subsided for 6 days.

Day one Saturday. However when swabbing mums mouth I noticed a massive / piece and amount of mucus / saliva heavy phlegm . Staff told us it was only phlegm and did not call a Doctor.

Day two Sunday. Mum has vomited brown liquid, staff said it looks like dried blood, they did not call a Doctor , nor the home management.

Day three Monday. Mum went into hospital to have her feed tube changed (endoscopy) . When she arrived back at the home, her tongue and lip were swollen followed later by difficulties with congestion (upper throat and chest) , still no Doctor called. A temperamental red suction machine has been left in mums room.

Day four Tuesday. Mum still has congestive problems with a swollen tongue and lip with bruising under her chin again no Doctor called. Arranged to see the nursing home Doctor tomorrow, on his regular Wednesday visit.

Day five Wednesday. I discovered mum had a tooth missing , which no one recorded or explained to us how where and when it happened , yet two nurses told us they noticed it missing? , I noticed a hospital suction machine left in mum’s room (serious issues arise from this discovery ) the nursing home Doctor who we asked to see the day before had disappeared before we got there? , told by staff he had ordered antibiotics for mum.
After this the emergency Doctor was called who immediately rang for an ambulance and oxygen for mum.
Mum arrived at the hospital 4 blood tests were taken.
One arrived within 30 mins , found she had a major infection, put her on antibiotics , she was transferred to the medical assessment unit, her breathing has eased a little.

Day six Thursday. I arrive to see mum it feels if she has been given up on, I am told she is very poorly. She has been taken off the antibiotics and saline drip . Her breathing and congestion has got worse. Why has she been left to die like this just 3 days after all she went through?
It is a shock and more than I can bear.

QUESTIONS ARE RISING FROM ALL OF MUM’S CARE AND LAST 6 DAYS!

1. The parliamentary ombudsman would not investigate this only access!
2.We have 20 questions and issues unanswered by the p ombudsman!
3.Find they had 9 limited powers to investigate!
4.The legality side, costs outweigh compensation for the elderly.
5.After 5 years investigating this , nowhere to go to get this looked into properly or fairly!
6.This raises serious questions for everyone!
7.If they cant look into mum’s case properly or fairly !
8.They cant look into anyone else’s properly or fairly!
9.How can this be right!

WHAT WE WANT ANSWERS TO ARE :-
Why did my mother go to have a feed tube change to keep her alive , to die 3days after!
Why was my mother put through all of this !
For what reason!
I simply ask the question WHY.

QUESTIONS I ASK DURING MY MOTHERS TREATMENT,AND MY 5 YEAR INVESTIGATING THE SYSTEM IN GREAT DETAIL ARE :-
1.Are the parliamentary Ombudsman fit for purpose to look into private nursing homes?
2.Are the CQC fit for purpose when they still do not look into individual cases in nursing homes?
3.Have nursing homes got enough staff and quality staff to take care of vulnerable patients who need 24 hour care?
4.Should patients like my mother ever have been put into these homes ?
5.Should there be special NHS units for 24 hour care patients with multiple health needs like my mums ?
6.What rights have the old , frail, and vulnerable got in private nursing homes?
7.Continuing health care funding for the very vulnerable paid by the tax payer to private nursing homes, yet have loopholes in the system not to be investigated thoroughly ?
8.Care means Care whether it is Private or NHS, when anything serious happens in nursing homes, and it involves the hospital NHS, both sides will not comment what the other side have done , yet are both caring for a patient, so the patient gets caught in the middle of all of this not getting clear answers to what has happened to them?
9.Equipment ie specialist equipment , profiling beds etc, no law to make the nursing homes provide , the CCG were set up to deal with this, but still problems with no law to provide?
10.Because of the system as it is ,when anyone finds anything out no one will talk after fear of legal action, there has to be a new system free from legal interference?
11.Because of continuing health care paid for 24 hr vulnerable patients, paid by the taxpayer, it is the Government NHS responsibility not the legal responsibility to investigate accountability and answers for the families of love ones who have been affected ?

MY RECOMMENDATIONS!

1.A big political debate about all my investigation raises!
2. The PASC should hold meetings only about the nursing home sector and nothing else ,so they know more and can scrutinise more!
3.The CQC and the parliamentary Ombudsman are not fit for purpose anymore to inspect , regulate , and investigate nursing homes and a new one body only needs to be set up , with more powers to regulate , inspect ,investigate nursing homes doing the job together, to investigate all individual cases , to get accountability , free from legal interference .
4.Because the system as it stands at the moment , no one will ever get justice.

No one under the word ‘Care’ should ever have to go through this .

Don’t let this happen to anyone’s mother again.

When independent consultant nurse Lynne Phair said in the Panorama Documentary ‘Behind closed doors ‘ on 30th April 2014 ” To pull out a vulnerable patients buzzer is to cut there lifeline , and to imprison them “.
That must be what happened to my mum , she was imprisoned for a crime she did not commit.
I believe these deplorable events must be brought to the public’s attention to prevent similar things happening again, after all , anyone of us who cannot talk , shout out for help without enough staff and quality staff to look after us must be in prison too.

Thanking you all for taking the time to read this,It is desperately important this gets out to the public.
Anything you can do to help will be appreciated .
Yours Sincerely
John Malcolm Barrass.
Thursday 26 th March 2015. ‘

Click here for a one page commentary by Steve Turner

Turn Up The Volume! Listening for safer care – graffiti walls

November 3, 2015 By Steve Turner

On 16th October we held a unique learning event, bringing together whistelblowers and health leaders from all quarters (staff, public, patients, carers, relatives) to speak out for safer care.

We collected (and continue to collect) a large amount or information, in the speaker videos , graffiti walls, question and answer sessions, feedback forms, emails, twitter (under #turnupbristol).

To help keep the conversation going here are the graffiti walls:

CLICK ON THE IMAGES TO ENLARGE THEM

CONCERNS:

POSITIVE THINGS:

PLEDGES:

OUTSTANDING QUESTIONS:

MOST IMPORTANT THING I LEARNED TODAY:

I NEED TO LEARN MORE ABOUT:

(Nothing put on this wall)

CLICK HERE FOR THE EVENT VIDEO SUMMARY (less than 3 minutes)

CLICK HERE FOR THE RESOURCE PAGE

Page updated: 11/3/15

The best for Mum, Dad and for me in our old age – Time for a revolution in Social care (updated)

February 24, 2015 By Steve Turner

Care of older people in comparison to other services:

My experience of care homes, and domiciliary services is probably very similar to many other people with elderly relatives. I’ve seen the best and the worst of care.

Experiencing the best is heartwarming and gives you faith in human nature, experiencing poor care makes me very sad, especially because I am convinced that the way we treat older people would never be tolerated if they were children or people who are dying with a terminal illness. It’s if it were happening in a different world.

I’m not trying to single out individuals here or even specific homes or organisations. We all need to consider how we value older people; why we have different standards for different illnesses and why we seem to consider care of the elderly as something which does not require much skill.

I work with many staff groups across many organisations and I take my hat off to to those who work in elderly care settings. They do a job I could not do day in and day out, often in difficult circumstances where organisations overlap in the care and treatment of individuals, and vital information frequently gets lost in the gaping cracks between services.

I don’t believe my Dad’s story is unusual:

Dad’s story:

My Dad (who lived in the Midlands) became increasingly confused and immobile in August 2011 and eventually was admitted to hospital. Following this, in the last 6 months of his life, he was in hospital twice and in three nursing homes, two of which were really poor and one of which was good. Fortunately, the home he died in was a kind and welcoming place. But I still feel guilty about the other two, and especially as I am a health care professional. Why I didn’t see they were not the right place for him from the outset?

And why did I find it so hard for my concerns to be listened to? (This will be the subject of a future blog).

In the first home he entered a whistleblower alerted the Care Quality Commission [CQC] to a shortage of night staff and resident’s bells not being answered. So Dad’s complaints that they ‘tortured’ him at night and never came to him, which led us to remove him, were for a good reason. The second nursing home looked tidy and clean. In reality it was a dismal institution which was run like a factory and, despite having some lovely staff, was generally unwelcoming. The third and final home looked a bit rough around the edges but was friendly, caring and welcoming.

Interestingly the two homes where he suffered were rated as good by the Care Quality Commission, the home he ended up in, which the family were very happy with, was rated as poor both before and after his stay.

So what can be done to end this suffering?

The first version of this blog contained a number of recommendations. On reflection I don’t believe that the current system (if you can call it a ‘system’) can be made better, we need to look at the situation in a completely new way.

Ways to make the transition include:

Stop measuring the providers input and measure the outcomes and quality of life for those cared for. Regulators currently look at ‘surrogate markers’ rather than asking those who receive the care, and their relatives / carers.
Involve patients and the public directly in inspecting services and care homes.
Make sure that we identify all existing good practice and take a strengths based approach to change.

Author: Steve Turner

Date: 26/2/15. Updated 1/6/2016