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

Children’s medicines – how listening to parents led to safer care

August 22, 2015 By Steve Turner

Case Study:

Background:
From 2008 to 2014 my company ran education sessions on managing medicines in a mental health trust. In common with some other mental health trusts the provider also looked after paediatric community services. This is not a mental health service. It covers children with complex health needs including enteral feeding tubes, ventilation; epilepsy and rapidly changing medicines. Children under the care of this service may be taking in excess of 15 different medicines per day, have complex titration regimes, emergency drugs with associated care plans, plus numerous ‘as required’ (prn) medicines.
It is not unusual for children with complex conditions to be under the care of up to five different providers, and to move between three different providers in one day. For example, from a Home Care Service to the Special School, to a Short Break House, maybe also being seen in an Outpatient Clinic on the same day too. As a result parents frequently have to repeat the information on their child’s medicines every time they move to another service, or a new person is involved.

Where to start?
The idea for change came about because of concerns that the staff in Children’s Short Break Houses were not learning what they needed about children’s medicines, as the learning was geared to the majority of staff who worked in mental health. So a new learning package for children’s staff was commissioned.
Part of the work to design the learning package included a baseline assessment which was conducted with parents and staff. This soon revealed that training alone was not the answer. It showed delays in medicines information reaching GPs, workarounds for obtaining information in order to administer medicines in the houses and a general lack of confidence in the whole process.
As a result we looked at the whole system starting with the area where most concerns had been raised, which was having an up to date complete list of a child’s medicines available at all times (medicines reconciliation). The system in place for Short Break Houses involved paying a local GP (not usually from the child’s GP Practice) to write up a medicines chart for each child. The process was fraught with difficulties and delays and widely disliked by everyone directly involved.
So we set about looking for a new way to manage the lists of medicines with more training and more input for the staff in the services involved. We came up with a new (and much more robust) process for medicines reconciliation in the Short Break Houses. This was fully documented in a new policy, and involved cross checking by both the staff and the parents.
Just before this went live, we asked the parents to review and comment on it and they said
‘If you’re producing an accurate and up-to-date list of my child’s medicines, why keep it the Short Break House, can’t it go with my child?’
So the My Medicines chart, which travels with the child, was born.

What was involved?
The My Medicines process led to the design and production of a new chart which has to be signed and checked by the parents.
It resulted in 40 children with complex conditions being offered a hand held paper record of their medicines (produced and validated by clinicians), which they take around with them wherever they go.

Benefits:
The new process, which continues to evolve, means that the child’s GP is now directly involved in day to day medicines reconciliation (they weren’t before); the parents are always asked to check and sign the charts (they weren’t before); verbal messages about medicines are never taken, and incomplete (or missing) directions are rapidly rectified (never worked around).
Some specific benefits of the new process include:
• It has reduced the risks of error, by providing full and accurate information on children’s medicine across their entire pathway.
• It cuts out the need for parents to keep having to repeat what medicines their child is taking to different professionals and care agencies.
• It frees up medical and clinical time which was previously spent chasing missing information.
• It has reduced the number of third part handovers and transcribing of prescription information.
Looking back it’s hard to believe that the old ways of working, which caused so many difficulties (especially for front line staff), were carried out for so long. These risky practices, or similar, are believed to still be commonplace in England.

Revealing hidden incidents and near misses:

In the first month of the project we raised 17 medicines or near misses. Of these 11 related to problems with communication of information across the child’s pathway.
Resolving these has resulted in improved communication and engagement between different clinical groups and providers, and a desire from all quarters to take the project further. Previously many of these incidents were not logged or tracked across organisations. In some cases it was only due to the vigilance of the staff and parents that they were spotted and errors avoided.

Accepting the changes:

The project was well received by parents and staff, and resulted in improved communication and engagement between different clinical groups and providers. This included the Consultant Paediatricians (working for the secondary care provider), who were initially sceptical.
The project was less well received by the relevant medicines and prescribing committees, who were understandably concerned about who owned the My Medicines chart and had agreed its content. Explaining this was made more difficult because it is hard to get across the complexity of the arrangements, due to the critical nature of the children’s illnesses, in a committee setting.
I make no apologies for ensuring from the outset that it was the parents who owned the charts, which were designed by the project team (not a committee) to meet all best practice standards. It always worries me that when it comes to cross- organisational working the formal committees and systems in place can inadvertently act as a barrier to safety rather than promoting it. There is no doubt we had designed a safer process and my company was happy to take accountability for any associated risks.
As a legacy of the project, a Community Paediatric Pharmacist was appointed specifically to work with this group of children. So whatever evolves will now be based on inter-disciplinary thinking and working and will have clear safety parameters. I am grateful to the enlightened thinking of the leaders who commissioned this work and supported this novel approach.

Steve Turner

Managing Director Care Right Now (CIC)

This example is incuded in the NICE Shared Learning resource and was highly commended in 2015.

Click here for the poster.

Last updated: 15.08.2019

For more information contact: info@carerightnow.co.uk

Medicines Optimisation – what does this mean?? Jargon Buster

August 5, 2014 By Steve Turner

These accounts are all fictitious but based on real events:

Ben’s holiday – (finding out what a medicine does by accident) :

Ben is a 16 year old boy who has been prescribed a drug for a behavioural condition, it’s a powerful drug (called an antipsychotic) which he has taken for over a year. His parents think it helps, Ben hasn’t said what he really thinks, but accepts the tablet.

A few years ago the family went on holiday to Bulgaria. During the holiday the volcano with the unpronounceable name in Iceland erupted. The family were stuck in Bulgaria waiting for the ash cloud to blow over. They ran out of Ben’s medicine and were unable to obtain any or anything similar. As a result, out of desperation, they gave Ben a saccharin tablet instead, and hoped for the best. He was fine. Over the next few weeks they even noticed an improvement in his mood and behaviour. He seemed to be enjoying life more. When the family returned to the UK they stopped giving him the ‘placebo’ tablets, and he has not needed to take medicines since.

Ian’s secret: (in jargon this is ‘intentional non-adherence’)

Ian is a 35 year old man diagnosed with bipolar disorder. When Ian moved to another part of the country he was allocated a new community psychiatric nurse [CPN] and, as he was unwell at the time, was re-started on medication. Over the next 18 months Ian’s condition improved so his CPN reported a ‘good response to the medication’. It was only after 2 years of knowing him that Ian confided in his CPN that he didn’t take the medication consistently, and never had.

The medicine was lithium, which requires regular blood tests. This is because too much of it is toxic and too little has no effect. Ian revealed that he had only taken it before his blood test days, then always stopped taking it in between.

Ian’s medical notes had stated that he always ‘responded well to lithium’! As a result of Ian being able to trust his CPN, and let on that he wasn’t taking it, his medical records were corrected to say that he did not want to be prescribed lithium, confirming that other options worked much better. These options include some medicines which he had previously ‘borrowed’ from someone else, or bought on the internet. Of course he didn’t tell medical staff about this at the time.

So his choice is now clearly written up, should he become unwell again.

…and now the ‘science bit’. If you want them I can provide references for medicines geeks like me! steve@carerightnow.co.uk

Medicines Optimisation is a powerful term because it brings in the:

Patient’s views and their decision

Clinical people may think they ‘know best’, but in the end it is the patients (you and I) who will decide whether or not we take the medicine, and we will not always tell the doctor or nurse if we don’t feel we can trust them. Statistically around 50% of people, (all ages all type of people), don’t take their medicines as prescribed.

The ‘human factors’ and health beliefs related to having to take medicines

Medicines aren’t always the answer. We may have strong beliefs in favour or against them; these beliefs are hard to change and need to be respected. Basically we usually know what’s right for us.

The ‘evidence base’, which means is it known to work?

People who prescribe medicines (usually doctors or nurses who have the qualification) need to offer the medicines which are proven to be most effective. And there is often a choice.

Repeatedly studies have shown that clinicians have a list of medicines they prescribe for various illnesses in their minds, and this list may bear little or no relation to the evidence available on what works best.

Medicines optimisation is not simply another term for ‘medicines management’, which is generally used to refer to the mechanics of the medicines process. This leads us to consider not just the process of selecting, prescribing; ordering; supplying; administering and monitoring, but also whether the person has enough knowledge to decide to take a medicine, actually takes the medicine and indeed whether the medicine is needed in the first place.

Sometimes people need multiple medicines (referred to as polypharmacy) because of the complexity of their illnesses, but this can be inappropriate if, for example, a medicine is simply added to counteract the side-effect of another medicine.

Author: Steve Turner Head of Medicines & Prescribing @MedicineGov & an Associate Lecturer at Plymouth University.

Click here for Steve’s digital profile

Updated: 28.01.0221