The theme of the GHP/UKCPA 9th Joint National Conference in May this year was ‘enhancing the patient experience’
Sarah Carter PhD
UKCPA General Secretary
It would come as a surprise to no one to learn that the Francis Report (relating to the care provided by Mid Staffordshire NHS Foundation Trust) was discussed in many presentations. In his keynote address, Mr Richard Cattell (Director of Operations at Dudley Group NHS Foundation Trust) urged the audience to read the Francis Report, and in particular the patient experience section. Patients are getting better at telling us what they want and how they want it. Are pharmacists ready for this?
Different generations are now coming through the NHS system as both staff and patients. They expect different things, tolerate technology differently, and vary in their risk-taking behaviours. Patients are greatly influenced by social and print media, so that news stories such as the Mid Staffordshire scandal can lead patients to believe that all hospitals are operating at sub-standard levels.
Pharmacists must listen to patients and must talk to patients. Organisations need to be open and honest when they receive complaints. But how can we do this when we still have fewer staff, lower qualified staff and fewer resources than ever? A lack of resources is a risk to patient safety and must be treated as such in the NHS system. We need to be patient-centred; the pressures will stay with us for a long time, so we need to face up to them.
Mr Cattell recommended a talk by Professor Michael West, an organisational psychologist from Lancaster University Management School, about how leaders can develop a culture of high-quality care and patient safety in their organisations. Professor West talks of inspirational vision, good people management, employee engagement and team working (http://goo.gl/I8kHa).
Mr Keith Ridge (Chief Pharmaceutical Officer, Department of Health) told the conference audience that, while pharmacy was not directly implicated in the terrible patient experiences at Mid Staffordshire, “pharmacy could, and should, have been influential”. Clinical pharmacy services were almost non-existent at the hospital.
Mr Ridge went on to describe some key areas of improvement for pharmacy: antimicrobial resistance, medicines waste, adherence and preventable hospital admissions.
“We need new antibiotics and we need to preserve what we have through stewardship”, said Mr Ridge. Global action is required to address antimicrobial resistance. It will be on the government’s risk agenda and will be discussed at the next G8 summit. A new UK antimicrobial strategy is coming soon in human and animal health, but we need global collaboration. The World Health Assembly will have it on their agenda, and there is a possibility of an international treaty.
He applauded the Royal Pharmaceutical Society’s four principles of medicines optimisation, and described a review of specialist pharmacy services that will fit into the context of medicines optimisation and make recommendations such as strengthening leadership governance, accountability and recognition as a national service delivered regionally and locally. He concluded his talk by urging the audience to “live the principles of medicines optimisation with your patients.”
Please treat me right
“Ask to see your hospital’s complaints from patients”, suggested Mr Tony West (Chief Pharmacist, Guy’s and St Thomas’ NHS Foundation Trust) in his keynote talk, “because we are in real danger of losing the trust of patients”.
Patients deserve access to best care and competent health professionals at the right level of practice. We need to take account of patients’ values and beliefs, their right to be informed, and their right to disagree.
In his personal stories of family members, Mr West outlined the challenges for the future in different generations: extreme old age, multiple long-term conditions, the treatment of more rare conditions, risky lifestyle factors and infectious diseases.
But the statement ‘please treat me right’ also applies to staff; we need to support poor performance in ourselves and others.
Delivery quality and optimisation
Mr Richard Seal (Chief Pharmacist and Clinical Lead for Medicines Optimisation, NHS Trust Development Authority) gave an informative talk about the NHS Trust Development Authority (TDA). He informed the conference delegates that the key functions of the TDA are to:
- manage the performance of Trusts that are not currently Foundation Trusts
- assure the quality, governance and risk management of NHS Trusts; and
- make appointments of chairs and non-executive members and trustees to NHS Trusts.
The TDA was set up to fill the gap left by the Strategic Health Authorities to support quality and assist Trusts in reaching Foundation status. The TDA aspires to deliver sustainable, high-quality services in every part of the NHS. Some Trusts are very close to achieving Foundation status and others need significant support or intervention.
The challenges for Chief Pharmacists include changes in delivery models, workforce/skill mix, professional isolation, lack of engagement and lack of innovation and resource. A key question to ask is “are you in the supply business, or in the business of delivering a service that improves patient care?”
Pfizer Patient Safety Award
Dr Adam Todd (Lecturer in Pharmacy Practice, Durham University) was the winner of the Pfizer Patient Safety Award 2013 for his work entitled ‘Prescribing of inappropriate medication in patients with limited life expectancy: a prospective study in a specialist palliative care unit.’
His award winning research investigated several life-limiting conditions (cancers, heart failure, COPD) and asked whether the medicines that patients were taking were appropriate, given their life expectancy.
He found that 15% of medicines were considered inappropriate and that over two-thirds of the patients studied were taking at least one inappropriate medicine. He also identified significant drug-drug interactions in these patients, where the risk of toxicity is high due to ever-changing liver function.
The ethical dilemma is whether to risk upsetting patients and their families by removing medicines that are unlikely to be of benefit during the patient’s short remaining lifetime.
Access to clinical trial data
Dr Carl Heneghan (Reader in Evidence-based Medicine, Director of the Centre of Evidence-Based Medicine, University of Oxford) spoke on systematic reviews and access to all clinical trial data. His interest in evidence-based medicine was first sparked when he realised that he had risked the lives of 20 patients by prescribing the anti-arthritis drug, Vioxx, which was withdrawn from the market in 2004 after disclosures that data on side effects were withheld.
He described the work recently conducted on the efficacy of Tamiflu. The predicted deaths from bird flu were hugely overestimated, said Dr Heneghan, and the media interest around swine flu was unbalanced, given that tuberculosis had caused many more deaths in the same period as swine flu. Governments around the world started to stockpile Tamiflu, but did we really know its efficacy and safety profile?
Articles in well-respected medical journals pronounced Tamiflu effective, but an international team of researchers questioned the accuracy of these claims. They found that the claims were based on very few published trials, and that much data from clinical trials of the drug were unpublished. The team went on to obtain the manufacturers’ clinical study reports that are submitted to regulators. Using these data, they found that there were serious adverse events associated with the drug, something, a fact that was omitted from the published literature.
They also questioned the efficacy of the drug. After analysing the raw data, the team concluded that “the effect was the same as Lemsip”, said Dr Heneghan. There was also no evidence that it would stop the spread of the virus, and that it may even interfere with the body’s natural ‘flu antibody production. The manufacturer has now agreed to release trial data on Tamiflu, eight years after GPs started prescribing it.
Dr Heneghan praised the UKCPA and GHP for supporting the AllTrials initiative, which campaigns for all clinical trials to be registered and all results to be reported. He urged the conference audience to sign the petition at www.alltrials.net.
Dr Heneghan advised the conference audience to make an effort to read the full details of published papers, and not just the conclusions.
The new safety landscape
Dr David Cousins (Associate Director, Safe Medication Practice and Medical Devices) gave a presentation entitled: ‘The new landscape for patient safety and medication safety: an update from NHS England). In this, Dr Cousins outlined the development of a safety ‘thermometer’ for medications, which can be used on wards to take a measure of ‘error free’ and ‘harm free’ care at any point in time.
Its measures will include the number of medicines a patient is taking, whether allergy status has been documented at the point of admission to hospital, whether the patient has had any omitted or delayed medicines in the last 24 hours, and whether the patient is taking any medicines that are at high risk of causing harm.
It is now in its seventh iteration and is being trialled in Manchester, and it is anticipated that the system will be launched by the end of 2013. If you are interested in piloting the thermometer, please contact Dr Cousins at [email protected]
Safety needles and splatter hazard
Mr Martin Roff (Health and Safety Executive, UK) gave a fascinating presentation on splatter hazard from syringe needle protectors (sponsored by Sanofi).
A variety of safety needles that have been designed to reduce the risk of puncture injuries are now available. These include models that have a retractable needle, or a needle sheath that requires bending the needle on a hard surface in order to place it in the safety cap. However, some of these designs cause splatter when activated, increasing the risk of transfer of micro-organisms and patient fluids onto work surfaces and the healthcare worker.
His research used fluorescent dyes to allow visualisation of the splatter patterns. His team found that, when trying to activate the safety needles, some splatter of the liquid in the syringe was left on the bench, sometimes on gloves, and occasionally at a distance of several inches from where the needle was activated.
There were also differences in how people activated the needle; some bent it so far that the needle broke. In one case, the needle tip broke off and was lodged in the user’s clothing, where it later fell out. It was also found that body fluids could be drawn back into the syringe, where it could then potentially be splattered onto the surface or beyond.
Mr Roff also warned that some viruses are resistant to cleaning and could potentially still be a risk for several days. He also warned that being vigilant about needle stick injury could distract from the risk of splatter on surfaces.
Research is core
Ms Beth Allen (Head of Research, Royal Pharmaceutical Society (RPS)) spoke to the delegates on developing the research pharmacist workforce for patient benefit and public health.
Ms Allen reminded the audience that research is ‘core’ business: it is in the NHS Constitution. “Promoting and participating in research is everyone’s responsibility”, she said. Unfortunately, we do not know how many pharmacists are involved in research, the evidence base for pharmacy is patchy, and the Research cluster of the Advanced to Consultant Level Framework is the weakest for pharmacy practitioners.
Barriers to research include time, funding, confidence, and the research culture.
In 2008, the RPS decided to focus its efforts in four key areas:
Undergraduate education: what do we really need students to know? We need to equip them with skills they need for practice, not just to pass the MPharm
- Infrastructure: We do not need to create new infrastructure but instead use and learn to navigate what is already out there, such as the NIHR Clinical Research Networks. Practitioners can get involved in existing research projects to build their track record, build relationships, take advantage of free training, and demonstrate their leadership and expertise
- Career pathways: There are currently no clinical academic career pathways in pharmacy. There is a lack of a clear route into academia and a shortage of posts. The nursing profession has developed pathways for academic careers and relevant funding streams are available
- Organisational and professional culture: The top Trust for research activity (Leeds Teaching Hospital) has developed and implemented a research strategy. We need organisational commitment and to put power into the individual’s hands. We need to create space and time for research and empower professionals to use patient data.
- The RPS has plans for addressing these areas:
- A Research Mentoring Programme exists in other health professions but not yet in pharmacy
- A national programme of internships could allow practitioners to gain experience of working in the research environment and would allow them to apply for funding more successfully.
- Research Leadership Programme would support practitioners day-to-day to implement research findings.
- Research Ready is an accreditation scheme for community pharmacists that launches in September 2013. It will provide opportunities for practitioners to participate in a wide range of research studies.
Save the date
UKCPA Autumn Symposium, Chester, 22-23 November 2013