In November 2022, London North West University Healthcare NHS Trust embarked on a person-centred care pilot that has changed the face of their pharmacy practice for the better. Helena Beer speaks to four of the key players about how they went about the ground-breaking project, the impact it’s having on patients, staff and the wider healthcare community, and their top tips for success.
You’d be hard-pressed to find a pharmacist or pharmacy technician who doesn’t strive to underpin their practice with person-centred care. After all, helping people in a time of need is the mainstay of the pharmacy professions.
But ultimately, person-centred care is an abstract concept and will mean different things to different people. With no real standard or training, individuals are largely left to their own devices, picking up tips from their colleagues, trying things out and hoping for a good patient outcome.
For the pharmacy team at London North West University Healthcare NHS Trust, this haphazard approach was far from the ideal. Previous training in this area had been voluntary and take-up was limited, which only exacerbated the issue.
Establishing a core priority
Despite having a role that rarely involved a patient-facing element, Cecilia Tse, the trust’s formulary lead pharmacist, was keen to establish person-centred care as a core priority for every member of the team and in all facets of pharmacy across Northwick Park Hospital.
This was driven by a patient interaction she experienced during a Saturday ward shift. A patient repeatedly came to the nursing station to ask the same question about his care, seemingly unable to retain the information he was given. Being ‘nosy and curious’, as well as concerned, Cecilia took it upon herself to investigate.
Mindful of creating a safe and respectful environment, and through careful questioning, Cecilia was able to discern that the patient had post-traumatic stress disorder.
‘It was then our job to actually help him to retain the information and make sure that he felt that he was being looked after and respected,’ she says. ‘I can tell you, within five minutes [the staff were] all hands on deck, everybody had come together and knew what to do.’
A prime example of where person-centred care was crucial, Cecilia immediately wrote an email to her colleagues Paresh Parmar, lead pharmacist for older people and stroke; Vicky Stevens, lead medicines management pharmacy technician; and Professor Nina Barnett, who was a consultant pharmacist in older people.
Cecilia flagged the additional issues that not having the usual multidisciplinary team (MDT) on a weekend had caused for that patient, and it was agreed that more needed to be done.
So, when the hospital’s directors announced that each department could have funding of up to £5,000 to find innovative solutions to old problems facing their teams, Cecilia saw it as a perfect opportunity to return the pharmacy department’s attention to person-centred care. And her bid for the innovation funding was successful.
A person-centred care precedent
The team was fortunate to have Nina as a key player in the trust. A champion of person-centred care and health coaching, Nina had previously developed the Pharmacy Integrated Care Service (PICS) in the care of the elderly team.
This referral-based service identifies vulnerable patients who have medicine support needs during their admission in hospital and minimises the risk of preventable, medicines-related hospital admissions and re-admissions.
The service support patients with unmanaged, complex medicine-related issues through the delivery of person-centred pharmaceutical care plans.
‘We needed to understand and learn skills of how to communicate with patients to tease out why patients were not taking their medicines, especially if it was intentional non-adherence, and how as pharmacists and pharmacy technicians, we could then engage with patients in a better way and empower and enable them,’ says Paresh, who leads on the service.
Multiple members of the pharmacy team were already involved with PICS and so, Paresh adds, ‘care of the elderly was chosen as a group to pilot the new project because we were practising a type of person-centred care over many, many years because we were fortunate to have Nina teaching us and developing health coaching within our team’.
Let the person-centred care pilot commence!
Building a strong team was the first step, and this included person-centred care champions within the hospital as well as colleagues to support with leadership and administration.
‘I was very important to make sure that – as we were a new team, situated in different locations – we could bring people together and identify what our strengths and weaknesses were,’ says Paresh. ‘We could then develop a shared vision and look at the attributes required to drive this project forward. So, it was critical that we have that at the very beginning.
‘And one of one of our staff pharmacists was recruited to “gel” us all together and help do that administrative and coordinating role for the team once the project was developed and underway.’
Set to run from November 2022 to January 2023, the pilot was designed as a six-week programme with different types of learning to appeal to as many people’s learning styles as possible.
Starting with computer-based, self-directed learning, the participants then moved onto teaching courses led by Nina and Vicky, followed by a practice-based application with learning via colleague and patient feedback. A period of self-reflection and semi-structured interviews then followed to assess how individuals integrated person-centred care skills into practice.
For Vicky, one of the most important factors of the project was training pharmacists and pharmacy technicians together.
‘Although there are two roles, they’re actually working very similarly in terms of the way in which we interact, the information that patients are giving us, and the fact that we are actually moving out of dispensaries and offices and onto the wards and we’re upskilling ourselves,’ she says.
‘When we are in front of a patient, they shouldn’t really be able to see the difference between the pharmacist and the pharmacy technician in the way in which we communicate with them or the way in which we treat them. Everybody should be treated the same and addressed the same.’
Another benefit of being trained together means that the two professions can recognise the extent of each other’s roles and responsibilities, which Cecilia says makes handover much safer.
At each of the pilot stages, a questionnaire was completed, and this data was analysed by the team in partnership with Dr Claire Easthall, lecturer in pharmacy at the University of Leeds and an expert researcher with expertise in behavioural change and teaching reflective practice.
Sam Barnett-Cormack, who is an expert patient with analytical academic experience in sharing patient perspective and working with healthcare professionals, also played a hugely supportive role in this area.
This collaborative analysis will form the basis of changes and additions to the project moving forwards.
Time and motivation challenges
While the feedback received from participants was generally positive, challenges around time and motivation soon became apparent.
Concerns centred on having the headspace to effectively embed person-centred care into practice – hardly surprising given the often relentlessly busy wards. And this required a mindset shift so that person-centred care was seen as a priority rather than an optional extra.
‘There is this idea that if you talk to patients for a period of time, you’re not saving time,’ Vicky explains. ‘But what you’re saving down the road is issues that may have come up. You may be saving a readmission, you may be saving issues around patients taking medication inappropriately, simply because they weren’t aware of how to take it properly.’
The next stage was innovative thinking to free people up to go for the training without feeling guilty or under pressure. This was done by splitting the team so one half went to the training while the other half covered on the ward.
Showing that senior management was giving support to this and filling staffing gaps with locums and temporary staff was also key to motivating the team and getting the all-important buy-in.
‘I think rather than say, we’re just going to have to cope with what we’ve got, it was actually saying, let’s work out where we think the challenges are and let’s do something about it,’ says Charlotte Bell, deputy chief pharmacist. ‘I think maybe that was the piece that was heard and then people felt it was being addressed. But I’m not going to try and sit here and say that we’ve completely remedied it all. Maybe some of it.’
For Paresh, giving protected time to do all the activities was paramount. ‘When they were going to have an interview, or they needed to do a reflective piece, or answer a questionnaire, they had that time and that space to do it uninterrupted. And it’s not within their lunchtime, or at home, it’s in work time. Protected time.’
And Cecilia sums it up nicely, too: ‘The moment people hear they’re not giving up anything in order to achieve what you want, I think people will have the buy-in.’
Invaluable leadership support
The importance of buy-in also extended to the trust’s pharmacy leadership. As Cecilia says, if the chief pharmacist and deputy chief pharmacist who commissioned the project ‘didn’t see this as a priority, it would never happen. So, I think that leadership was a big role in this whole project’.
The aim of the pilot project was to establish exemplar best service and best care, and for Charlotte a key component was making person-centred care robust and consistent in every patient interaction.
‘This approach is quite unique. I think the training is very innovative and unique. But I think that the standard of care we’re trying to achieve and the overall outcome is not,’ she says. ‘It’s what everyone’s trying to achieve. It’s just that I think the team have identified some quite innovative ways to realise that.’
Another part of Charlotte’s buy-in related to a pre-assessment she had undertaken with a man many years before – an example that she loves.
Along with a long list of other medications, the man was taking steroids. He developed a stomach ulcer and was struggling to sleep so was prescribed medication to remedy the two side effects.
‘It was only at the point when he said, “I work shifts, I work nights”, that everything came into the picture,’ Charlotte explains. ‘He was taking his steroid in the morning because he’d been told to take a steroid in the morning and then he was going and getting in bed. So, he had an empty stomach, which he put a steroid into, and he got in bed and then he couldn’t get to sleep and he developed a stomach ulcer.’
It was only by chatting to the man and his wife and finding out about the person behind the conditions that Charlotte was able to truly optimise his care. And it highlights why this is known as person-centred care and not patient-centred care.
Charlotte adds: ‘It’s lifestyle factors like whether you smoke or not, or whether you live alone or not, whether you work shifts. Every element of your life impacts on your healthcare, and your healthcare impacts on every element of your life.’
Positive reactions from the MDT
Evidence of success comes in many forms, and there are numerous examples from the person-centred care pilot project. But the one that sticks out in the team’s minds was from a consultant who had overheard a pharmacy technician’s telephone consultation after she had undertaken the training.
Paresh says: ‘The consultant sent an email to me and said, “what a fantastic consultation that your pharmacy technician had on the ward. A lot of our junior doctors could learn from her on how to carry out a person-centred conversation”. And that sort of validated that what we’ve done through the pilot actually is working, because this is a chance encounter with a third-party consultant overhearing a conversation. That just says, you know, we’re doing something, right.’
Previously, Nina had undertaken health coaching for doctors at the trust, which has set a foundation, but now the pilot is complete there’s a multitude of opportunity to expand the project and work more closely with doctors.
‘How that unfolds, we don’t know yet, but definitely there is scope for that. And not just doctors – what about speech and language therapists, physiotherapists, occupational therapists? And we can learn a lot from them as well,’ says Paresh. ‘We work within a multidisciplinary team and pharmacy is very much embedded in that team. So, there’s lots of sharing of knowledge and practice to be done.’
The current person-centred care landscape
The next steps for the person-centred care project are well and truly underway, and while collaboration is certainly one priority, recruitment is another.
Charlotte has now recruited many different posts for which person-centred care has been mentioned in job specifications and interview questions to really show its priority status at the trust.
‘It’s both a really nice showcase of the work that’s being done at LNW but also a sort of mandate to give to people when we’re interviewing them to say, “this is the project, how do you think your role might overlap? How do you think your role might impact on this type of work?”,’ she says.
This has enabled the recruitment of reflective and insightful people who have a human touch and will be able to help the team drive the person-centred care agenda forwards.
The impact of ePMA
Another thing that will be key to elevating the person-centred care agenda is the advent of electronic prescribing and medicines administration (ePMA).
Paresh says: ‘I think the big challenge coming forwards is the whole electronic processes where you’ve got a screen in front of you and not to forgetting there’s a person behind that hospital number. So, my role is very much about training and developing our staff into making the patient the focus rather than the screen.’
Cecilia would go so far as to say that she’d rather ‘people see ePMA is optional extra and person-centred care being here as the mainstay’. Quite simply, having that end-of-bed conversation is so crucial to understanding how the person is coping with their condition and their medication. No computer can tell you that.
The ePMA system has been rolled out across the trust over the last few months in tandem with person-centred care and Charlotte says this has been important.
‘From a time point of view, what you’re saving with ePMA, you can spend on better patient care,’ says Charlotte. ‘We can say, well, look, in this new world of ePMA, if you do it like this you don’t have to go up to the ward in the afternoon when they bleep you for a stock item or a medicine that’s available because you can sit at your desk and do it. And that 15 minutes you save is how you did that brilliant counselling session in the morning. It’s just making sure that’s a clear message to people.’
Expanding the pilot beyond acute care
While there’s still a long way to go to finesse the person-centred care project to embed it consistently in everyday practice across the trust, the team have been thinking about expanding its reach even further.
Vicky has been meeting with NHS England to look at how person-centred care could be part of integrated training for the legacy pharmacy technician workforce as well as trainees of the future. She says: ‘We considered how we could look at including it as a mandatory or additional skill with different training bodies, and allowing for the whole person-centred care ethos to be expanded so pharmacy technicians can become leaders and champions in this area. It was received quite positively.’
And Charlotte is also having conversations via the local integrated care system (ICS) to encourage trusts to share their methodology and work together on it.
‘We have a really strong research ethos within the trust, so I think we need to syphon that down into pharmacy and have a research group of some variety,’ says Charlotte. ‘And I think that’s the sort of forum where we would use expertise, learn from this to shape future research in our department, and for the learning to develop further. But it’s also a really great route to escalate to our trust research groups and across the region to say, “we’ve done this great piece of work, and we’re going to keep talking about it.’
Focusing on the primary-secondary care interface and working with GP practices and community pharmacies is another part of the longer-term plan. ‘The challenge that we always face in the acute provider environment is that we know we’re going to be the transient person in that person’s life. If we’re lucky, we might see them every day for five days. But we’re not going to be the person that sees them when they go home. That’s the bit we need to bridge, isn’t it? And by building relationships with community pharmacy, that’s how we actually move forwards.’
‘Don’t be afraid, just do it’
The team is indeed steadfast in their belief that similar initiatives should be embraced across other trusts in the UK, as well as inspiring teams across Europe. But what are their top tips for those hospital pharmacy teams thinking about embarking on their own person-centred care journeys?
For Cecilia, the most important thing to remember is that, when starting out, teams don’t need all the answers, they simply need an idea and a direction of travel.
‘I think one thing that we’ve learned is, when you’ve got an idea, whether it’s an innovative idea or not, it doesn’t matter. It doesn’t need to be fully formed when you start a project,’ she says. ‘You just need to be brave, call the right people to come, and then the idea will develop, strategy will come and then you’ll get there.’
Her other top tip is to have loud and proud conversations in the hospital corridors about the project. ‘Once people hear about it, they are curious about it. I will encourage any other organisation who wants to pick up our project and do a similar thing to not be hush-hush and say, “this is a major project we’re doing and we’re not going to tell anybody”. Do exactly the opposite and let people hear what you’re going to do and let them come and join the conversation.’
Paresh’s words of wisdom centre on mindset, focus and, naturally, the patient. ‘Don’t forget why you’re here. There’s a patient, there’s a person,’ he says. ‘Become a team that has a shared vision, be infectious with what you’re doing. Have a passion, drive it and then you’ll be fine.’
And for Vicky it’s very simple: ‘Don’t be afraid, just do it because, at the end of the day, there are so many obstacles, but just taking your time and doing it is the first step.’
An important person-centred care legacy
The Northwick Park Hospital team were devastated to share the news that Professor Nina Barnett sadly passed away in September 2023. After dedicating 37 years to the pharmacy profession, she is remembered for her phenomenal influence to drive pharmacy practice and her unparalleled passion for person-centred care, shared decision-making on medicines use, and interprofessional collaboration.
Cecilia paid tribute to her ‘visionary work and her universal power to relate to every one of us’.
And in a moment of remembrance of a ‘cherished colleague’ at the recent Royal Pharmaceutical Society (RPS) Annual Conference, Claire Anderson, RPS president, said: ‘Nina Barnett was not just a pharmacist, but she was a beacon of inspiration who dedicated herself to our profession. Her wisdom and passion led her to mentor countless pharmacists, her experiences of which she shared in blogs and publications, providing invaluable guidance for others.’
She added: ‘[Nina’s] impact on our profession was so profound and her legacy rooted in inclusivity and compassion and that will forever guide us. Nina was a true role model, and she will be dearly missed, but her impact will endure through this profession, which she loved.’
Indeed, without Nina’s vision and tenacity, the person-centred care project at London North West University Healthcare NHS Trust is unlikely to have seen half the success its achieved, if it would have happened at all.
But now, person-centred care is running through the veins of the pharmacy team. And with multiple plans underway to spread the word to the trust, ICS, NHS England and beyond, there is safety in the knowledge that countless patients will be better off because of this one trailblazer and the work of her extraordinary team in making the person-centred dream a reality.
Helena Beer was speaking to Paresh Parmar, lead pharmacist for older people and stroke; Vicky Stevens, lead medicines management pharmacy technician; Cecilia Tse, formulary lead pharmacist; and Charlotte Bell, deputy chief pharmacist at London North West University Healthcare NHS Trust – pictured above, left to right.