Palliative and End of Life Care – getting it right first time

Sudhir Sehrawat, Community Pharmacist and RPS Welsh Pharmacy Board member
Sudhir Sehrawat, Community Pharmacist and RPS Welsh Pharmacy Board member

by Sudhir Sehrawat, Community Pharmacist and RPS Welsh Pharmacy Board member.

 

Getting it right – first time.

 

In every day working life we strive to get things right so we achieve the results that people need. It saves time, avoids duplication of effort and you get the result you want. Yet, as a community pharmacist, I see palliative care as an area where we sometimes don’t get things right first time due to the complexity of the systems and processes involved.

 

What happens when we get it wrong

 

In a real life scenario I was presented with a prescription by a patient’s relative for end of life medication on a Saturday morning. The medication prescribed was not on the Health Board Palliative Care Formulary and the family had spent most of the previous day travelling to various community pharmacies to get the prescription dispensed. I contacted the out-of-hours GP explaining the situation and the relative was asked to attend the out-of-hours service for a new prescription. They returned after lunch with a new prescription, however, the hand written prescription did not meet the controlled drugs regulations. I contacted the out-of-hours service again and the family member was asked to pick up a new prescription and return to the pharmacy. The controlled drug was supplied in part due to limited stock held but was enough to last until Monday evening. I explained we could order the remaining stock and deliver it when it arrived. After work on Monday evening I visited the patient’s address with the remaining medication only to discover the patient had sadly, already passed away on Saturday evening.

When a patient is at end of life members of the family and friends need to be with their loved ones, not chasing supplies of medication.

There’s lots to consider within this one real life scenario.

  • Why was a non-formulary palliative care medication prescribed?
  • Why was the alternative controlled drug prescription not written correctly?
  • Where were the communication channels to let the community pharmacy know the patient had passed away?

This single case is typical and highlights multiple opportunities to improve care at the end of life.

 

Getting it right in future

 

I welcome the upcoming policy on palliative and end of life care by the Royal Pharmaceutical Society in Wales. This leading policy will address the issues we healthcare professionals face and importantly, allows patients high quality coordinated care. Patients and carers have the right to be treated with dignity and respect. The policy outlines key areas to ensure patient empowerment through timely access to medication, providing the right support through shared health care plans and offering education and training to the workforce.

If we work on an All Wales approach and implement the key recommendations of the policy, we have the opportunity to drive quality improvements as well as reduce demands on our health and social care services. I’m fully behind the policy as I hope many of you reading this blog will be. Lets get it right – first time.

 

RPS new Palliative and End of Life Care policy for Wales will be published at the end of November, and launched at the RPS Medicines Safety Conference in Cardiff on November 22. 

Medical exemption fines: could they be better spent?

by RPS England Board Chair Sandra Gidley

The Government have announced plans to strengthen checks at pharmacies for entitlement to free prescriptions in England.  Whilst we all want to see fraud stopped, I have to ask – is really the right approach?

Only patients in England can be judged to have committed prescription fraud because prescriptions are free in Scotland, Wales and Northern Ireland.

Many patients who fall foul of the medical exemption fine have simply forgotten to renew it. They only need to do this every five years, so it’s a diary date that is easy to miss. We shouldn’t label people with a serious long term condition who have forgotten to renew their medical exemption certificate as fraudsters because they have made a genuine mistake. Read more Medical exemption fines: could they be better spent?

Volunteering at FIP 2018

Elisa Lee, Fourth Year MPharm student at Robert Gordon University 

What I did

I was one of the few fortunate students who was elected as a volunteer for the 78th FIP world congress in Glasgow 2018.

I started my volunteering a few days before the event, along with other student volunteers from all over UK, where we were split into different working areas. These included FIP booth, press and speaker room, accreditation and registration, and poster session. On the first two days we helped set up the exhibition hall, work stations, equipment and helped pack badges.

I was part of the accreditation and registration group for the duration of the congress. My role consisted of handing out evaluation forms, recording any filled-out forms on excel and answering any questions regarding accreditation. I also helped at the registration desk, helping participants collect their membership badges, handing out programmes and helping with any other general enquiries. Read more Volunteering at FIP 2018

Palliative Care & The Pharmacy Team – what do we have to offer?

by Elizabeth Lewis, Palliative Care Pharmacist

What do we pharmacists have to offer?

I have just retired, having had a very rewarding career as a palliative care pharmacist. I firmly believe pharmacy has a key role to play in supporting patients and their families, as well as other professions, in the delivery of palliative care services in both community and secondary care. Currently we are an under used resource but have the potential to offer much more to existing services.

Community Pharmacists are ideally placed to advise on the safe and effective use of medicines. The local pharmacist is a readily accessible source of information and advice for both the patient and those supporting them. With improved communication with fellow professionals in both the community and secondary care services they would be better placed to ensure the supply of essential medication and support. This in turn would help community services in supporting patients who wish to die at home.

In secondary care the inclusion of an advanced specialist pharmacist in the palliative care multidisciplinary team is beneficial in providing advice on all aspects of medicines management from the suitability and availability of drugs and the prescribing options to the use of drugs in renal and hepatic failure. Non specialist pharmacists also have a role in ensuring symptom control is optimised, appropriate and effective.

For pharmacists to reach their full potential in the field of palliative care they need access to education and, where appropriate, the opportunity to gain experience in working with palliative care patients.

The scope of palliative care includes many non-cancer diagnoses and, with an ageing population, there are more patients requiring palliative care input than ever before. Pharmacy needs to rise to the challenge. We have made a start in Wales and have formed the All Wales Palliative Care Pharmacist Group, for pharmacists with a particular interest in palliative care.

*The group undertakes projects on a national basis such as the Just in Case Box scheme and the development of the syringe driver chart and also acts as a support group for its members.

We need to build on these foundations to ensure pharmacy provides great care for palliative care patients and continues to develop expertise in palliative care medicines use across the whole range of pharmacist roles

Elizabeth Lewis is a major contributor of expertise to our new Palliative and End of Life Care policy for Wales, which will be published at the end of November and launched at the RPS Medicines Safety Conference  in Cardiff on November 22.

FIP – like hosting the pharmacy Olympics

I spent the first week of September in a surprisingly sunny Glasgow, at the 2018 FIP World Congress of Pharmacy and Pharmaceutical Sciences. This was the 78th FIP event and the first time it had been held in the UK for nearly 40 years. We had the privilege and huge challenge of hosting it – and let no one underestimate the size of this challenge! A global gathering of pharmacists and we were responsible for the venue, the catering, much of the programme, the formal opening ceremony and the big events. It’s like hosting the Olympics except for pharmacy! It took considerable effort from our great events team and many other colleagues to plan and deliver this.

The ‘myth’ concerns the view sometimes expressed that such events are irrelevant to the majority of the profession and are only for a select few – the ‘pharmacy elite’ from academia, science, research and pharmacy politics. If you’d asked me previously what FIP was all about, I may have told you rather dismissively and from an uninformed position, that it was not really relevant to us in the UK, out of reach to the ‘typical’ pharmacist and out of touch with the younger generation. What a huge misconception that proved to be!

Glasgow 2018 really did dispel that myth for me. Many community pharmacists and their representative organisations were in attendance actively participating in the event, as well as people from hospital practice and chief pharmacists from all across the globe, including our own from here in the UK. Read more FIP – like hosting the pharmacy Olympics

Supporting System Leadership

by Amandeep Doll, RPS Regional Liaison Pharmacist

I’m one of four Regional Liaison Pharmacists at the RPS, working on system leadership for pharmacy and medicines optimisation in England, delivering national strategy at a local/regional level.

We know there is a need to bridge the gap between the strategic and operational levels of healthcare and mobilise the profession to get involved with system leadership to improve health outcomes for patients. It’s vital to ensure that medicines optimisation and pharmacy services are considered core criteria when planning and implementing healthcare services.  Read more Supporting System Leadership

Our take on the NHS Long Term Plan

By Gareth Kitson, Professional Development and Engagement Lead  

The way the NHS delivers care to patients is constantly evolving and aiming to meet the changing needs of an aging population and people living with multiple conditions. As a busy pharmacist providing the best possible care to our patients, it can often be difficult to get to the bottom of the changes and truly understand how the changes might affect you in your day to day roles.

A few weeks back, NHS England launched a discussion paper looking at how the NHS should be developed over the next 10 years, the Long Term Plan (LTP).  The plan is split into three sections, each examining specific areas which will need to improve, if we are to continue to provide the best possible care to our patients. These areas include:

  1. Life stages
  2. Clinical priorities
  3. Enablers of improvement

Each section will resonate with healthcare professions differently and I’ve highlighted areas in each that might be relevant to our members. However, one of the biggest changes that will affect most pharmacists will be how care is provided to our patients.  The traditional method of providing care to patients (the patient moving around different parts of the health system) is a relatively inefficient way of delivering care and one that does not put the patient at the centre of everything we do.  A new, proposed method of providing care is through the use of Primary Care Networks.

Primary Care Networks

We’ve already seen improvements in the way that care is provided to our patients and I would expect the NHS LTP to build on this and develop it even further – I’ll talk through some of these proposals and the LTP later on. However, as I previously mentioned the way we are providing care to patients is changing.  You may have already seen the development of the Primary Care Home (PCH) model which sees care services being redesigned and delivered around a defined population, with the patient being placed at the centre of care provision and the MDT working around them.  You may also have heard about Primary Care Networks.  More information about them can be found here.  However, how might this new model of care affect pharmacists working with patients on a daily basis?

It’s important to remember that this new way of providing care to patients is a positive step for pharmacists as it will allow us to support patients using the full breadth of our skills and showcase the value we can add to patient care. There have already been some great examples of where pharmacy have become integrated into a primary care home model and have had a lasting impact upon patient care.  We’ve seen pharmacists managing long term conditions for their patients, COPD and hypertension, for example.  We’ve also seen them change how patients on multiple medications are managed and highlight the importance of polypharmacy to both patients and prescribers.  Integration of pharmacy into this new model of care also promotes better collaborative working, improved working relationships and more effective use of resources, which in turn, leads to better care for our patients.

The RPS realises the importance of promoting pharmacists and ensuring they are included in any new model of care. Consequently, we have produced 5 key considerations that we think should be included in the formation of any new primary care network that is designed to support our patients.  The key considerations and further information about our work with Primary Care Networks can be found on our website. I’d encourage you to read it and discuss with your colleagues and local leaders to ensure that pharmacy is at the forefront of any changes that are made to how care is provided to your patients.

NHS Long Term Plan

When reading the NHS discussion paper, it can be difficult to picture how you might be affected by these changes.  It can also seem quite intimidating to submit your views and give your opinion on how the plan that will be developed over the next few years.  As your professional body, the Royal Pharmaceutical Society is developing a response to the discussion paper which aims to represent the views of our members.  The finalised plan will be developed and published in good time but what might the future NHS look like and how might this affect you?

Life Stages

The LTP has dedicated the first section of the consultation to different life stages; Early Life, Staying Healthy and Aging Well. Pharmacists are well positioned to support all areas of this section.

Pharmacists from all sectors come into contact with thousands of people every day. Through these contacts, we can promote public health campaigns and work collaboratively with our primary care colleagues to support our patients throughout all life stages.  Pharmacists already do a great job in this area; the flu vaccination service being a prime example.

Mental Health is a huge priority for our health service over the next few years and I would expect all pharmacists to soon be playing an even greater part in supporting the public in this area. Mental Health is a topic that crosses all life stages and the RPS have recommended that this should be the one of the top priorities for addressing health inequalities over the next five to ten years.

Furthermore, as the experts in the safe and effective use of medicines, pharmacists will continue to have a key role to play in ensuring patients with long term health issues get the most from their medication and are empowered to make informed decisions about their health and treatments. This role is sure to develop and pharmacists and their teams will be key in ensuring this is a success.

Clinical Priorities

The LTP highlights three main clinical priorities that will be focused upon, over the next five to ten years. These are Cancer, Cardiovascular and Respiratory Health, Mental Health and Learning Disability and Autism.  Once again, pharmacists are already doing wonderful work in these areas and our recent Mental Health campaign in England, showcased some of these.  One area where pharmacists could play a bigger role in these specific areas could be through supporting disease prevention services (for example, supporting stop smoking services via community pharmacists) or working alongside other healthcare professionals, such as GPs and other doctors, to help reduce the incidence of cardiovascular and respiratory diseases.  Many pharmacists already work to help detect atrial fibrillation but this is an area that could be expanded over the next few years, with more pharmacists being used to recognise early signs and symptoms of LTCs.  This could also see pharmacists doing more to support the physical health of patients with mental health conditions.  This is something that the RPS have recently highlighted as part of our mental health campaign  

Workforce

We all know the exceptional work that members of the NHS workforce do. As the system develops, we need to make sure that the workforce is also developed and supported to be the best they can be.  Without a highly trained, compassionate and effective workforce, the NHS will not be able to deliver the best care to patients.

At the recent FIP conference, the report on the global trends in the pharmacy workforce was launched with some interesting findings.  I’m sure that everyone has been involved in workforce discussion at some point in their carer and have seen how the workforce greatly impacts upon patient care.

Therefore, as part of this consultation, the RPS have highlighted that the pharmacy workforce needs to be included in any changes made to the NHS. As a workforce, we are expertly placed to use our skills to help deliver services to patients using new and innovative methods.  Some pharmacists within our workforce are independent prescribers and are skilled to support patients to manage their long term conditions and to support them with problems they may encounter when taking multiple medicines.  The advancement of technology is undeniable and therefore, we also need to pay particular attention to ensuring our workforce is digitally literate and can translate this in to ensuring we support our patients, to the best of our ability.

 

How pharmacists can support older people with mental health issues: a personal view

By Dr Amanda Thompsell, Chair of the Faculty of Old Age Psychiatry of the Royal College of Psychiatrists

Having met with members of the Royal Pharmaceutical Society to talk about their mental health campaign it made me reflect on the many ways that pharmacists support older people with mental health issues.

Not only do pharmacists give helpful advice around reducing unnecessary medications, on side effects and potential drug interactions and ways to improve adherence, but pharmacists help in so many other ways that can go unnoticed. Read more How pharmacists can support older people with mental health issues: a personal view

A Welsh perspective on FIP World Congress 2018 

Jodie Williamson MRPharmS, Pharmacist at the Royal Pharmaceutical Society
Jodie Williamson MRPharmS, Pharmacist at the Royal Pharmaceutical Society

by Jodie Williamson, Professional Development and Engagement Lead at the Royal Pharmaceutical Society in Wales.

 

Last week 3000 pharmacists from 108 different countries came together in Glasgow for the International Pharmaceutical Federation (FIP) World Congress. This is a conference where pharmacists from around the world can share advances and developments from their country with an international audience in order to improve the benefits patients get from their medicines on a global level. With RPS hosting this year’s conference, I was lucky enough to attend and represent our team in Wales. FIP World Congress last came to the UK nearly 40 years ago, so getting to attend the conference so close to home was a once-in-a-lifetime opportunity for me.

 

We know that healthcare systems around the World are facing increasing pressures and demands on their services and this resulted in a real sense of the need for pharmacy services to change amongst all delegates. It was an eye-opening week for me!  

 

I learnt about how community pharmacists in Portugal are now working with general practices to offer early screening for a variety of conditions and are able to refer patients directly to the most appropriate services if a condition is identified, relieving the pressure on their GPs. They also run clinics with nurses and nutritionists to offer advice about diet and nutrition on the high street and now their patients are calling for them to be able to request blood tests and interpret their results. Community pharmacies are the first port of call for most healthcare needs in Portugal. 

 

I also attended an emotive and thought-provoking session on death and dying. We heard from countries where euthanasia has been legalised about the role of pharmacists in the process and how they are trained and supported to deliver excellent end-of-life care. The session challenged my thinking around the guiding principle for healthcare professionals to do no harm. An excellent quote that resonated with me during the session was “sometimes death ends suffering, not life”. 

 

Welsh RPS representatives at FIP 2018
Welsh RPS representatives at FIP 2018 (L-R) Avril Tucker, Andrew Evans, Dai John, Jodie Williamson, Suzanne Scott-Thomas, Rob Davies, Cheryl Way, Sophie Harding, Sarah Hiom

 On the other hand, the conference also made me realise how lucky I am to be trained and practicing in the UK. Our healthcare system, the quality of our training and development, and the standards that we work to are the envy of so many pharmacists from around the World. Whilst I learnt a lot from other countries a number of our Welsh pharmacists were also presenting their innovative work. From our community pharmacy Discharge Medicines Review (DMR) service to developments in cancer care at Velindre Cancer Centre, our pharmacists are doing an excellent job of putting Wales on the map as leaders of the profession on a global scale! 

Pride in Practice : Being brave

by Dr. Claire Thompson, RPS Deputy Chief Scientist

She…

I’ve written lots of blogs on science or leadership but never about being gay, so this is my first professional outing.

I’m fortunate in that I have never experienced overt homophobia in the workplace. This is in stark contrast to my personal life, where experiences have ranged from:

– Being abandoned by groups of friends at school;
– Family members not coming to my wedding because they didn’t “agree with it”; and
– Strangers in the street shouting “You deserve to die” for simply holding hands with my girlfriend. (No, this wasn’t the 1950s, it was 2003)

Even though they haven’t been painful professional experiences, it doesn’t mean there haven’t been uncomfortable ones. Like every time someone asks “What does your husband do?”. I’ve lost count of the number of times I’ve responded “They….” or “My partner….” Because I didn’t want people to feel uncomfortable or embarrassed. But the longer you leave it, the more uncomfortable the discussion gets.

When is the right time?

So, when is the right time to say “She” or “My girlfriend” or “My wife”? Over the last few years, I’ve made a conscious decision to get “She” in early. The birth of my daughter really helped with this. As a proud parent, I would show people photographs and they would say “You look great for having a young baby” to which I could respond “Oh my wife gave birth to her, and she looks better than I do!” (See the photo below as proof). I find that openness, humour and a baby photo go a long way to diffusing any discomfort. Of course, there have been occasions where I have just taken the compliment (please don’t tell my wife)!

Dr. Claire Thompson (right) with her family

Brave

Coming out to colleagues still doesn’t come naturally, it always takes an element of bravery and I do admit that there are some people that I still don’t tell because I know they will judge me unfairly. Ultimately, we need to be comfortable with what we share about ourselves.
But if you do want people in the workplace to know that you are gay, take a deep breath and go for it.
Be brave. Be you.