Reducing antibiotic prescribing through system leadership

by Katie Perkins, Medicines Management Adviser Hastings & Rother Clinical Commissioning Group

At the end of 2018 I took on the role of CCG medicines management lead for antimicrobial prescribing (alongside promotion to Medicines Management Adviser and respiratory lead). I work across two CCGs which cover 43 GP practices.

RPS AMS training

The RPS AMS training programme became available at just the right time in terms of my new role and immediately before the start of our 2019/20 prescribing support scheme. I was already out and about talking to GPs about their antibiotic prescribing and in particular three out of the 10 practices that I look after were particular outliers for antimicrobial prescribing. The learning that I undertook as part of the course, particularly in Quality Improvement (QI) methodology was invaluable and we were given a brilliant opportunity to “try this out in practice” with tutor support.

My QI project

The QI project I chose was to reduce inappropriate prescribing of antibiotic rescue packs for COPD exacerbations and ultimately for this to help reduce the total number of antibiotic items (per STAR PU) prescribed by the practice.

I carried out a patient level search at the practice to identify people with COPD who were prescribed an antibiotic rescue pack on repeat prescription. 22 people were identified and 9 of these had received six or more courses in the preceding twelve months.

In preparation for presenting this to the practice I met with a nurse at another practice which had robust and effective processes in place for the issue and follow up of COPD rescue packs – this was helpful in ensuring that I had a realistic handle on what is reasonable to expect in practice.

I met with the four practice GPs, pharmacist and practice manager and presented them with the list of these patients. I asked them to review each one to determine if the antibiotic remains appropriate. I provided them with current national guidance from NICE on this area as well as our local formulary guidance.

Where an antibiotic rescue pack was appropriate, the GPs were asked to consider only prescribing this as an acute prescription (not on repeat) or, as a compromise, if they would prefer to keep them on repeat, to consider a maximum of two issues before the patient was reviewed. I was surprised that the practice agreed to move all prescriptions to acute and for all new rescue pack prescribing to be issued only on acute.

They also agreed to include instructions in the rescue pack directions for the person to contact the surgery when they started taking it. The practice already had a leaflet that they give out to people when they are first prescribed a rescue pack – they now aim to give this out more consistently.

Results and impact of my QI project

Before the QI project (February 2019) the practice was the highest prescriber of antibiotics in the CCG (total items/STARPU). The latest data from PrescQIPP (August 2019) shows that the practice has dropped to the 9th highest (out of 23 practices) and reduced their total antibiotic prescribing by 10%.

Practice bar charts Antibacterial items/STAR-PU showing 12 months rolling data to August 2019

This is likely to be in part due to the reduction in rescue pack prescribing but I suspect that the project may also have provided a renewed focus on reducing inappropriate antibiotic prescribing more generally.

Getting all the GPs and the practice pharmacist together and presenting the data to them face to face really got them thinking about the possible consequences of these repeat prescriptions. They all committed to reviewing these patients and they have changed their behaviour when it comes to managing COPD rescue pack prescribing.

Next Steps

As mentioned previously the response to my QI project proposal by the practice pleasantly surprised me and this has given me the confidence to roll the QI out to the other 42 practices across the CCGs. I also plan to look at other areas of repeat prescribing of antibiotics such as UTI prophylaxis and long term prescribing for acne and rosacea.

Find out more about our AMS training in England

Mentoring – a role for retired pharmacists

by Theresa Rutter, FFRPS FRPharmS

Most of us will have done some mentoring and many like me will have no formal qualification. I became interested after being mentored years ago by a non-pharmacist working towards a formal mentoring qualification. I found the process so useful that I wondered why it wasn’t embedded within the profession as a self-development tool.

Mentoring as a retired pharmacist

We retired pharmacists have the experience and skills to support the self-development of pharmacists at all stages of their career.

I started to mentor before retiring and have continued since with up to 6 mentees at varying intervals. They work in different sectors and levels of seniority.

Their areas of focus have included leadership, effective team work, staff management, prioritising, change management, problem solving, negotiating, influencing and work life balance.

The competencies (in the Advanced Pharmacy Framework) relating to these generic skills do not go past their expiry date.

I’ve found that career progression often means that mentees come to value satisfaction about their performance and recognition more highly.

Feedback from my mentees about their experience of mentoring

  • Mentoring provides a safe space and encourages them to explore options and find solutions to challenges
  • Retirees may have more time & flexibility to fit round the working hours of mentees
  • The empathetic relationship helps them to be honest about problems and areas for self-improvement
  • The sessions give them head space for reflection and creative thinking

What’s in it for mentors?

  • Stimulates neuronal pathways (use it or lose it)
  • The opportunity to share expertise and see mentees thrive is rewarding
  • It’s always good to get positive feedback

How you can get involved in mentoring?

It’s easy to sign up – RPS has launched a new mentoring platform which facilitates easy and appropriate matching of mentor to mentee. You need to reflect on the skills you can offer to the mentees, complete your profile and then keep an eye on your emails for requests from potential mentees, which you can either accept or decline.

For mentees, the same principles apply. They need to reflect on what they would like to get from a mentoring relationship and once registered can select a mentor based on their preferred profile of skills and experience, interest and local area (optional).

Sign up at www.rpharms.com/mentoring 

Our mentoring relationship

Being a mentee: Aamir Shaikh

I met my mentor Aamer Safdar whilst working at Kings College London. I was the 3rd year Professional Lead, and was introduced to him and he told me about his background, both personal and professional.  Just by listening to him, I knew that his values were similar to my own. 

Challenge

I now work at BUPA as the Chief Pharmaceutical Officer’s Clinical Fellow, but before that I worked within the Education Directorate at RPS.  It was there I worked alongside Aamer in projects involving undergraduates.  You will hear that pharmacy is a small world and this is one such example!  My manager explained how it is important to work alongside colleagues who will challenge your thinking and I found this in Aamer.  Our mentor/mentee relationship first established when we went out for dinner as a post-work group; it was here when I decided to formalise my mentor/mentee relationship with him. 

Benefits

I’ve benefited greatly from the mentor/mentee relationship. It’s given me thinking space but its been advantageous to both my personal and professional life to have someone to challenge my own thinking in whatever situation or scenario I am experiencing.  In our last meeting Aamer and I spoke about authenticity, congruence and integrity.  I found it particularly useful hearing from someone in Aamer’s position, a current GPhC Council member and previous RPS English Pharmacy Board member, about how important it is to stay true to your own values and what these values really mean.

We use the RPS mentor platform to record our meetings and have found that, as well as the normal methods of keeping in touch, the platform has been beneficial in keeping us focused. I couldn’t stress the importance of having a mentor enough.  It has really helped me focus whenever I have found myself in a sticky situation and I’m grateful for the time Aamer has shared with me.

Being a Mentor: Aamer Safdar

I have been a mentor to many people inside and outside of pharmacy and have used a variety of methods with my mentees which have included traditional face to face sessions as well as mentoring exclusively by email and by phone; in the latter two cases, I never met my mentees in real life until much later in our relationships! 

I currently mentor two pharmacists, at different stages in their careers, using the RPS mentoring platform.  The platform is useful because I have outlined the areas in which I would like to mentor in to manage my mentees’ expectations. 

Sharing experiences

In both of my meetings, we spoke about our careers and challenges at different levels and I was able to share my experiences and wisdom from both my day job and from being in national boards.  Much of my wisdom has come from my own mentors, who have been different people at different stages of my career,and with different perspectives and advice.  Without a mentor to bounce things off, I doubt I would have done many of the things I have done in my career.

Find out more about our mentoring scheme exclusively for members

Strengthening Antimicrobial Stewardship through training

by Vincent Ng, Professional Development Pharmacist

The challenge   

This year the UK Government updated its 5 year action plan on Antimicrobial Resistance (AMR), which details ambitious goals such as reducing antimicrobial usage in humans by 15% and halving gram negative blood stream infections by 2024.

A major part of this plan involves improving how antimicrobials are used through Antimicrobial Stewardship, for example by reducing inappropriate prescribing. As experts in medicines and advocates for medicines optimisation, all pharmacists have a role to play.

Supporting pharmacists through training

Earlier this year, we delivered a 3-month training programme to pharmacists from primary and secondary care in London, Kent, Surrey and Sussex, funded by the Health Education England AMR Innovation Fund. This was an exciting opportunity for us to support pharmacists from a range of settings and scopes of practice to learn about Antimicrobial Stewardship and get involved in their workplace.

What did the training involve?

  • Face-to-Face training day delivered by national experts
  • Quality improvement project in the workplace, supported by online group feedback sessions facilitated by UKCPA Pharmacy Infection Network tutors
  • Structured self-assessment and self-directed learning
  • GPhC revalidation entries
  • End of training assessment with experts from our Antimicrobial Expert Advisory Group

What our learners are saying

“I was given the opportunity to be part of the AMR programme this year and found the programme very useful. It has propelled me in the right direction with regards to leading on AMR within my organisation.  The key resources provided during the programme and the link to a tutor gave the confidence I needed to complete my project. My quality improvement project involved the review of patients with UTI to ensure appropriate prescribing and accurate documentation process.  Although the project was only focused on a small cohort it was very useful to see the changes and improvement that was made. I have not just stopped with the project but have also made myself an AMR champion with AMR now formally included in my work plan. I am now creating a training matrix to increase awareness within my organisation.”

Jenkeo Olowoloba, Community Health Specialist Pharmacist, Medway Community Healthcare

“The training helped me develop my skills as a competent and confident AMS practitioner. Participating in this training programme enabled me to significantly improve my quality improvement skills, extending my skills beyond audits and re audits. I demonstrated QI methodology and embedded behavioural interventions to improve the quality of the 72-hour antibiotic review carried out by clinicians.  I also designed a scoring tool on the Perfect Ward App to measure the quality of an antibiotic review which led to reducing data collection time from 15 minutes to 5 minutes. I enjoyed the entire experience and valued the constant support provided by our tutors, RPS team and colleagues. The practice-based discussions benefitted my practice significantly, being able to share ideas and learn from experts as well as each other. Thank you RPS for an amazing opportunity!

Bairavi Indrakumar, Senior Clinical Pharmacist, Royal Free London NHS Foundation Trust

Getting started

Take the first step by finding out more about how your organisation is doing against key AMS indicators. Work with your peers and colleagues to better understand how things are working. PHE Fingertips and OpenPrescribing.net are examples of useful open-access sources of data that you can explore.

Talk to your key stakeholders to come up with shared objectives and work together on a plan to make improvements.

Inspire and get inspiration

Why not link up with others who are also working on AMS and AMR?

Update! We’ve been commissioned to provide AMS training in England in 2020. Find out more and book your place.

We are undefeatable: join the campaign to get active!

by Suzanne Gardner, Sport England

I am part of the team that has developed Sport England’s “We Are Undefeatable” campaign. It aims to support people living with health conditions to build physical activity into their lives, in a way that their condition allows, and to celebrate every victory big or small.

The TV adverts you’ll have seen are inspired by, and feature, the real-life experiences of people with long-term health conditions getting active despite the ups, downs and unpredictability of their condition.

Pharmacists already play a key support role for the 1 in 4 people now living with at least one long-term health condition. People with health conditions are twice as likely to be inactive[i] despite the compelling evidence for the role of physical activity in the prevention and management of long-term conditions.

Want to get involved? Check your activation pack!

Many pharmacists are already supporting people to get active through the Healthy Living Pharmacy scheme. To help you make the most of the national campaign 12,000 Community Pharmacies in England have been sent activation packs, which include:

  • An activation brief providing details about the campaign and links to resources to support you to have physical activity conversations with customers. These include the Faculty of Sport and Exercise Medicine’s Moving Medicine resource (developed in partnership with PHE and Sport England), the Royal College of GPs Physical Activity and Lifestyle Toolkit and the PHE E learning for health physical activity modules.
  • 2 A4 posters featuring Jo and Heraldo (Two of the Undefeatables).
  • 100 conversation starters and a dispenser for these for use in the pharmacy.
  • Access to a campaign film for use on screens
  • Social media content.

Healthy Living Bonus

The great news is that these resources can also be used to help meet the Healthy Living Pharmacy requirements linked to lifestyle advice and physical activity.

And if the campaign inspires you to get active yourself it’s a bonus!

Further copies of these resources can be accessed through the Public Health England Resource Centre  https://campaignresources.phe.gov.uk/resources


[i] (Sport England (2019) Active Lives Survey 2017/2018). 

Women in leadership: believe and achieve!

by Amandeep Doll, RPS Regional Liaison Pharmacist

This year I am delighted to be co-chairing our Women in Leadership event on 3rd October 2019 with the RPS President Sandra Gidley.  We had an incredible response to our event last year and want this year to be even bigger and better!

Believe and Achieve

The theme of this years event is Believe and Achieve. The day is full of practical advice and workshops to help you believe in yourself, celebrate your successes and be comfortable with your ambition. We have sessions with Clare Howard and Frances Akor who are current leaders; they will be sharing who their role models are and what values they believe you need to be successful.

Women are often negatively labelled according to their personality traits such as ‘too aggressive’ when they’ve demonstrated confidence in their roles, and others have included ‘too serious’, ‘too questioning,’ ‘too emotional’ and ‘too caring’.

You’ll learn how to achieve your next leadership role by challenging these stereotypes, as well as getting practical advice on how to overcome difficulties, increase your resilience and craft a winning CV.  We have workshops by Harpreet Chana and Heather Fraser from IBM on increasing your confidence and position yourself to get that leadership post.

To embrace the diversity of experiences and beliefs that women bring to leadership teams we also have a men as allies session, to celebrate the differences between men and women and how we can work together to be a successful team.

You’ll leave the event feeling more confident to apply for and take on leadership roles and also to support female colleagues to take those steps to becoming a great leader. 

Come and take part in our Women in Leadership event on 3rd October.

A question of confidence

by pharmacist Harpreet Chana, certified professional coach, speaker, trainer and founder of the Mental Wealth Academy

I am so excited to be leading a workshop on confidence at the RPS Women in Leadership Event! After attending the event last year and learning that the main barrier we face as women in progressing up the ranks within our sector was confidence, I wanted to run a workshop to address this issue and am delighted to be doing so.

Never too late

From my own experience, I understand that confidence, resilience, emotional intelligence and better outer/inner communication are essential life and leadership skills. They enable us to be mentally tough, deal with life’s challenges and are core skills that help reduce the impact of mental health on performance and life fulfilment. We are not taught these at school or university, but the good news is, it’s not too late! We can still learn these vital skills and how to apply them to our daily lives so that we are all much healthier and happier individuals as a result.

Confidence matters

How confident are you really? Has there ever been a time where a lack of confidence has stopped you from going for what you really want? From speaking up? From asking for a pay rise/promotion? From putting yourself forward for opportunities at work or at home?

How do you talk to yourself on a daily basis? Are you very critical of yourself if you make a mistake or can you forgive yourself and seize the opportunity to grow and learn from every slip-up? No matter how confident we think we are, there are always times when a lack of confidence or our biggest fears can hold us back from achieving our true potential. My confidence mini masterclass will help you to address how you see yourself and to appreciate how truly awesome you really are!

Come and take part in Harpreet’s workshop at our Women in Leadership event on 3rd October.

Asking patients using pharmacy services what they need

by Stephanie West, RPS Regional Liaison Pharmacist

In our previous blog, Nicky Gray spoke about the ‘strength and authenticity’ of relationships between stakeholders as central to successful integrated working. The same holds true when engaging the populations we serve. Promoting a positive patient experience of health and social care services, through providing integrated out-of-hospital care for patients, is a central aim for PCNs.

Community pharmacy has firm foundations to build upon. The National Healthwatch Report 2016 found that:

  • Three quarters of people say they would go to a pharmacist, rather than a GP, to get medication for a minor illness.
  • Over half would go to a pharmacist to seek advice for a specific minor illness or injury.
  • A third of people would consider using a pharmacy instead of visiting a GP for general medical advice.’

Community pharmacy was also the healthcare service of choice for ‘traditionally harder to engage groups.’ Significantly, the report found that participants ‘trusted the pharmacist’.

Asking patients

One thing that strikes me is – how are patients being consulted and educated about the increasing clinical services delivered by pharmacists? How is the patient voice being captured?

GP Practices have engaged with patients through Patient Participation Groups for many years, to make sure ‘that their practice puts the patient, and improving health, at the heart of everything it does’ These could be a useful forum to capture patient views on new ways of accessing care from the wider PCN team. If you are part of a group focussing on the role of pharmacists in the practice, please get in touch.

Community pharmacists have to conduct an annual patient survey. This focuses on traditional services and advice-giving and could be developed to raise awareness of different clinical services. 

The Berwick Review called for the NHS to ‘Engage, empower, and hear patients and carers at all times’. NHS Trusts have patient and public engagement strategies, recognising the importance of capturing patient views. There are opportunities to do this, many trusts will have patient representation on their Medicines Safety Committee, but can we engage them more widely as strategies for pharmacy and medicines optimisation are developed across Integrated Care Systems?

Shared decision-making

Liberating the NHS: No decision about me without me  focussed on shared-decision making. How are pharmacists ensuring that patients are fully involved in decisions about their own care and treatment? How is pharmacy linked with local communities, groups and networks? NICE Guidance identifies Shared decision-making as ‘an essential part of evidence-based medicine’ and the NHS Patient Safety Strategy 2019 commits to: ‘Commission shared decision-making (SDM) training for clinical pharmacists moving into PCNs, to work with patients with atrial fibrillation (AF) on anticoagulants’.

Get in touch

Our new System Leadership Resource section on ‘Culture Change’ includes a focus on meaningful engagement with local people. If you have a case study showing how you have improved health outcomes or developed a service through patient engagement, shared-decision making and/or co-production we would like to share your insights so please do contact us.


 


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Bring your whole self to work

By Robbie Turner, RPS Director for Pharmacy and Member Experience

Pharmacy is a very diverse profession, especially in terms of gender and ethnicity.  As your professional body, we want to recognise, celebrate and encourage a variety of voices and experiences across pharmacy to better represent you.

The diversity we see is not necessarily represented at senior and leadership level though. Things could be better, and as an organisation we recognise we could also do more in this space.

That’s why I’m so excited we have launched a new programme of work on inclusion and diversity. 

Pharmacists often work in isolation, and especially in the case of community pharmacy, may often be the only healthcare professional on the premises. It can be hard to bring your authentic self to work when your environment means you don’t feel comfortable expressing who you are.  When we don’t bring our whole selves to work we can suffer – in terms of our wellbeing and our work.

We are about to go out to the profession as a whole to get your views on how inclusion and diversity can be improved and celebrated. There will be opportunities to engage with us on this to make sure that our strategy is truly created hand in hand with you.

We’ll be launching a survey at the end of the month as a starter. It’s incredibly important that as many of you as possible complete it – it’s your chance to be in at the start and ensure you inform what we do, both in the short and longer term.

After that we’ll be creating and celebrating some key events such as Women in Leadership and Black History Month in October.

We’ll be sharing our initial thinking at our annual conference on 17th November. 

I’m convinced this programme is the right way forward for the profession, as is everyone at the RPS. Who you truly are matters. We want you to feel able to bring your whole self to work and experience a sense of belonging. I hope you join us on this journey. 

It’s not business, it’s personal!

by Nicola Gray, RPS Regional Liaison Pharmacist

I have no doubt that the success of forthcoming integration across systems and sectors is going to be determined by the strength of personal relationships between stakeholders. Human beings crave connection with others above all else and the strength and authenticity of these connections will influence partnership working.

Making connections

These connections cannot be formed ‘on demand’. Sometimes people meet and immediately recognise a ‘soul mate’, personal or professional, but this is rare. And even then, we have to hope that the first flush of exhilaration for a strong new connection settles into something enduring and mutually enriching.

Developing relationships

I was recently a guest of Greater Manchester LPC at the NPA Conference in Manchester, and a thread about relationships became apparent across a number of presentations. Ed Waller from NHSE highlighted the importance of developing relationships and collaborative networks to enable community pharmacy to play its optimum role in PCNs. Simon Dukes from PSNC reflected on why partnerships fail, including lack of trust, stalemate, and the perceived power of one party over the other.

Later, Rose Marie Parr, Chief Pharmacist in the Scottish Government, countered that good relationships are built upon a shared vision, effective leadership and trust. Russell Goodway from Community Pharmacy Wales spoke of delivering a shared ambition through a willing partnership, and our own Paul Bennett spoke of unprecedented co-operation among representative bodies through aligning on the major issues facing pharmacists

Focus on what’s real

I think it is time to reflect on the strongest connections and most enduring, authentic relationships that each pharmacist has made – without exploiting them but focusing on mutual benefit. An obvious source of many enduring connections for pharmacy is with patients. How can pharmacists really tune into those connections to find out what is most relevant and valuable to their local population? Is that not the foundation on which our ‘offer’ to the local health system must be based? How, can we then share this common vision and facilitate strategic change at local level?   NHSE is sending a strong message through PSNC that a ‘tsunami’ of separate pharmacy approaches to PCNs will not be welcomed. What is needed is a coordinated effort from contractors within each locality.

Make use of support

We should also reflect on wider support from the pharmacy system that we can draw upon. From connections with colleagues in local hospitals, and our ‘academic hubs’ in our Schools of Pharmacy. Reminding us who we are, where we have been, and where we are going – not least with what we have to offer to the health system of our understanding of new medicines and new science. For those who already have strong and enduring relationships with multidisciplinary partners in primary care and beyond, try to anticipate the turbulence that they must also be experiencing and consider how you can help them to achieve shared objectives for your community.

So let’s take stock now of our best and most enduring connections, and pool our knowledge to make maximum impact when the time is right.

Our new resource on system leadership helps point the way. It includes case studies from pharmacists working in different levels of the system and links to tools, standards and guides to develop the leadership qualities required to work collaboratively across boundaries within your local health and care systems.