medicines use and safety webinar september 2018 · • learning from new models of care, including...
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MEDICINES USE AND SAFETY WEBINAR
SEPTEMBER 2018
• Welcome to the MUS Webinar on Carter 2 - Operational Productivity:
Mental Health and Community Services
• The webinar itself will start at 1pm. Shortly before 1pm the SPS webinar host
will be doing sound checks so bear with us if you hear this more than once!
• To join the audio call 0203 478 5289 access code 144 606 460.
• The webinar will be recorded and both recording and slide set will be
available on the SPS website – under Networks (you need to be logged onto
the SPS site to access the recording)
• If you want to make a comment or ask a question – please use the “chat”
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the drop down box)
• The presenters will answer questions at the end of the presentation
12 September 2018 1
www.sps.nhs.uk 2
Upcoming MUS Events
Webinars:
10th October – Health and Justice update – Denise Farmer
14th November – Patient Group Directions – Jo Jenkins
THURSDAY 13th December – Anticholinergics – Delia Bishara
FACE TO FACE EVENTS
27th November – Older People Network Event
Contact [email protected]
to join networks and receive mailings
NHS operational productivity: unwarranted variations Mental health Community health services Pharmacy, Medicines & Pathways
Ann Jacklin
Professional Pharmacy Advisor Mental Health & Community Services
4 | 4 |
How the sectors are configured
Total NHS spend = £17bn
192 trusts deliver community services
82 trusts deliver mental health services
Community health services
Mental health trusts £9.3bn
Mental health services
Estates 7.8%
Procurement – 6.7% Medicines – 1.9%
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• No two community or mental health trusts delivered the same services, and nearly all trusts we examined provided a mixture of community health and mental health services.
• Most trusts delivered over 100 distinct service lines, however, a core common set emerged:
What services are delivered
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Lord Carter concluded
• There is significant good practice but there need to be stronger mechanisms for sharing this between trusts.
• Learning from new models of care, including Integrated Care Pioneers and the Vanguards needs to be strengthened
• The Getting it Right First Time Programme (GIRFT) needs to extend its focus to services delivered in the community.
• Action must be taken to reduce the £500 million spent annually on inappropriate out of area placements in mental health inpatient services.
• The commissioning landscape has led to a fragmented system that is difficult for patients to understand and is not delivering value for the tax payer. More focus needs to be given to standardising this.
• Workforce productivity is mixed, particularly in services delivered in the community.
• The use of mobile working and technology to drive efficiency and productivity is inconsistent and poor in many areas.
• There is scope for trusts to take rapid and specific action in a number of other areas to improve efficiency,
7 | 7 |
Medicines, Pharmacy & Pathways
NOT about spend and spend reduction
• Acute trusts medicines spend pa £7,000,000,000 (£7 bn) • MH &CHS medicines spend pa £262,000,000 (£0.262 bn)
IS about value
• To optimise pharmacy services & extend of clinical pharmacy services
• To optimise medicines and medicines related products • Pathways, outcomes, relapse, readmission, formulation, • Review and physical health
• To identify pathways with medicines / medicines related products for which variation will have a significant impact on patient outcomes or non pharmacy staff utilisation or service delivery costs
•
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Current service delivery models
Clinical
Governance
Infrastructure
Services in mental health & community trusts • Infrastructure
• Governance • Clinical
0%5%
10%15%20%25%30%35%40%
0%
10%
20%
30%
40%
50%
Mental Health Community Services
Clinical 38% Clinical 30%
Mental Health
Community
9 |
Delivering increased patient facing clinical pharmacy services
Infrastructure Apply Carter 1 metrics and/or explore alternative models
Governance Opportunities for ‘do once’ nationally
Clinical Expand & address unmet community based need
Clinical
Governance
Infrastructure
Clinical
Governance
Infrastructure
10 | 10 |
Clinical Pharmacy vs Patient activity in these sectors
bedded
community
Spot the difference?
Growing evidence base to support services in the community for pharmacy
staff including:
• Running clinics – clozapine, anticoagulant, dose titration
• Medication review – domiciliary and clinic based
• Child and Adolescent Mental Health services
• Crisis teams
• Memory services
• Community Mental Health Teams
Clinical pharmacy activity
11 | 11 |
Recommendations:
Quality of care and Getting It Right First Time (GIRFT)
The GIRFT programme should ensure that the role of community health services is
considered in all relevant clinical specialities and make rapid progress in undertaking work in
mental health. For mental health, this should include supporting the elimination of
inappropriate out of area placements for adult acute mental healthcare by 2021.
Delivered by:
• Piloting a new project to test the GIRFT approach on wound care services delivered in the
community to reduce unwarranted variation in clinical quality, productivity and efficiency,
linking with the NHS England and NHS Improvement Wound Care Strategy Board.
• Starting the work on mental health, including completing all data collections by December
2019 and publishing three national GIRFT reports by April 2020 that describe the standard
model of care for each pathway.
12 | 12 |
• “One of the most significant areas of community health service provision we identified in discussion with cohort trusts was wound care. Managing wounds is a critical service in community nursing”
• “Most trusts, however, do not capture basic information on wound care including the number of patients with wounds, wound types, treatment plans or, most critically, wound heal rates”
• “Many trusts also lack protocols for how to manage different types of wounds”
• “We observed significant variations in how specialist tissue viability nurses were deployed, the use of mobile technology and how much providers pay for wound care supplies”
What Lord Carter said about wound care
13 | 13 |
Piloting a new project to test the GIRFT approach on wound care services delivered in
the community to reduce unwarranted variation in clinical quality, productivity and
efficiency, linking with the NHS England and NHS Improvement Wound Care Strategy
Board.
GIRFT
• Paper going to September meeting proposing recruitment for a Nurse Clinical Lead to pilot a
GIRFT wound care project.
• Business case may be required to secure funding for clinical lead and analyst support
National Strategic Wound Care Board
• Governance structure under development
• Year 1 funding obtained for programme manager an support
• National workshop 21 September
• Date first Board meeting tbc
Wound care update
14 | 14 |
Wound Care
Leading change
adding value
Burden of Wounds
AHSNs
Safety Thermometer
National Stop the Pressure
React to Red
GIRFT
TVS projects
RCN TVS
networks
Academic
work
Local projects
Right Care
Betty’s
story
Wound care - the need for a
National Strategy
15 | 15 |
Vision and Mission for the National Wound care strategy
16 | 16 |
National Wound Care governance and assurance
Forum Members
Operational Delivery Work Streams
Stakeholder council
Chair: Jo Gander
Industry Stakeholder
Forum
Chair
Forum Members
HCP Stakeholder forum
Chair
Forum Members
Patient stakeholder
Forum
Chair
NHSI GIRFT
Executive sponsor
Stakeholder council Chair
Senior Innovation and
delivery Partner
Chairs of the operational workstreams
Eiri Jones
Ruth May
Jo Gander
Tracey Ward
Strategy Board
Baroness Watkins
Margaret Kitchin
Una Adderley
Mike Burrows
Independent Chair
SRO
Programme Director
AHSN
Workstream expert team
data, technology and Info
workstream
Chair
Workstream expert team
Supply, Dist. And
Commissionng workstream
Chair
Workstream expert team
E, T and workforce
workstream
Chair
Surgical Wound workstream
Chair
Workstream expert team
Research Workstream
Chair
Workstream expert team
Pressure Ulcer workstream
Chair
Workstream expert team
Lower limb Workstream
Chair
Workstream expert team
Information Flow
17 | 17 |
Starting the work on mental health, including completing all data collections by December 2019 and publishing three national GIRFT reports by April 2020 that describe the standard model of care for each pathway.
• 3 national clinical leads to be appointed for mental health
• First appointed from 3 September
• Mental health rehabilitation
• Clinical Lead, Dr Sridevi Kalidindi
• Meetings being arranged
“Prescribing is such a key area in Rehab where ~ 85% of the service users have treatment resistant psychotic conditions, and many (up to 50% in some cohorts) have co-morbid physical health LTCs. This is the group with the premature mortality gap due to physical health conditions too.”
“Reducing unwanted variation around medicines, will be a key aspect of improving several outcomes, from lengths of stay to the prevention/reduction of physical health LTCs.”
GIRFT Mental Health update
18 | 18 |
• The GIRFT programme focuses on reducing unwarranted variations in clinical settings for 35 work streams.
• Clinically led speciality or pathway based workstreams
• For each specialty or pathway
• identify specific areas of unwarranted variation based on local and national data, and
• provide a detailed, clinically led engagement process with each trust to improve patient outcomes.
• So far, the programme has made 1,100 visits to trusts and published reports on three clinical work streams with another 10 reports due to be released in 2018.
• As a by-product of improving patient pathways and clinical outcomes, it is expected to deliver more than £1.4 billion of savings by April 2021.
Getting It Right First Time (GIRFT)
19 | 19 |
20 | 20 |
Model Mental Health and Community Services
Extend Expand
Get your log in: https://model.nhs.uk
Recommendation 15 – Model Hospital NHS Improvement should develop the current Model Hospital and the underlying metrics to ensure there is one repository of data, benchmarks and good practice so all trusts can identify what good looks like for services they deliver.
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Model Hospital current MH & CS
22 | 22 |
Q3 2018/19
• Inpatient (ward)
• Services delivered in the community (phase 1)
• 4 mental services lines initially (community mental health teams, crisis home teams, forensic mental health teams)
• To be followed by LD, general & psychiatric liaison
April 2019
• Medicines and Pharmacy (phase 1)
• builds on acute compartment
• New metrics include
Model Hospital compartments planned
% Pharmacy technician Time spent on Clinical Pharmacy Activities % pharmacy assistant time spent on Clinical Pharmacy Activities] Total number of multidisciplinary team meetings (where individual patients are reviewed) attended per week Average number of consultant/registrar/other ward rounds with pharmacy input per week Average cumulative number of hours per week spent providing clinical pharmacy support for Home Treatment Teams / Community Teams. Does the organisation have pharmacists that regularly go out and see patients in their own homes, community clinics or other community setting?
Pharmacy staff (WTE) working in: generic CMHT Pharmacy staff (WTE) working in: CAMHS community teams
Pharmacy staff (WTE) working in: Home treatment teams
Pharmacy staff (WTE) working in:clozapiine clinics
Pharmacy staff (WTE) working in: forensic services
Pharmacy staff (WTE) working in: early intervention in Psychosis teams no clozapine clinics with pharmacy staff as % of total clozapine clinics
% of users on CPA who receive physical health check once a year
23 | 23 |
Medicines and pharmacy optimisation recommendations Trusts should develop plans to ensure their pharmacists and other pharmacy staff spend more time with patients and on medicines optimisation
Delivered by:
• Increase specialist pharmacy professionals:
• including advanced clinical practitioners (pharmacists) working within multidisciplinary teams to lead and coordinate medicines use for cohorts of patients across health and social systems to reduce fragmentation
• Increase numbers of pharmacist prescribers to add capacity, expertise and value
• Pharmacists and other pharmacy staff spending more time on patient-facing medicines optimisation activities
• National ‘do once’ systems should be developed for:
• PGDs & Medicines policies
• Education and Training materials
• Innovative use of pharmacy staff, systems and technologies
• CAMHS, clozapine, antipsychotic, medicines administration, medicines automation and polypharmacy reviews.
• Infrastructure collaboration with other providers and infrastructure acute trust Model Hospital targets met.
• Dispensing, homecare, FP10 supply chains should be reviewed for patient in the community
• Stockholding, e-ordering & e-invoicing
24 | 24 |
NHS Improvement and trusts examining the potential to streamline processes for the ordering, approval and delivery of medicines and clinical products to patients receiving services in the community during 2018/19. This should include the use of homecare and FP10s.
Trusts reviewing the value for money of all infrastructure activities to release capacity for patient-facing work. Opportunities to collaborate with other providers should be explored during 2018/19.
• Scheduled for discussion at the cohort meeting 26 September
• NHS England System leadership pilots may provide insights
Trusts that provide their own stores and distribution services consolidating medicines stock-holding, and aggregating and rationalising deliveries. This should seek to reduce stock-holding days to a maximum of 15 and deliveries to less than five per day, and ensure 90% of orders and invoices are sent and processed electronically by 2020/21.
• Model hospital metrics from April 2019
Infrastructure recommendations
25 | 25 |
The Centre for Pharmacy Postgraduate Education developing a system-wide approach to developing medicines teaching materials for mental health and community trusts starting in 2018/19 to release local staff time to education and training delivery.
• CPPE Clinical Fellow working with team in the North West to test data gathering concepts
• Exploring new library system which HEE have developed
• Meeting scheduled 2 October
NHS England’s Specialist Pharmacy Services and the regional medicines optimisation committees developing a national ‘do once’ system for organisational medicines governance, including national standardised medicines policies, patient group directions and other essential organisational governance documents during 2018/19.
• Medicines governance do once secretariat established June 2018
• RMOC paper going to South RMOC end September 2018
• Ambulance short life working group first meeting held July 2018
• Antimicrobial short life working group first meeting scheduled October 2018
Governance recommendations
26 | 26 |
Trusts increasing the numbers of specialist pharmacy professionals – including advanced clinical practitioners (pharmacists) – working in multidisciplinary teams to better lead and co-ordinate medicines use for cohorts of patients across health and social care systems by 2020/21.
Trusts increasing the numbers of pharmacist prescribers to add capacity, expertise and value starting with increased numbers in training in 2018.
• NHS England mental health pharmacy workforce strategy implementation work ongoing
• Model Hospital metrics available for benchmarking from April 2018
• Case studies to be developed throughout 18/19 to support local business cases
Health Education England ensuring that workforce plans include capacity to support the development of higher numbers of pre-registration trainee placements, vocational foundation trainees, specialist pharmacists and pharmacy technicians in mental healthcare settings, including increasing the numbers of advanced clinical practitioners (pharmacists) and consultant pharmacists by 2020.
• NHS England mental health pharmacy workforce strategy implementation work ongoing
• Meeting with 4 regional pharmacy deans scheduled for 20 September
Clinical recommendations (1)
27 | 27 |
Trusts identifying local opportunities for the innovative use of pharmacy staff, systems and technologies using case studies provided by NHS England and NHS Improvement during 2018/19. This should include reviews into CAMHS, use clozapine and antipsychotics, medicines administration, automation and polypharmacy.
• Model hospital metrics from April 2019 will enable benchmarking
• Case studies to be developed throughout 18/19 to support local business cases
• Links to the acute trust programme of job planning and e-rostering being explored. Early case studies suggest e-rostering releases capacity.
Clinical recommendations (2)
28 | 28 |
Case Studies Clozapine clinics
Northumberland, Tyne and Wear NHS Foundation Trust changed its model for administering clozapine to service users, to a pharmacy technician-led clinic. This helped to improve patient experience by supporting service users in need of clozapine to access their treatment more easily and in a way that better suits their service needs. The new model combines blood monitoring with medicines supply, and has halved the number of required visits and improved the levels of missed appointments. The new model has reduced the cost of an initiation from £3,000 to £300, and avoided costs of about £100,000 during the first two years of operation.
Wound Care dressing supply (not included in
report)
Central & North West London NHS Foundation Trust
identified inefficient process for providing wound care
dressings. This process was time consuming as there
was lapse between the identification of a need for a
dressing and the delivery of this care. The Trust
carried out a patient satisfaction survey following
changes of wound dressings for household patients in
Hillingdon. In November 2016, changed the way
dressings were prescribed to avoid patients given
boxes of unnecessary dressings. There was a 75%
response rate and 74.75% of patients stated before
the remodelling their prescriptions for dressings had
not been received. 61% of patients had nurses re-visit
with the correct dressings. The findings found
reduction of wasting products and the new process for
providing wound dressings had a positive impact for
patients with 42 (74%) out of 57 saying it was
beneficial to them.
29 | 29 |
Medicines self-administration
Kent Community NHS Foundation Trust invested £185,000 in additional pharmacy staff to support patients to self-administer medicines, and worked with local GPs and patients to improve the quality of communication with patients about medicines. Through this programme, and by improving the relationships and understanding of medicines optimisation across and with other organisations, the trust estimates annual savings of £1 million from fewer community nurse visits and medicines usage reductions.
Sussex Partnership NHS
Foundation Trust (CAMHS) The trust employed a specialist mental
health pharmacist in a CAMHS team
and achieved a net annual saving on its
drug budget of £97,000. This successful
change led the trust to expand the
example, and placed specialist mental
health pharmacists in more of its
community teams. The pharmacists
help triage referral calls to the team and
have been able to keep some patients
with their GP with modifications to their
treatment to improve care.
Helping care for patients in their homes
(OPAT) Patients with diabetic foot ulcer infections
involving osteomyelitis can require long term
treatment with intravenous antibiotics, and some
will require these to be administered three times
a day. Kettering General Hospital NHS
Foundation Trust recognised that in the absence
of sufficient capacity in its community teams
these patients often needed to be treated in
hospital as an inpatient. Following a successful
pilot in 2015, the trust has already reduced
numbers of acute inpatient admissions and
estimates that it will save 1,900 bed days a year,
or about £360,000
30 | 30 |
Automation
Northumberland, Tyne and Wear NHS Foundation Trust have used automation extensively: a combination of automation on wards and in pharmacy led to the rationalisation of three dispensaries into one with pharmacy staff redeployed to support medicines use on wards. Using ward-based automation, the time nurses spent on medicines rounds on the wards reduced. This trust recently installed a robotic dispensing system for filling multi-dose packs for all 1,700 clozapine patients. It is planning to use the robot’s spare capacity to provide services to other trusts locally.
In summary
Our review demonstrated that pharmacy services are underused in
these sectors. Better use of pharmacy staff to support patients and
other clinical staff with medicines can offer tremendous value to the
NHS and address much unmet need. We believe collaborative
working offers opportunities, including the deployment of technology,
to release pharmacy staff time. Not only will this improve patients’
experience and outcomes, but it represents good value for money.
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Questions?
Operational Productivity Mental Health & Community Services Medicines, Pharmacy & Pathways
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Poll Question Number 1
Overall I found the webinar content useful to me:
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Poll Question Number 2
I would recommend this learning event to others:
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