Northumberland Tyne and Wear NHS Foundation Trust (NTW) has developed a medication clinic within the Sunderland Learning Disability team focused on adherence to the NICE NG11 guideline.
This ensures that the use of antipsychotic medication is only considered for challenging behaviour once non-pharmacological methods have been tried and do not fully remove the behaviour. The process ensures that when medication is considered there are clearly targeted behaviours together with robust review timescales for benefit and side effect evaluation. It also focuses on length of treatment together with an exit plan should the medication fail to achieve its desired targets.
The process will also look at reviewing longstanding prescriptions with a view to reduction and discontinuation of an antipsychotic if no longer evidenced as being beneficial. This meets the criteria for a STOMP style review (Stopping overmedication of people with a learning disability).
Aims & Objectives
The overall aim is to ensure the correct initiation and review of antipsychotic medication relating to the prevention and intervention of challenging behaviour. This will ensure that medication is only used as a second line treatment for behavioural management and never as monotherapy. This meets the aims of the Winterbourne View Hospital: Department of Health review and response document December 2012 into the care of people with a learning disability, which highlighted the over reliance on antipsychotic medication for challenging behaviour.
The objectives are:
- To ensure the that all non-pharmacological methods of behavioural intervention are considered before medication
- To ensure that medication, when initiated, is used in conjunction with non-pharmacological methods
- To ensure the correct recording of why medication is being used by targeting specific behaviours
- To ensure the correct baseline monitoring is completed when initiating medication
- To ensure patients, carers and family members have access to quality information about the medication including in easy read format to enable full agreement to it being used
- To ensure medication is reviewed at the appropriate timescales (3-4 weeks and stopped at week 6 if not working, week 12 then every 6 months). This includes an appraisal of benefit and side effect burden
- To ensure the information given to primary care at the point of discharge includes all relevant behavioural information, expected time on the medication and a withdrawal schedule.
The work started to the Trust response to the Department of Health’s Winterbourne View Hospital report highlighting over reliance on psychotropic medication. In 2015 a study by Public Health England ‘Prescribing of psychotropic drugs to people with learning disabilities and/or autism by general practitioners in England’ showed that 1 in 6 people with a learning disability received a psychotropic medication half of whom did not have a mental illness. This equates to 30,000-35,000 prescriptions per day for medication thought to be for behavioural management.
The Trust also highlighted recording, reviewing and monitoring of antipsychotic medication in the Prescribing Observatory for Mental Health (POMHUK) audit topic 9c Antipsychotic prescribing in people with a learning disability. This audit highlighted that most medication use was being recorded and reviewed but did not stipulate the quality. It also showed that the monitoring rate for antipsychotic use, including blood tests and lifestyle factors was below 50%
The Sunderland Team developed an audit tool to assess psychotropic recording and monitoring at the time of the publication of the NICE Guidance. The attached audit tool, developed by Kerry Graham Specialist Nurse in Challenging Behaviour, targeted all aspects of medication initiation and monitoring. Initial results were poor in relation to a record of behavioural intervention. The monitoring of medication was similarly well below expected standards and a re-audit is currently being evaluated
A review into the quality of information shared with primary care showed a wide variation in standard with fewer than 30% of discharge information complying with the NICE NG11 guidance. Information seldom included behavioural targets and there were no reduction/review plans.
A clinic was developed within the Sunderland Community Learning Disability team focused on implementing the standards of NICE NG11. A Nurse, Pharmacist Independent Prescriber and a Consultant Psychiatrist developed a clinic model based on the NICE NG11 principles. This ensured that all patients requiring behavioural intervention received full Positive Behavioural Support (PBS) before medication was considered.
The clinic represented a new way of working utilising the wider multi-disciplinary team. The unique nature, using a pharmacist as a prescriber, had not been trialled before and the team did not have the benefit of past experience. The use of a pharmacist within the team had not been utilised previously and the Sunderland staff needed to become familiar with the specific role that a pharmacist might play. It meant that a period of 6 months was considered for all parties to become more aware of each other’s roles. The pharmacist needed to overcome initial suspicion from other members of the team as to the input that was being considered. Taking time to build robust working relationships was key to its future success.
At the time of development the clinic was also a method to counter the challenges being faced by Learning Disability Psychiatry. Recruitment and retention in this area has been a national issue and the clinic also functioned to release psychiatrist time.
The pharmacy department monitored the impact of the pharmacist role and built a business case for ongoing funding. This bid was accepted and money found within the existing budget of the team – No additional funding was required to set up the service.
When medication was initiated it was recorded in line with the NG 11 principles and captured on the clinical system. A separate clinic was established with the Positive Behavioural Support (PBS) team to identify individuals needing a full enhanced review of medication with a view to support reduction and even discontinuation of the regime. This would be supported by the PBS team using non-pharmacological behavioural control – in effect this is the initiation principle in reverse and ensures that medication is never considered as monotherapy. PBS staff would refer clients they had been working with to the STOMP clinic established by the prescribing pharmacist.
When medication was considered for initiation, the clinic ensured the presence of a trained healthcare worker to capture all baseline monitoring including bloods, lifestyle discussion and physical parameters such as blood pressure, weight etc. An electrocardiogram (ECG) was facilitated if indicated that this was required. During initiation, this monitoring continued until the prescribing could be handed over to the GP under shared care principles.
Review dates were set within the guidance deadlines where benefit and side effect burden, using a validated scale (GASS – Glasgow Antipsychotic Side effect Scale) were captured.
Results and evaluation
The following results were captured:
All medications initiated since September 2016 have been recorded effectively. The previous level was below 50%. Work is underway to develop a specific recording page on the clinical system detailing initiation in line with NG11.
All antipsychotic medications initiated since September 2016 have been reviewed within NICE NG11 timescales. Three medications were stopped by week 6 due to poor response or side effect burden.
All antipsychotic medications have a validated side effect scale completely at least annually if no dose changes with newly initiated ones having a side effect scale completed after each dose change. The scale was not officially used before the clinic was established hence this represents a 100% improvement.
Previous figures for monitoring of antipsychotics was 30%. This is now 75% within the medication clinic structure and has improved over a 6 month period. Work is ongoing to ensure all patients have the correct monitoring recorded. This includes training sessions for support workers in how to undertake physical checks and capture relevant details on the clinical system.
In relation to the removal of medication, the STOMP clinic has produced the results illustrated in the graph here.
Four people have successfully stopped medication with a further four undergoing a reduction strategy. All have been fully supported with input from the PBS team.
Key learning points
The key to success in implementing the principles of NICE NG11 is to gain commitment from all members of the wider multi-disciplinary team. Ensuring everyone understands the principles and supports their achievement is the correct starting point.
Undertaking an audit of current practice will allow clear planning of what needs to be achieved to implement to guidance. Understanding the limitations of the team is also key and may help to formulate potential timescales to achievement. The Sunderland team was fully established with trained staff making it easier to implement.
Develop a clinic structure to support the guidelines and clearly define roles within the team, who captures background information and populates the clinical record. Who will capture side effect information and how will the clinic appointment be structured are all keys to success.
Be patient as it may requires operational change including the necessity to train staff in new ways of working. Set milestone targets to full achievement as it may take several months to fully develop the team.
Detail the recording process in full and share so there is total continuity. One pitfall was the recording of similar information across different sections of the clinical record by different prescribers. Agree what it required and communicate this requirement.
Regularly monitor progress against your timescales and share finings with the team
One pitfall is that each community team within the Trust is commissioned to a different service specification. This means not all teams will have access to a full PBS team for support with medication initiation and removal.