Developing a medications policy and procedures for use in social care

Adult Community Services (ACS) at Suffolk County Council (SCC) have responsibility for providing health and social care services to adults living in the community.

Within this remit ACS commissions care providers to deliver a range of services, which may incorporate medication support. However, SCC ACS does not commission medication only domiciliary care calls unless there are exceptional reasons and medication is not included within the Care Act 2014 eligibility outcomes.

Following several medication incidents, SCC ACS identified the need for a robust policy and procedure on medication support. All key stakeholders recognised the need for an overarching policy and subsequently NICE guideline NG67 was published which was used as the starting point for developing the policy in collaboration with Suffolk Hospitals, Pharmacists, Clinical Commissioning Groups, Home First the local reablement service providers and care providers.

The aim of the project was to develop a local medication policy and ensure that all domiciliary care providers and the Home First reablement provider had clarification around what their responsibilities were in relation to medication. The main aim of the policy and procedure was to standardise practice and provide an example of good practice for care providers who are assisting adults receiving social care services within the community to manage their medication.

Adopting a standardised practice in providing medication support across all care providers, would ensure that a consistent approach reflecting best practice could be followed. The objectives were for adults to be supported to remain independent or regain independence with their medication wherever possible, and for this to be encouraged by care providers.

The policy and procedure are aligned with the recommended standards outlined in NICE Guideline NG67 and NICE Quality Standard QS171. The policy covers all oral medication, transdermal patches, warfarin, insulin, topicals, subcutaneous anti-coagulants, prn (when required medicines) and medication disposal. Efficiencies and cost savings related to the storage and disposal of medication were also identified. The project involved liaising with Surrey and Norfolk County Councils who already had similar policies. This a Suffolk County Council sponsored policy, which was ratified through the organisations existing governance framework, agreed at the ACS Directorate Management Team, and an equality impact assessment was carried out as part of the policy development.

Prior to the development of the policy and procedure each domiciliary care provider, the reablement provider and the hospital pharmacies had their own individual processes for ensuring that patients had access to their prescribed medication. For patients in hospital an assessment of medication support would be undertaken in the community once the patient was discharged.

Following several medication errors, issues were identified by social work and safeguarding processes, which highlighted a lack of training and inconsistencies in the administration and support for medication for patients across Suffolk. For example, there were significant differences in the medication recording forms used by different domiciliary care providers. All stakeholders acknowledged that there was a need to improve communication between hospital pharmacies and the care and reablement providers.

It was proposed that reducing medication errors, which may have the potential to require medical intervention or hospital admission would lead to better health outcomes for patients and avoid unnecessary costs associated with hospital admissions and incident investigations. For example, it was identified that there was a considerable risk of incorrect dosages of warfarin being administered which can have profound consequences for patients and lead to urgent medical attention being required.

Further benefits of the policy and procedure development included:

• More efficient use of time for domiciliary care visits through the provision of clearer guidelines and the competencies required of care staff.
• Improved communication across health and social care providers.
• Improved patients independence with medication, leading to reduced costs across health and social care by facilitating people to manage their own medication rather than reliance on care providers to do.

Although there was no direct patient involvement a wide range of stakeholder involvement was sought in both primary and secondary care. The impact of this policy is county wide across Suffolk, which has a population of 758,00 people across a geographical area of almost 3800km2. The proportion of the population aged 65 and over is disproportionately higher in Suffolk (22.9%) compared to the East of England (19.5%) or England (18%). The percentage of people living with a long-term illness or disability is also higher in Suffolk at 17.9% compared to 16.7% in the East of England region and dementia prevalence is also 0.1% high.

The NICE Implementation and Core Local Authority Guidance Review Group (NICER) is established within Suffolk County Council to review published NICE Public Health guidance and facilitate and monitor the implementation of NICE guidance relevant to Suffolk County Council.

This was the starting point for identifying the need to develop the policy. A working group was established with representation from SCC, Home First, West Suffolk Hospital, Ipswich Hospital, James Paget Hospital, the CCGs and GP representatives. The policy development was commenced in February 2018 and completed in September 2018. Prior to the policy being ratified a separate care provider working group was established to road test the feasibility of the policy and to trial assorted options for a standardised documentation template for medication administration.

The draft policy was also disseminated for consultation and progress was monitored by the NICER group within SCC. On policy launch communications were developed for internal and external use. In addition, SCC ACS commission medication training for care providers which was redesigned to support the policy implementation and in line with the associated NICE guidance and quality standards. This training is delivered by a pharmacist who was also a member of the working group. Policy feedback was sought through the provision of a central contact included within the policy.

The project was successful in meeting its aims and objectives as the necessary policy, procedures and training were developed and implemented in consultation with key stakeholders.

This has resulted in a consistent approach to medication management in the community by reablement and social care providers, which has reduced the number of medication incidents in the county. The providers have been engaged and consulted on developing the suite of products and this has had a positive impact on staff morale.

The training which has been delivered has also evaluated well. Reducing medication errors avoids unnecessary healthcare usage which has cost savings, although it is hard to quantify this in financial terms. The benefits for service users are consistency in approach to their medications management as well as provision of support to assist them in maintaining independence with medication where appropriate.

Some of the key learning identified in developing the policy and procedure includes:

Using existing guidance and documentation is a key aspect in developing a comprehensive policy which needs to be adopted by multiple care provider across a complex healthcare system.

The importance of considering how the approach might need to be tailored to ensure that guidance and the quality standard was interpreted with reference to the local context. Where stakeholders are working in isolation, there is a need to have a united approach and to develop consensus locally among all stakeholders.

It was a challenge to get GPs on board and if approaching this project again we would acknowledge the challenges of this and consider how to engage with them better. There is also a need to build in measures to ensure compliance with the policy during contract development and negotiations and to consider appropriate monitoring and audit requirements.

There is a huge benefit in having a multi-agency group within the local authority to support and oversee the implementation of NICE guidance particularly in community and non-hospital settings. Through the project one of the ACS clinical leads championed the development of the policy, without which it would not have been successful. Hence, we learned that local champions are key for developing and implementing complex multidisciplinary clinical policies.