Patient Led Clinical Medicines Reviews

The aim of which is to allow people the option to lead on their own care through a guided conversation with professionals, providing a chance to discuss options in more detail in a safe and supportive environment. This service tackles three key areas:

• Firstly, this starts to address is the fact that specialists in different areas of medicine only ever review the medicines they have prescribed. So people end up with a continuation of medicines they don’t need and often medicines which make things worse. By going through this in some detail, led by the person themselves who is free to ‘tell their story’, we are helping them make changes.
• Secondly, it helps bring out the things people don’t normally tell their doctors (we all do this). In the jargon this is called ‘intentional non-adherence’. This increased trust and openness seems to be because we deliver these reviews as part of larger project led by users of services, so by the time we see people they have built up a degree of trust in the process.
• Thirdly, we’re finding some unexpected patient safety benefits. We’re learning that, because of the way the sessions are carried out, some people feel able to share information on their medicines and treatments with us that they haven’t previously shared with anyone. On a number of occasions, we have been able to give advice on medicines safety and signpost people to services they need, but had previously either avoided or been unaware of.

This work was initially commissioned by the Department of Work and Pensions [DWP] as part of a Condition Management Course. The primary aim was to help people who are in receipt of Employment Support Allowance [ESA] on the route back to work. This has affected how we evaluated the project, as Primary Care services were not part of the original project team.

The DWP funded course was open to anyone on ESA with long term conditions. There was no restriction on what these conditions were.

Participants were given a group session on medicines, which covered all areas such as 'what is a medicine?' - 'where do I find reliable information?' - 'side-effects and interactions' - 'having a meaningful conversation with clinical people'. We were able to build references to NICE Guidance, resources and patient decision aids into the group and individual sessions, and tailor this to the needs of the individuals.

The participants were then asked if they would like an individual support session on their medicines. About 1/3 of the group participants took part in this session. The remainder were satisfied that the group session gave them all the information they needed.

The sessions were carried out in towns in Cornwall and Somerset. Participants were recruited by the local Job Centres. The course was not mandatory, and participants had the option to opt out at any stage. Each course consisted of a maximum of 18 participants and there was a wide variation in group numbers between areas. The course met its aim of helping people on the route to employment and was recommissioned three times. In all we saw 120 people in the group sessions, of which 28 opted to have an individual session on medicines.

There were several common areas related to medicines which came up in the group and individual sessions. We were particularly active in answering questions and suggesting new options on muscoskeletal problems, mental health issues and appropriate use of prescribed medicines particularly in relation to intentional non-adherence. One course was in a town with a high level of deprivation and social issues, where a much of our work was related to substance misuse and engagement with services. This included setting out options for available treatments and therapies, and advice on referral pathways.

In the group sessions we gave a general overview of NICE guidance, and then focused on the relevant guidelines for the audience. In the individual sessions we were able to give specific advice related to NICE guidance and resources, include this on the options plan we gave to people, and follow this up with them (usually with a check ‘phone call) where necessary and agreed. We carried out the first three group and individual sessions as a pilot, and tailored our subsequent sessions to accommodate feedback, results and reflections.

The main problems we faced were firstly that we didn't know in advance what conditions the participant had. This turned out to be an advantage, as we were able to tailor our approach to the individuals and everyone felt included.

Secondly, several people revealed previously unreported safeguarding and risk issues. As a result we rapidly learned that both the group and individual sessions needed two facilitators. We have also developed robust governance procedures, and staff support, specific to this type of work. This two facilitator approach also benefits the participants as they are able to have a built in second opinion, and we found we were able to cover a wider range of issues in more depth. The combination of a Mental Health Nurse prescriber and Pharmacist was found to be particularly beneficial by the participants.

Originality we had produced some 'cue cards' with a list of common medicines related problems and ways to solve them. After the pilot we discontinued these, as it became clear that we had time to work on the problems identified by the participants. This appears to be a much more effective approach.

We used feedback (informal, verbal and written) from participants to evaluate the effect of the medicines sessions. In addition, we kept a reflective log of the individual sessions and gave participants the option to feed back on the result of these sessions. Most of the participants in the individual sessions were happy to feed back on what happened after the review and how they used the notes we gave them. In fact, only one person declined to do this.

A specific evaluation of the cost benefits of the medicines sessions was not included in this work, however through evaluating and reflecting on the feedback we were given we have been able to produce a set of evaluation criteria for future projects; align this with local and national priorities and the Sustainability and Transformation Plans.

Benefits identified to date include improved adherence with medicines; improved quality of life; reduced unnecessary medicines; identification and actions on previously unreported patient safety issues. A thematic analysis of the feedback showed that out of the 28 people who had an individual session 19 were given advice on referral pathways; 9 signposted to existing resources (such as Medicines Use Reviews) and trusted source of information; 9 people were recommended to ask for a clinical medicines review, 4 were advised on options for opioid switches and 10 on dosage, side-effects or interactions. This prompted one person to comment:

‘In the support session you listened to me, and helped me work out what I needed to say. I gave the notes to my G.P. who changed my medicines and made the referrals you suggested. I now no longer walk with a stick, and feel a lot better. I thoroughly recommend these sessions’

We also carried out a thematic analysis of the presenting issues in the individual sessions, based on the feedback and on our reflective log. The top five issues were mental health problems (13/28); suicidal ideation (5/28); use of non-prescribed medicines, including borrowed and illicit substances (5/28); anger issues (5/28); previously unreported risk or safeguarding issues (3/28).

Our initial findings also pointed to a potential reduction in ‘bouncing’ referrals, less missing information and fewer unnecessary contacts with services. This is something which would need to be evaluated in a further study. We are discussing how we can do this with a local Medicines Management Team and colleagues at NICE.

In summary, we found three main areas of benefits:

• Addressing the fact that specialists in different areas of medicine only ever review the medicines they have prescribed. So people end up with a continuation of medicines they don’t need and often medicines which make things worse. By going through this in some detail, led by the person themselves who is free to ‘tell their story’, we are helping them make changes.
• Helping bring out the things people don’t normally tell their doctors (we all do this). In the jargon this is called ‘intentional non-adherence’. This increased trust and openness seems to be because we deliver these reviews as part of larger project led by users of services, so by the time we see people they have built up a degree of trust in the process. From the feedback, it appears to help greatly that we do not keep any notes; instead giving the action plan directly to the person we are seeing.
• We’re finding some unexpected patient safety benefits. We’re learning that, as a result of the way the sessions are carried out, some people feel able to share information on their medicines and treatments with us that they haven’t previously shared with anyone. On a number of occasions we have been able to give advice on medicines safety and signpost people to services they need, but had previously either avoided or been unaware of.

Mental Health and Wellbeing:

We also used the Warwick Edinburgh Mental Wellbeing [WEMWBS] Scales to assess if mental wellbeing improved over the course of the project. The average score at the beginning of the course was 41.1 and afterwards the average was 47.46. A difference of 3 to 8 points is considered meaningful, demonstrating that ‘mental wellbeing improved over the course of the project’. Our study showed an average increase of 6.3 points. N= 30. (Time covered Jan to March 2016).

It is possible and effective to deliver a generic patient focused medicines education programme. This seems to have some advantages over condition specific work. The structure and approach of the work enabled some patient safety issues and intentional non-adherence to be tackled by the people themselves. This needs robust governance.

Because of the way this programme was commissioned by the Department of Work and Pensions, we have had no direct feedback from GP’s on the work. NHS services stand to make cost savings for this type of work; however this is yet to be evaluated.