Download 5.5 To minimise financial risk associated with medicines.

WEST LONDON MENTAL HEALTH TRUST
MEDICINES MANAGEMENT STRATEGY
2012 – 2015
Michele Sie, Chief Pharmacist, West London Mental Health NHS Trust Feb 2012
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1.1
Introduction
Medicines Management encompasses the way medicines are selected,
procured, delivered, prescribed, prepared, administered, stored and reviewed
to optimise the contribution they make to producing informed and desired
outcomes of patient care.
Medicines management is central to the provision of quality healthcare with
recent audit data illustrating that 99% of WLMHT inpatients receive medicines
as part of their care plan. Robust financial management is also important with
WLMHT currently spending approximately £3.5 million on medicines per year.
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Strategic Context
2.1
The Department of Health’s (DoH’s) Medicines Management Framework 2001, the NHS Executive’s, Controls Assurance Standards for Medicines
Management - 1999, ‘A Spoonful of Sugar - Medicine Management in NHS
Hospitals - 2004’ published by the Audit Commission, and ‘Talking about
Medicines – The Management of Medicines in Trusts Providing Mental Health
Services - 2007’ published by the Healthcare Commission, provide a clear
indication that medicines management continues to be high on the
Government’s agenda.
2.2 The Board approved the Trust’s first Medicines Management Strategy in 2009.
This initial strategy was based on the ten focus areas for a vision for medicines
management from The Healthcare Commission’s publication, ‘Talking about
medicines: The management of medicines in trusts providing mental health
services’.
2.3 The importance of effective systems to manage medicines has been
demonstrated by the inclusion of medicines indicators in the Trust’s regulatory
framework. Medicines management is an outcome in the Care Quality
Commission (CQC) ‘Essential Standards of Quality and Safety 2010’.
Compliance with these essential standards will be continuously monitored and is
essential for the required registration to provide health care. The NHS Litigation
Authority requires certain medicine related policies to be in place.
2.4 The Trust’s Medicines Management Strategy should therefore be seen as an
essential framework to support the Trust meeting its strategic objectives.
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Vision
3.1
This revised strategy seeks to build on the Trust’s established medicines
management systems and processes and aims to ensure service users
receive safe and clinically effective medicines appropriate to their individual
needs, taking into consideration cost effectiveness where appropriate.
3.2
The Trust will develop recovery focussed personalised medicines
management. As such, service users will be considered essential partners in
decisions relating to selection and use of medicines, and will receive
education and support relating to their use of medicines.
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3.3
The Trust will consider potential gains through technology and where viable
support implementation to ensure improved risk management, clinical
information, documentation, clinical audit, and financial management of
medicines.
3.4
Clinical staff will be competent in Medicines Management aspects of patient
care.
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Update from 2009 -12 Medicines Management Strategy
4.1 The Medicines Management Strategy was approved by the Trust Board in
September 2009 following the CQC investigation. The action plan was integral
in providing assurance to the CQC that concerns highlighted had been
addressed.
4.2 The transfer of the pharmacy services provided under SLA's to WLMHT has
been achieved.
This transfer represents a significant milestone in the
management and development of Trust pharmacy services. The rationale for
this transfer was:

To directly manage the provision of pharmacy services with resultant
development leading to improvement in quality and timely supply of
medicines to individual patients across the Trust.

To support and develop pharmacy staff in order to provide high quality
individualised patient care based on needs of service users.

To review the pharmacy service configuration across WLMHT and
explore potential efficiency gains through economies of scale and
technology. This has also reduced vulnerability to increasing costs of
pharmacy service provision through service level agreement
arrangements.
4.3 The Trust signed up to the Choice and Medication website in March 2011, which
gives detailed but easy to digest information about all kinds of medications that
are encountered in mental health and a number of mental health conditions and
is aimed at helping you individuals make an informed choice about a treatment.
4.4 The Mental Health Law Group introduced a number of initiatives to ensure that
the consent to treatment provisions in MHA 1983, Part 4 are met, where
appropriate.
4.5 Medicines management has been embedded into the clinical governance
structure and is a standing agenda item for each CSU‘s clinical governance
meeting.
4.6 The Trust has not had a substantive permanent Chief Pharmacist in post for one
year and this has led to delays in the implementation of the Medicines
Management Strategy. The Chief Pharmacist post was appointed to in January
2012.
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4.7 The three year action plan has progressed but has not been fully implemented.
Progress with outstanding areas and forward actions will be included in this
medicines management strategy.
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Strategic Objectives
The strategic objectives have been derived from a number of National
publications which support the Medicines Management Agenda (appendix 1)
5.1
To provide a high quality safe, effective and timely service to
efficiently and effectively supply and administer medicines.
5.1.1 Governing Use of Medicines
The Trust Medicines Management Group (MMG) is responsible for
overseeing clinical governance aspects of Medicines Management. The
MMG is responsible for ensuring provision of high quality guidance and policy
to manage risk associated with medicines use.
The following Policies will be reviewed and updated by the MMG on a regular
basis (every 3 years) as well as in response to new national guidance and
regulations:
Medicines Policy (M2)
Medicines Reconciliation Policy (M11)
Oxygen Policy (O3)
Rapid Tranquilisation (R10)
The following policies will be developed:
Controlled Drugs Policy
Non-Medical Prescribing Policy.
Implementation and monitoring of these policies will be overseen by the group
who will commission audits to provide assurance of successful
implementation.
This group will also produce an annual report on the progress of the
medicines management strategy.
5.1.2 Management of Controlled Drugs
There are a number of legal and best practice requirements relating to how
NHS Trusts manage controlled drugs. It is important that these are regularly
audited to ensure that controlled drugs are being used appropriately and all
stock can be reconciled.
Management of controlled drugs is currently addressed with in the Medicines
Policy. With the review of this policy Management of Controlled drugs will
become a policy in its own right to ensure legal and best practice
requirements are addressed.
The Shipman Inquiry has also resulted in a requirement to improve monitoring
and collaboration with partner agencies on trends and patterns of controlled
drug use. Systems are now established to monitor controlled drug incidents
and to share these with intelligence networks to ensure safe and appropriate
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use of controlled drugs. The Chief Pharmacist will provide quarterly reports
on incidents of concern regarding controlled drugs to the Trust Accountable
Officer for CDs for reporting to the North West London intelligence network.
Pharmacy will conduct regular audits on management of controlled drugs
within the organisation, which will be reported to the Accountable Officer.
Electronic prescribing will assist on monitoring prescribing of controlled drugs
within the Trust.
5.1.3 Non-Medical Prescribing
Nurses and pharmacists can now legally prescribe through the DOH
approved independent and supplementary prescribing schemes (The Health
and Social Care Act 2001). The non-medical prescribing programme gives
patients quicker access to medicines, improves access to services and makes
better use of nurses’, pharmacists’ and other health professionals’ skills.
WLMHT will support non-medical prescribing by appropriately trained and
registered non-medical prescribers in circumstances when a service need and
demand has been identified.
A non-medical prescribing policy is currently being developed. There will no
longer be a requirement for each non-medical prescriber to produce a
proposal, as the Trust will now only need to endorse the area of practice. So
far the following areas have been approved for non-medical prescribing to be
integrated into practice: Clozapine Clinics, Memory Clinics and ADHD Clinics.
For new areas of practice a clear process will be in place to ensure timely
review.
A clear method to progress supplementary prescribers to independent
prescribers will also be developed.
Patient Group Directions will continue to be used where appropriate.
5.1.4 Learning Lessons from Medication Errors and Incidents
Medication incidents will continue to be reported on the Trust electronic IR1
system and included in reports sent to the National Reporting and Learning
System established by the National Patient Safety Agency.
A standardised three monthly medication report will be devised which will be
used across all CSU’s. Identified nurses will continue to collate medication
errors on a quarterly basis for their areas and provide actions and outcomes.
The Medicines Management Group will have an overview of all medicine
incident reports to identify themes across the Trust which require system
reviews and promote cross CSU learning of good practice. Incidents relating
to medicines use at the interface, and in primary care, will be shared with our
PCT colleagues to ensure effective learning across the local health economy.
Further work is required to ensure that the role of medicines are considered
as part of incident investigations.
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5.1.5 Collaborative working with Primary Care
The 2008 White Paper: “Pharmacy in England: building on strength-delivering
the future” supports the collaboration of all sections of pharmacy (hospital,
PCT and community) to progress collaborative working to improve services to
patients. The CQC report (Nov 2009) on “transfer of medicines across the
interface” illustrates how much work there is still to be done to ensure safe,
effective prescribing. WLMHT Medicines Management Group has
representation from local PCTs (Pharmacists) to ensure that implications for
the local health economy are considered.
A recent audit highlighted the poor governance around information transfer to
primary care at discharge. The Medicines Management Group will identify
current systems for transfer of information to primary care at discharge and
propose solutions.
The Chief Pharmacist will continue to represent WLMHT at the North West
London Medicines Management Network which co-ordinates shared care
guidelines for both primary and secondary care and considers issues relating
to effective medicines management within the local health economy.
5.1.6 Medicines Audit Programme
In order to provide quality assurance on prescribing, the Medicines
Management Group will work collaboratively with the audit team to inform an
annual medicines audit programme. This will take into consideration CQC
requirements and the implementation of NICE, CQC and POMH-UK
recommendations and prioritise areas where the Trust is required to submit
data. Consideration will be taken to data collection methods to ensure data is
accurately presented.
5.2
To deliver excellent personalised care and support for service
users on pharmacological treatments
The majority of users of WLMHT services need to take medication for long
periods of time, often indefinitely. Information provision on medication and
conditions is often highlighted by service users and carers as an area of high
importance which is often not addressed. Ease of access to medication and
appropriate information on medicines, which meets the needs of our service
users, will help improve the patient experience in relation to medicines.
5.2.1 Promoting Choice
Patients have a right to be involved in decisions around medication choice
and have information needs regarding the medication they are being asked
to take. Evidence has highlighted that if patients have a good understanding
of; the benefits of medication, how it should be taken, and adverse effects
which may occur, they are more likely to take their medicines successfully.
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The MMG will review and ensure systems are in place to educate patients
on use of their medicines prior to discharge from the Trust.
The Trust will continue to provide access to the Choice and Medication
website which provides accurate, peer reviewed information on psychotropic
medications and conditions. This will need to be continually publicised to
ensure its effective use.
A review of alternative formats of medication information will be undertaken.
Exploration of audio information which could be utilised by patients with mp3
players will be carried out.
The MMG will also assess systems in place to facilitate ‘advance directives’
within the Trust.
5.2.2 Supporting Recovery
A range of medicines management services encourage people to become
more involved in their own medicines. Self-administration is a process which
empowers patients to develop the skills to manage their own medication in a
supportive manner and supports recovery.
A self-administration procedure has been in operation in the Trust for a
number of years and is consistently used on some rehabilitation wards.
Work with the three CSU’s will be carried out to identify other areas where
self-administration can be introduced.
Pharmacists will provide expert advice in the development of user led
education and carer training programmes on medicines to support a
Recovery focused approach and improve patient involvement and choice in
the medications they take.
5.2.3
Ensuring Seamless Care
The Department of Health Medicines Management Framework (2003) states
that “patients should be receiving a medication history review within 24
hours of admission to hospital.” NICE/NPSA issued joint guidance in
December 2007 with regard to medicines reconciliation across all patient
entry and exits into care.
The M11 Medicines Reconciliation Policy has stipulated the systems to
ensure this occurs, yet the data to be able to evidence this is proving difficult
to collate from current clinical documentation systems.
The Trust has recently participated in the POMH-UK audit on medicines
reconciliation. The results of this will be reviewed by the Medicines
Management Group and recommendations incorporated into the Medicines
Management Strategy Implementation Plan (MMSIP).
A clear process will be developed to ensure documentation of medicines
reconciliation can be utilised to collate benchmarking data.
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All pharmacists will be provided with an nhs.net account to allow secure
transfer of discharge medication to GP’s and other providers who have an
nhs.net account.
5.2.4
Ensure appropriate and effective use of medicines in people’s
care.
Reducing length of stay is a current Trust target. Ensuring effective use of
medicines may impact on this.
Current processes on reviewing medication will be mapped. The use of
symptom rating scales to inform treatment effectiveness will be considered.
A clear process for medication review and documentation will be developed
to ensure medicines optimisation. Processes for high dose (above British
National Formulary recommended maximum) prescribing will be reviewed
and standardised across the Trust.
An objective in the previous MMS was to ensure that each service user on
medication has a care plan which covers the role of medicines, ongoing
monitoring requirements and the person’s preference for medicines,
including advanced directives if appropriate.
Some progress has been made on this at Broadmoor where a standard
format care plan for medicines management has been developed. A RIO
care plan needs to be developed which will be implemented across the
other CSU’s.
5.2.5
Assessment of Side Effects
The Trust will develop standards on assessment of side effects, in
collaboration with service users, which will outline the responsibilities of
members of the multi-disciplinary team.
5.2.6
Contribution of Pharmacy Services to the Patient Experience
Pharmacy service provision across the Trust will be benchmarked with a
view to establishing equitable levels of delivery of pharmacy service Trust
wide.
Clinical pharmacy service standards have been developed and are currently
undergoing consultation.
The Chief Pharmacist will oversee the
implementation and monitoring of these standards.
5.2.7
Medicines Information (MI)
A review of medicines information has highlighted that the current provision
of medicines information has been managed by one member of staff which
has led to delays in answering queries.
Structures will be developed to ensure medicines information queries are
responded to in a timely fashion and the service is not based on one
member of staff. All pharmacists will be given access to MI databank to be
able to access and document MI queries.
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5.3
To engage meaningfully with service users and carers to
improve and align our services to meet service users medication
needs
5.3.1
Involving Service Users and Carers
The MMG will seek to attain the views of service users and carer to improve
our understanding of their needs to inform the Trust on development of
patient centered medicines management.
5.3.2
Assessing Patient Experience
A medicines management audit/survey will be developed for the new
patient experience system to collect data on provision of medications
information.
5.4
To improve Trust information systems to support the
appropriate choice and safe prescribing of medicines, and to
improve performance management
With the advent of PBR in mental health it is imperative that the Trust is
using medication in an efficacious and cost-effective manner.
5.4.1
Electronic Prescribing
Currently the Trust’s lack of information technology systems (e.g. electronic
prescribing) to support medicines management makes financial control,
medicines audit (clinical effectiveness), and establishment of full electronic
patient medicines records problematic.
An options appraisal has highlighted the need for a business case to be
developed to inform the Trust of the strategic direction. Funding has been
secured to develop the business case utilising external expertise in this
area.
5.4.2
Clinical Dashboard
A review will be undertaken of currently available data on prescribing costs
which could be incorporated into the clinical dashboard.
Systems for electronic recording of pharmacy clinical activity and on call will
be developed.
5.5
To minimise financial risk associated with medicines.
5.5.1
Managed Entry of New Medicines
The current system for managed entry of new medicines will be revised to
include financial forecasting based on the predicted treatment population.
New medicines approved for use within the Trust will have guidance to
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ensure appropriate use, as well as implementation advice which will include
educational resources for staff.
5.5.2
Management of Medicines Expenditure against Budget
The pharmacy service will work closely with each CSU to implement
systems to ensure medication expenditure is regularly reviewed against
budget.
When overspend is identified pharmacy will highlight areas of high or
increasing expenditure to inform management.
The pharmacy service will continue to horizon scan to ensure that cost
savings related to generic medication is maximized.
5.6
To build an engaged workforce, which is competent to work with
medicines
5.6.1
Training and Competency in Medicines Management
The effectiveness of medicines management is heavily dependent on the
effectiveness of the staff (doctors, nurses, pharmacists, agency staff) who
prescribe, administer or dispense medicines.
An e-learning module will be developed on the use of the Trust prescription
chart for all staff who prescribe to inpatients.
Medicines Management training will continue to be provided and will be
regularly reviewed and updated to reflect new guidance.
5.6.2
Pharmacy Staff Development
Many of the improvements in Medicines Management rely on changing
roles of professionals.
Pharmacists’ and pharmacy technicians
contribution to patient care and improved medicines management can be
enhanced through further qualifications. We will continue to endeavour to
provide access to post-registration qualifications to develop the skills of
pharmacy staff to create an effective skill mix.
5.7
To support the Trust’s Research and Development Activity
Pharmacy services will continue to establish staff with expertise in clinical
trials to support the research and development activity within the Trust.
Pharmacy will develop standard operating procedures for clinical trials to
provide an assurance framework.
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The pharmacist responsible for clinical trials will be an integrated member of
the R+D team to ensure medicines are considered at the earliest
opportunity of trial set up.
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6.1
Implementation
Delivery of the strategic objectives will be progressed through the
prioritisation, development and implementation of a triennial implementation
work plan for the period covered by the strategy via the trust’s Medicines
Management Group and the Drugs and Therapeutics Committee.
Implementation will be monitored by the Trust Clinical Effectiveness and
Compliance Committee.
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Appendix One: National Publications Supporting the
Medicines Management Agenda

CQC: Essential standards of quality and safety. March 2010

White paper – Pharmacy in England: building on strength – delivering the future
DH 2008

CQC – Investigation into West London Mental Health NHS Trust 2009

CQC – Managing patients’ medicines after discharge from hospital 2009

Healthcare Commission: Annual report on controlled drugs 2008

NHS National Prescribing Centre: Moving Towards Personalising Medicines
Management April 2008

The Healthcare Commission. Let’s talk about medicines: managing medicines in
mental health trusts 2007.

NICE/NPSA Guidance on medicines reconciliation Dec 2007 (review 2010)

The Safe and secure Handling of Medicines: A Team Approach (Duthie II):

NHSLA Risk Management Standards – includes aspects of Medicines
Management

Choosing health through Pharmacy – A programme for pharmaceutical public
health: 2005-2015: DH April 2005

Building a safer NHS for Patients – Improving medication safety DH 2004

National Standards, Local Action, incorporating ”Standards for Better Health” DH
July 2004

A Vision for Pharmacy in the new NHS: DH 2003

‘Performance Management Frameworks for Medicines Management in Hospitals’
DH 2001 and 2003

The Audit Commission’s “A Spoonful of Sugar, medicines management in NHS
hospitals” (December 2001)
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