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Macmillan Rural Palliative Care Pharmacist Practitioner Project

Phase 2 Report

January 2015

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Macmillan Rural Palliative Care Pharmacist Practitioner Project

Phase 2 Report

January 2015

This work was undertaken by the Strathclyde Institute of Pharmacy and Biomedical Sciences,

University of Strathclyde, in collaboration with NHS Highland and the Macmillan Rural Palliative Care Pharmacist Practitioner Project Team

NHS Highland University Team

Mrs Alison MacRobbie Professor Marion Bennie Dr Gazala Akram

Boots Company PLC Dr Rosemary Newham Mrs Gill Harrington Mrs Emma D. Corcoran

Acknowledgements Macmillan Cancer Support Boots Company PLC NHS Highland Steering Group: Alison MacRobbie (Chair), Laura Adamu-Ikeme (Associate Development Manager NHS Highland), Linda Bailey (Care Home Manager), Cathy Brown (District Nurse, Skye), Dr Charles Crichton (GP Skye), Dr Paul Davidson (Clinical Lead/Rural Practitioner), Kate Earnshaw (District Manager), Findlay Hickey (West Operational Unit Lead Pharmacist), Pat Matheson (District Nurse Team Lead), Barbara MacDonald (Macmillan Community Nurse), Fiona MacFarlane (Boots Development Manager), Dr Leo Murray (Clinical Lead Rural Practitioner), Nancy MacAskill (Macmillan Community Nurse), Marie Noble (Care at Home Manager), Chrissan O’Halloran (Community Hospital Charge Nurse), Lis Phillips (Macmillan Community Nurse), Dr Gill Pilling (Associate Specialist, Highland Hospice), Janice Preston (Macmillan Senior Development Manager), Jean Sargeant (Macmillan Associate Development Manager), and Dr David Simes (Chair, North Skye Cancer Group), Susan Sutherland (Macmillan Development Manager North of Scotland- left post in 2013 and replaced by Joanne Adamson)

All participants of the interviews and questionnaires and those who facilitated in collecting audit data.

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Table of Contents

Abbreviations…………………………………………………………………………………………………………………………………. 4 Executive Summary………………………………………………………………………………………………………………………… 5 1. Purpose………………………………………………………………………………………………………………………………………. 13 2. Background………………………………………………………………………………………………………………………………… 12 3. Phase 1……………………………………………………………………………………………………………………………………….. 16 4. Phase 2……………………………………………………………………………………………………………………………………….. 17 4.1 Aims……………………………………………………………………………………………………………………………………… 17 4.2 Delivery………………………………………………………………………………………………………………………………… 17

4.3 Participant Recruitment………………………………………………………………………………………………………… 19 4.4 Methods……………………………………………………………………………………………………………………………….. 20

4.5 Phase 2 Results……………………………………………………………………………………………………………………… 22

i. Education, Training & Awareness…………………………………………………………………………………………….. 22 a. Care Home Staff………………………………………………………………………………………………………………….. 22 b. Healthcare Professionals…………………………………………………………………………………………………….. 26 c. Patient & Public Awareness…………………………………………………………………………………………………. 27 ii. Integration of the MRPP in the MPT……………………………………………………………………………………….. 31 a. MRPP Key Clinical Services Delivered & Reflections…………………………………………………………….. 31 b. Feedback from Stakeholders………………………………………………………………………………………………. 35 5. Phase 3……………………………………………………………………………………………………………………………………….. 43 6. Conclusions………………………………………………………………………………………………………………………………… 45 References……………………………………………………………………………………………………………………………………… 47 Appendix 1- Controlled Drugs Audit……………………………………………………………………………………………….. 48 Appendix 2- Macmillan Information Leaflet Usage…………………………………………………………………………. 54 Appendix 3- Other Academic, Professional & Public Dissemination of Project Information……………. 55 Appendix 4- Method 2 Gold Standards Review Details from Oral Histories…………………………………… 56 Appendix 5- Method 2- Drop-In Clinics Details from Oral Histories…………………………………………………. 57 Appendix 6- Method 2 MRPP Hospital Pharmacy Work………………………………………………………………….. 58 Appendix 7- Highland Hospice Phone Line Audit…………………………………………………………………………….. 59

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Abbreviations

CD Controlled Drug(s)

CMS Chronic Medication Service

COPD Chronic Obstructive Pulmonary Disease

DP Dispensing Practice

GP General Practitioner

GSR Gold Standards Review

IDL Immediate Discharge Letter

eKIS electronic Key Information Summary

KSL Key Service Lead

MPT Multi Professional Team (aka MDT or Multidisciplinary team)

MRPP Macmillan Rural Palliative Care Pharmacist

MSP Member of the Scottish Parliament

SVQ Scottish Vocational Qualifications

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Executive Summary In 2012 NHS Highland secured funding from Macmillan Cancer Support in collaboration with The

Boots Company PLC to explore a new service delivery model for the rural Skye, Kyle & Lochalsh

population. The project would pilot the development of a full-time Macmillan Rural Palliative Care

Pharmacist Practitioner (MRPP) within in the area, and test the ability of this post to: develop

community pharmacy capacity to effectively, efficiently and safely support the needs of those in this

rural community with palliative care needs regardless of care setting; improve service provision/co-

ordination of services ensuring opportunities are developed for training and peer support, and;

provide quality information to support practice. The Strathclyde Institute of Pharmacy and

Biomedical Sciences (SIPBS) at the University of Strathclyde was commissioned to undertake the

project evaluation.

This project is seen as a demonstration project to inform national policy with direct alignment to the

objectives of the Scottish Government national action plan 'Living and Dying Well' , the Vision and

Action Plan: “Prescription for Excellence” and the progressive integration of health and social care

services across Scotland (1-3). The project was divided into three phases:

Phase 1 (February – December 2013)

A baseline report was produced in December 2013, focusing on the first year of project activity -

specifically the investigations to characterise community pharmacy palliative care services in the

project area (Skye, Kyle & Lochalsh) and to identify service gaps and key issues to inform a quality

improvement programme (see Figure 1). Detailed information on the results are available in the

Phase 1 report (4).

Phase 2 (January – December 2014)

Findings from Phase 1 provided the framework for Phase 2. The aims of Phase 2 were to: investigate

previously unexplored areas of current service so as to provide useful recommendations for

improvement; develop evidence-based resources for healthcare professionals and patients for use in

the community setting, track the developments over the project duration; and provide a set of

recommendations upon which the service could be developed further (Phase 3).

This report presents Phase 2 of project activity. A mixed case study approach was used, comprising

questionnaires, interviews, audits and documentary data. GPs, patients, carers, Steering group

members, Key Service Leads, care home staff, management and the Macmillan Rural Palliative Care

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Pharmacist (MRPP) all contributed to the data. The results are summarised under two key areas:

Education, Training and Awareness (Figure 2) and Integration of the MRPP in the multi-professional

team (MPT, Figure 3).

Phase 3 (2015 onwards)

The results from Phase 2 were shared with the Project Steering Group to gain consensus on the

prioritisation of areas for future development (Figures 4 and 5). In addition, based on the evidence

gathered throughout the project and discussion with the Steering Group, a service development and

sustainability model for community pharmacy palliative care services was created (Figure 6). The

model, based on findings from a rural area, is designed to be flexible and applicable in a wide variety

of community settings.

The model is made up of 3 steps: Start-Up, Development and Maintenance. Moving through these

steps the key roles and responsibilities of the MRPP gradually shift towards the local Community

Pharmacist(s), seeing the MRPP graduate from assuming a locality-based hand-on role to a more

regional-based supporting and facilitating role for local champions. It was acknowledged that

successful delivery of the model is dependent on alignment of resources, infrastructure and strategic

and local community support.

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Education, Training & Awareness

Enabling Practitioners

Care Home Staff

Ongoing: The development and roll out of additional Sunny Sessions training materials

Ongoing: Access to further learning resources beyond Sunny Sessions (e.g. The Current

Learning in Palliative Care and the NES Pharmacy Technician training pack)

Phase 3: Support staff in their knowledge of new medicines with medicines information

sheets

Phase 3: Explore a mechanism to make Sunny Session training a national resource.

Healthcare Professionals

Ongoing: Deliver tailored GP talks on request (e.g. symptom management i.e.

breathlessness, use of ‘specials’ etc.)

Ongoing: Maintain locality group pharmacy peer-review and training development

Phase 3: Improve access to all training through the use of webinars and other technology

Phase 3: Facilitate local multi professional team training

Phase 3: Explore potential for further distribution of the mouse mats, mugs and any other

educational materials across NHS Highland

Phase 3: Test the roll out of the Sunny Sessions care home training information packs to

other health/social care support workers (SVQ Level 2 and 3).

Enabling Patients & Carers

Phase 3: Adapt and test the roll out of Sunny Sessions training and make available to family

carers, patients and members of the public through established settings (e.g. Macmillan days

etc.)

Phase 3: Promote further MSP visit to the project area following MSPs Dave Thomson and

Rhoda Grant’s visits

Phase 3: Test currently developed materials i.e. “Ask 3” cards and medicines information

cards

Phase 3: Explore use of twitter account and hashtag to enable non-direct contact with

patients (#SkyeLochPharm)

Phase 3: Explore access to medicines information materials in non-clinical settings e.g.

libraries.

Figure 4: Education, Training and Awareness Work Planned for Phase 3

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Integration of the MRPP in the MPT

Gold Standards Review Meetings

Ongoing: Attend GSR meetings to provide information and insight into palliative medication

related issues in patients

Ongoing: Raise issues at a local level at GSR meeting from Highland Hospice calls

Phase 3: Explore how Community Pharmacists can contribute to GSR meetings through the

use of technology

Phase 3: Develop Top Ten Tips guide for healthcare professionals for conducting GSR

Meetings.

Further Engagement Opportunities

Ongoing: Raising ethical issues in the quarterly Palliative Care Model Schemes Newsletter

starting Nov 2014, with feedback request & answers in next quarterly newsletter

Ongoing: Provide continued advice and support to Macmillan Nurses relating to palliative

care medicines

Phase 3: Conduct a follow-up audit of CD prescribing

Phase 3: Support Community Pharmacists across the project area in developing and hosting

their own drop-in clinics, independent prescribing clinics and/or providing teach-back

experience for patients’ improved understanding of medicines.

Access to Patients’ Medicine Information

Phase 3: Implement a system where access to patient hospital admission and discharge

information, including Immediate Discharge Letters (IDLs) as well as more advanced

information for Community Pharmacists is arranged.

Figure 5: Integration of the MRPP in the MDT Work Planned for Phase 3

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Figure 6: Service Development and Sustainability Model

Conclusions

For NHS Scotland, the evidence from this project presents for the first time, a conceptualised clinical

practice model for community pharmacy palliative care services in rural areas, building upon the

experiences from NHS GG&C, i.e. a highly populated urban environment (5). The model aligns with

existing key health policy, namely “A Route Map to the 2020 Vision for Health and Social Care” (2),

“Living & Dying Well” (3), “The Healthcare Quality Strategy” (6) and the recently published Vision

and Action Plan: “Prescription for Excellence” (1). Adoption of this model will maximise community

pharmacists’ professional competence in planning and delivering specialist clinical services while

maintaining a generalist role. The model provides detail of the key roles and responsibilities to

support the safe and effective use of medicines for patients and their carers, but provides it in a

format that enables flexibility for the deployment of these functions depending on local business

planning, service delivery frameworks and community setting.

Step 1:

Start-Up Phase

Step 2: Development

Phase

Step 3: Maintenance

Phase

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References

1. Prescription for Excellence: A Vision and Action Plan: Scottish Government; 2013. Available from: http://www.scotland.gov.uk/resource/0043/00434053.pdf. 2. A Route Map to the 2020 Vision for Health and Social Care: Scottish Government 2013. Available from: http://www.scotland.gov.uk/Resource/0042/00423188.pdf. 3. Living and Dying Well: a national action plan for palliative and end of life care in Scotland Edinburgh: Scottish Government 2008. Available from: http://www.scotland.gov.uk/resource/doc/239823/0066155.pdf. 4. Bennie M, MacRobbie A, Akram G, Newham R, Corcoran ED, Harrington G. Macmillan Rural Palliative Care Pharmacist Practitioner Project: Mapping of the Current Service & Quality Improvement Plan University of Strathclyde, 2013. 5. Bennie M, Akram G, Corcoran ED, Maxwell D, Trundle J, Afzal N, et al. Macmillan Pharmacist Facilitator Project- Final Evaluation Report. Macmillan Cancer Support: University of Strathclyde, 2012. 6. The Healthcare Quality Strategy for NHSScotland: Scottish Government 2010. Available from: http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf

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Macmillan Rural Palliative Care Pharmacist Practitioner Project

1. Purpose

The project is a demonstration project developed to inform national policy and has direct relevance

to the new Scottish Government Vision and Action Plan: ‘Prescription for Excellence’ (1). The project

pilots the development of a full-time Macmillan Rural Palliative Care Pharmacist Practitioner (MRPP)

within the rural setting of Skye, Kyle & Lochalsh. A positive evaluation would allow the model to be

shared with other cancer and palliative care providers across the UK and be promoted as a model for

use in rural areas. The project delivery and evaluation was divided into three phases:

Phase 1 (February – December 2013)

A baseline report was produced in December 2013, focusing on the first year of project activity,

specifically the investigations to characterise community pharmacy palliative care services in the

project area (Skye, Kyle & Lochalsh) and to identify service gaps and key issues to inform a quality

improvement programme. For detailed information on the results, please see the Phase 1 report

(4).

Phase 2 (January – December 2014)

Findings of Phase 1 provided the framework for Phase 2. This report presents the collation of that

project activity.

Phase 3 (2015 onwards)

The results from Phase 2 were shared with the Project Steering Group to gain consensus on the

prioritisation of areas for future development (Figures 4 and 5). In addition, based on the evidence

gathered throughout the project and discussion with the Steering Group, a service development and

sustainability model for community pharmacy palliative care services was created (Figure 6). The

model, based on findings from a rural area, is designed to be flexible and applicable in a wide variety

of community settings.

2. Background

Palliative care is defined by the World Health Organization (WHO) as ‘an approach that improves the

quality of life of patients and their families facing the problems associated with life-threatening

illness, through the prevention and relief of suffering by means of early identification and

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impeccable assessment and treatment of pain and other problems, physical, psychosocial and

spiritual' (7).

Palliative care is most common amongst cancer patients, with 90% of specialist palliative care

services in Scotland provided to cancer patients (8). However, long term conditions such as heart

failure, COPD and dementia account for around 60% of all deaths (9). Consequently, it is now

generally accepted that people living with serious chronic illnesses will also require palliative care

and therefore palliative care should be offered more widely and integrated more broadly across the

health care services (10, 11).

Palliative Care and Pharmacy Policy Framework in Scotland

Initially, Audit Scotland published a ‘Review of Palliative Care Services in Scotland’ (2008), which

found a lack of a coordinated national strategy for palliative care (8). The Scottish Government then

launched ‘Living and Dying Well: A national action plan for palliative and end of life care in Scotland’

(3). 'Living and Dying Well' is the first plan for a single, cohesive and nationwide approach, ensuring

consistent, appropriate and equitable delivery of high quality and person centred palliative care

based on patient and carer needs. A number of established good practice frameworks are in the

Action Plan including the Gold Standards Review Framework.

The Gold Standards Review Framework is a systematic approach to support primary care teams to

improve the organisation and quality of care for patients nearing the end of life in the community. A

modified Scottish version of the GSF, the GSF Scotland (GSFS), was introduced in 2003.

Subsequently, the Healthcare Quality Strategy (2010) provided an additional palliative-specific

direction of travel for NHS Scotland (6). This is taken forward in “A Route Map to the 2020 Vision of

Health and Social Care (2013) (2) published by the Scottish Government which details three key

aims, three quality ambitions and twenty-five key deliverables covering twelve priority areas for

improvement in health and social care. Focusing on medicines and pharmacy , “Prescription for

Excellence: A Vision and Action Plan” (1) published by the Scottish Government in 2013 set out a

strategy, whereby all patients, regardless of their age and setting of care, should receive high quality

pharmaceutical care from clinical pharmacist independent prescribers. The strategy is to be

delivered through collaborative working between patients, carers and all members of the direct and

wider MPT. Prescription for Excellence will directly and significantly contribute towards ten of the

twelve priority areas of the 2020 Route map, including: person centred care; safe care; primary care;

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unscheduled & emergency care; integrated care; care for multiple and chronic illnesses; health

inequalities prevention; innovation; and efficiency and productivity.

Macmillan Project

NHS Highland has an estimated population of 324,107 (12) and is comprised of 4 operational units

(Argyll & Bute Community Health Partnership (CHP), North & West Operational unit and South &

Mid Operational Unit and Raigmore Hospital Operational Unit). The Health Board covers a

geographical area from the Inner Hebrides in the West to Cromdale in the East, and from John O’

Groats in the North to Southend near Campbeltown in the South (13). The Skye, Kyle & Lochalsh

project area has an estimated total population of 13,238 (12). The Isle of Skye covers 1.6km² and

has an estimated population density of 6 people per km² (14). The area is serviced by 7 GP Practices,

including 4 Dispensing Practices, 3 Community Pharmacies, 2 District Nurse Teams, 2 Community

Hospitals and 5 Care Homes. Further detail is available in the Phase 1 report (4).

NHS Highland sought funding from Macmillan Cancer Support in collaboration with The Boots

Company (PLC) to explore a new service delivery model to support the objectives of the national

action plan 'Living and Dying Well' and Prescription for Excellence for the Skye, Kyle & Lochalsh

population. In 2012, Macmillan Cancer Support agreed to fund a 2 year project (February 2012 –

December 2014) to pilot the development of a full-time Macmillan Rural Palliative Care Pharmacist

Practitioner (MRPP) for the area, and test the ability of the post to:

Develop community pharmacy capacity to effectively, efficiently and safely support the

cancer and palliative care needs of those in the regardless of care setting

Improve service provision/co-ordination of services ensuring opportunities are developed

for training and peer support

Provide quality information to support practice.

Additionally, specific objectives expected to be met over the project’s lifespan:

Improve the support of community pharmacy networks in relation to palliative care

Ensure opportunities are developed for training and peer support and provide quality

information to support practice

Promote pharmacy engagement in multi-professional review meetings within GP

practices

Provide relevant pharmaceutical care support for patients at home alongside the multi-

professional team and voluntary agencies

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Provide clinical pharmacy support to local community hospitals including medicines

management advice and support at service interfaces e.g. admission, discharge to

improve continuity of care for patients with palliative care and cancer needs

Provide pharmaceutical care support to Care Home staff caring for palliative care

patients.

The project has been delivered by the NHS Highland Project Team which comprised the Project Lead,

and the appointed MRPP. In addition, the project is supported by the Steering Group comprising of

NHS Highland management, Macmillan Cancer Support and Boots representative, project team

representatives, and representatives from the university evaluation team.

Highland implemented a lead agency model for the integration of health and social care service

delivery as a development exercise for the Scottish Government in April 2012 (15, 16). The project

was implemented against a complex background of service change including review of community

hospital services.

The aim of the evaluation is to inform the development, and demonstrate the effectiveness of, the

Macmillan Rural Palliative Care Pharmacist Practitioner Project.

3. Phase 1: Strengths, Challenges and Opportunities for Development (Dec 2013)

The Phase 1 evaluation identified that the strengths of service delivery and good practice included:

the presence of a stable demographic lacking in major fluctuations out-with the tourist season;

awareness and acceptance of the inherent environmental challenges of the area; a strong sense of

community; a palliative care service designed to address individual patient needs; reliable access to

core palliative care medicines; and 24/7 access to the Highland Hospice Phone Line for patients,

carers and professionals.

Whilst issues such as weather, geography and population density cannot be controlled, their

potential adverse effects can be addressed by resource planning and education / training. On the

whole, little if any problematic issues were identified but greater use of formalised contingency

planning was noted. A number of challenges were identified from the baseline service evaluation

and became the focus for Phase 2 of the project. These included: more detailed education and

training for qualified healthcare professionals, generalised education about palliative care for

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untrained staff in Care Homes and GP Dispensing Practices; creating greater awareness of lesser

used (extemporaneous) palliative medicines including ‘specials’; integration of the pharmacist into

the wider multi-professional team, to improve MPT understanding of the pharmacists role and

expertise as well as their ability to provide pharmaceutical support, i.e. forward planning to

facilitate access to and use of palliative care medicines.

4. Phase 2- Improvement Programme

4.1 Aims

To evaluate the implementation of the recommendations made in Phase 1

To investigate previously unexplored areas of current service to provide useful

recommendations for improvement

To develop an evidence-based resource, tracking the developments over the current project

To provide a set of recommendations upon which the service can be developed further

(Phase 3).

4.2 Programme Delivery

Three key areas were identified for Development: Education & Training; Integration of the MRPP

into the MPT; and Forward Planning. The focus of year 2 of the program was to address the

Education & Training aspects and Integration of the MRPP, with Forward Planning as a focus for year

3. Figure 1 shows the work and activities associated with these areas.

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4.3 Recruitment of Participants

Table 1 provides details of all the participants recruited in Phase 2 and the summary methodology

applied. The job titles of interviewees have been omitted to ensure anonymity.

Table 1- Methodology and Participant Details

Methods Details Total Participants* (N=28)

Method 1 Follow-Up Telephone Interviews conducted with healthcare professionals, Key Service Leads, patients and carers regarding the experience and perceived impact of the MRPP.

N=11 GP (n=2) Patient (n=1) Carer (n=1) Project Lead (n=1) Key Service Leads (KSL) (n=6)

Method 2 11 oral Histories conducted with the MRPP over 21 weeks MRPP (n=1)

Method 3 Care Home staff completed questionnaires (and some follow up telephone interviews) after short “Sunny Sessions” training on palliative care.

N= 16 Care Assistant /Social Carer (n=14) Senior Staff /Manager (n=2)

Method 4 Additional project activities were documented via the Project Work Plan (no participants).

NA

*”Participants” refers to actual individuals who provided data as part of Methodologies 1-3. Advice was sought by the NHS project lead from NHS Highland’s Clinical Governance Manager and

NHS Highland’s Research and Development Manager as part of the North of Scotland Research

Ethics Service. Ethical review under the terms of the Governance Arrangements for Research Ethics

Committees (REC) in the UK was deemed not to be required, because:

The project was part of a service development programme and as it was the service being

evaluated- it was deemed unnecessary to apply for full research ethics

Participant recruitment was invitational and any data would be irreversibly anonymised to

protect identities.

Furthermore, the University of Strathclyde’s Code of Practice on Investigations Involving Human

Beings does not apply in situations that are part of routine practices in professional contexts, a

service evaluation or an audit of an existing service. In addition, participants were either service

providers or users of the service and were invited by the MRPP or the clinical project lead and were

not patients randomly recruited via other methods (e.g. flyers distributed to the general public etc.).

All participants received a full explanation of the study and assurances about confidentiality and

anonymity were given.

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4.4 Methods

Method 1: Follow-Up Interviews

All interview participants from Phase 1 plus additional individuals engaged in the program but who

had not been available during Phase 1 were identified as potential interviewees. The aim was to

capture their experiences of the MRPP role, assess the impact of the role and highlight any

improvements that could be made.

Eight of the 12 Phase 1 participants were re-recruited for Phase 2. Three individuals were ‘new

participants’. Since the MRPP role was now up and running, it was considered valuable to speak to

patients /carers who had used the services. The MRPP obtained consent from one patient and one

carer with whom she had provided services. The researcher contacted all participants and arranged

to interview by telephone. Each participant was provided with a verbal explanation of the rationale

behind the interview and provided verbal consent to their participation. Interviews were recorded

and transcribed using an intelligent verbatim approach. Interviews lasted between approximately

10 and 40 minutes. One researcher read all of the transcripts (with one transcript each being read

by two other researchers to ensure validation). A list of themes was compiled and further

refined/validated through peer consensus on a sample of the interviews. This revised framework

was applied to the remainder of the transcripts and refined as appropriate.

Method 2: Oral Histories with MRPP

The researcher and the MRPP made regular phone contact to profile MRPP activities throughout the

data collection period. Eleven calls took place over a 21 week period from 17 January to 13th June

2014. The time between calls ranged from one week to 30 days, with an average time between calls

of 14 days. Call time ranged from 12 minutes to 55 minutes, with an average length of 33 minutes.

All calls were audio recorded and typed in note form. This allowed a chronological timeline of

activities to be developed. The aim of this exercise was to track the development of the MRPP

workload.

Method 3: Questionnaires & Follow-Up Telephone Interviews with Care Home Staff on

“Sunny Sessions” Palliative Care Training

Questionnaires for Care Home Staff

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Phase 1 findings recommended that Care Home staff should receive training on basic palliative care

principles. The Project Lead and the MRPP, with input from another Macmillan pharmacist, designed

two (initial) short training sessions for this staff group (entitled “Sunny Sessions“). The sessions were

intended to be delivered quickly and with minimum interference with day to day duties. A

questionnaire was distributed amongst the staff after training to gauge their satisfaction of the

Sunny Sessions. Potential impact and usefulness of the training was also determined. The

questionnaire was compiled by the research team and reviewed by the MRPP and Project Lead.

Questions were altered and removed where appropriate. Participants were given the option of a

subsequent short telephone interview to discuss their views further.

Follow-Up Telephone Interviews

Attempts were made to contact all participants approximately 6-8 weeks after the last training

session had been delivered. A convenience sample of 3 was recruited for short telephone interviews

that were conducted at mutually convenient times. Verbal consent was obtained. Semi-structured

telephone interviews (lasting no longer than 15 minutes) were conducted, using a short interview

schedule based upon the Kirkpatrick Four level model of evaluation (17).This proposes four areas of

interest associated with assessing the impact of any educational program: the learners’ reactions to

the programme; learning of skills and knowledge from the programme; changes in learner behaviour

as a result of the programme; and the overall results of the learning opportunity.

Questions focused around the initial reactions and satisfaction of participants, any new knowledge

or skills learned, whether participants had applied the training they had received and the impact of

the training over time. Participants were also provided with the opportunity to add other comments

not already explored. These telephone interviews were transcribed and analysed thematically.

Method 4: Project Action Plan Documented Activities

A project action plan was devised at the beginning of Phase 1. The action plan was routinely updated

as developments occurred and was shared amongst the Steering Group at all meetings. This involved

entries against the action plan, including activities undertaken, personnel involved and any notable

comments. This documentary evidence was reviewed to assist validation of data generated through

the other methods used and capture any additional activities not documented elsewhere.

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4.5 PHASE 2 RESULTS

The results of Phase 2 are divided into two areas of focus:

Education, Training & Awareness

Integration of the MRPP in the MPT

i. Education, Training & Awareness

Aims To document the development and dissemination of education resources

To explore training and educational opportunities facilitated by the MRPP

To explore the reception and perceived usefulness of the Sunny Session Care Home Training

Results

Sixteen participants were recruited from Method 3. Action Plan data collected in Method 4 is also

included here (see Methods section for short descriptions).

a. Care Home Staff

Resource Development

Initially short 10-15min training activities in the format of ’games’ that could be delivered during tea

or lunch breaks were developed. However, it was ultimately decided that longer sessions would be

more valuable and that it would be unfair to ask staff to take part in training during their breaks.

The final topics of the training and their outcomes are illustrated and detailed in Figure 2 (further

detail in Project Toolkit).

Figure 2- Sunny Sessions Palliative Care Home Training Titles and Outcomes

Session 1 (Part 1): What is Palliative

Care?

• Recognising what palliative care is

• Recognising what is end of life care

• Being confident in knowing the difference and what this means for you

Session 1 (Part 2): What is End of Life

Care?

• What needs to be considered for anticipatory planning for end of life care

• Recognise problems that may be related to medicines

• Know what action to take

Session 2: Assessing Pain in Elderly

Patients

• Recognising the presence of pain

• Have the tools to identify pain

• Know what action to take

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The MRPP approached one of the Care Homes who had expressed an interest in staff development

through delivering the training. The MRPP piloted the training on a small sample before producing

the full set of materials. . The MRPP visited this Care Home in March 2014 to give them an outline of

the training proposed. Two sample training sessions (with the first being split into two parts) were

developed and consisted of paper resources, a word search puzzle based upon terminology used in

palliative care delivery and true/false question and answers. An “assessing pain” session involving

role play (patient and carer) was included with true/false activities/questions.

Resource Delivery

The training was delivered between 10th July and 10th September 2014 in three care homes and all

participants completed evaluation questionnaires. Participant demographics were collected. Sixteen

participants who had completed the training sessions completed questionnaires. The majority (n=14,

88%) were Care Assistants or Social Care workers. One senior Social Care worker and one Manager

also took part. Twelve participants worked full-time hours and the remainder were part-time.

Duration in job ranged from 5 months to 25 years (median= 9.5years).

All 16 questionnaire participants were agreeable to being contacted by the researcher to take part in

follow up telephone interviews. The researcher attempted to telephone all 16 participants. One,

participant declined to participate, one no longer worked at that care home, and four individuals

were either sick or absent, resulting in a potential cohort of 10. In total, the researcher completed

interviews with three participants from two of the three Care Homes sampled (19% of original 16

participants). Interviews lasted approximately 10-15 minutes each. All three participants were Care

Assistants, two worked part time with experience ranging from 18 months to 12 years. The other

participant worked full time and had 3 years’ of experience.

Feedback on resources

Participants rated their satisfaction of the training using a 5 point Likert scale (“Strongly Disagree” to

“Strongly Agree”) of responses to attitudinal statements in the questionnaire. Table 2 details the

responses to each statement.

Delivering the training during scheduled work hours and at the participant’s regular place of work

were the most favourable options. As the sessions were scheduled for normal working hours, it

was important that it did not distract staff from their duties. Participants were asked if the length of

the training was appropriate (approximately 45 minutes per session, 2 hours 15 minutes in total).

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The vast majority responded that the face-to-face training approach, delivered during work hours in

the work environment was the most favourable. Even though the training was designed to take a

short amount of time, one participant commented that it all took around 2 hours combined, which

was longer than expected. However, this was seen as appropriate and practical amount of time.

Table 2- Sunny Session Training Evaluation - Questionnaire Statements Responses (n=16)

Not all questions were answered hence not all responses add to 100%

Participants largely perceived the training to be appropriate and useful for untrained care home

staff. Participants also appeared to understand the information presented at the training; therefore

a desire for more knowledge may come from their enjoyment of the training and willingness to build

on current skills and knowledge.

All participants agreed that the training was useful and practical. General comments provided (n=7)

were complementary, with participants stating the training was “useful”, “informative” and “well

delivered”. All three telephone interviewees said the training was informative and useful:

Questionnaire Statement Responses Provided % “I liked the format of the training” Strongly Agree 50%

Agree 50% “The training sessions were the right length of time” Strongly Agree 44%

Agree 56%

“The training sessions were too long” Strongly Disagree 50%

Disagree 44% Strongly Agree 6%

"The training occurred at a time convenient for me"

Strongly Agree 56% Agree 38% Neither Agree nor Disagree 6%

“The training occurred in a place convenient for me” Strongly Agree 50%

Agree 44%

Neither Agree nor Disagree 6% "The training content was too challenging"

Strongly Disagree 50% Disagree 37%

Strongly Agree 6% “I learned something new at the training” Strongly Agree 50%

Agree 37% Neither Agree not Disagree 13%

“I would welcome more detailed information on the topic(s) I covered”

Agree 44%

Strongly Agree 37% Neither Agree nor Disagree 6%

25

“Yeah it was very good…we know a lot of things because we do it day to day but

there was a few little bits that sort of opened your eyes a bit more…some of the

paperwork that she was giving us was really well detailed and there was plenty of

little bits on it that just actually made you think a lot more about what you do and

how you’re doing it.” (Care Assistant, 18 months)

The more experienced participant said the training reiterated knowledge that they already had, but

felt it would be valuable to staff who were less experienced:

“It has been beneficial…there’s girls there who work here who have never

experienced end of life and pain management and that yet, so to me yes it must be

beneficial for them.” (Care Assistant, 12 years)

Interviewees also provided examples of where they had applied their new knowledge/training. All

said that they had the opportunity to use the training because palliative care was a daily occurrence

for them. One participant identified that prior to the training, they weren’t aware of the full extent

of planning that went into preparing for a patient’s end of life and ensuring the patient and their

family’s wishes were met. Another participant said the training had increased her awareness of

proper mouth care for palliative patients who may be experiencing issues associated with certain

medications.

Participants were also asked about the potential results of the training and the overall impact it

could have. All said it was useful, especially those staff with limited experience. One participant

commented that the knowledge and skills gained from the training could be passed on to other

newer staff members over time if they had access to any of the materials:

“Because [palliative care is] a regular occurrence here it’d be nice to have a few

extra bits from that course that we can pass on to other people as well, because

we’re working with a lot of different staff here so there’s a few of us who are

doing these kinds of courses, so it’s nice just to sort of reinforce bits that we do

anyway and maybe give a few tips to the other workers in here.” (Care Assistant,

18 months)

26

In the questionnaires, none of the participants could offer suggestions as to how the training could

be improved. One participant said the training was satisfactory, but felt that it was a challenge to

include the appropriate personal and emotional element into palliative care training:

“I wouldn’t fault the training we had…but I sometimes feel it lacks compassion,

feeling, because people who are writing this and telling you what to do, you almost

get the feeling, they’ve not been there…but I couldn’t fault what we got.” (Care

Assistant, 12 years)

Overall, participants responded that the training was useful and informative. All participants

complimented the MRPP in her delivery of the training and enjoyed the relaxed, face-to-face, group-

learning experience they had.

b. Healthcare Professionals

Resources

Based on the anecdotal evidence that errors were common in the writing of CD prescriptions, two

activities progressed. Firstly, an audit of CD prescriptions presented for dispensing was conducted

(see Appendix 1 for full aims, methodology, results & discussion) and secondly, educational

materials about opioids were developed. Following discussion with the Steering Group and

additional GPs and Nurses in the area, it was agreed that the use of computer mouse mats and

tea/coffee mugs be explored as a tool for providing opioid prescribing and conversion information in

an easily accessible manner to compliment paper resources such as those in the Highland Palliative

Care Folder resource. The materials themselves were designed and developed by the Project Lead

and MRPP. One of the mouse mat designs was based on materials from the Macmillan NHS GG&C

Project as well as Royal Pharmaceutical Society (RPS) guidance and were produced via a local printer.

The mugs were adapted from guidance from the Medicines Management Group, Marie Curie/NHS

GG&C (18). The materials were disseminated by the MRPP to the Project Steering Group, Highland

Hospice medical staff, all GP practices, Community Pharmacies, District Nursing Bases, Community

Hospitals, and Macmillan nurses between the months of September and November 2014.

Guidance

The MRPP was involved in the general education and training of the wider (professional) healthcare

team. Through the Highland Palliative Care Network, all GP Practices, Nurses, Macmillan Nurses,

27

Care Homes, Community Pharmacies and Hospital bases have access to prescribing guidance within

the Palliative Care Information Pack. Users of the pack are emailed updates whenever updates are

available and are responsible for printing and inserting this new guidance into the relevant section of

the information packs. However, the extent to which this is done is unknown. The MRPP was

therefore contacted and visited all of the different professional groups to check that the Information

packs had been updated in all locations within the project area. Online distance education resources

via NHS Education for Scotland (NES) Pharmacy website were also promoted to community

pharmacy staff. The annual palliative care course run by Highland Palliative Care Network, and the

Pharmacy Palliative Care Training (delivered by the Community Pharmacy Palliative Care Network

Co-ordinator aka Project Lead) were also promoted to staff.

Education Sessions

The MRPP also gave a talk on palliative care to Boots pre-registration pharmacists on palliative care

medicines related issues. Thirty-six Pre-Registration Pharmacists attended the Care Services training

day on 1st May 2014 in Glasgow. The MRPP discussed her role and how this fitted into future plans

for pharmacy (namely Prescription for Excellence). The MRPP also stressed the importance of

professionalism and ethics, particularly when dealing with other healthcare professionals in settings

such as GSR meetings as well as the need to overcome the view that pharmacists are “shop-

keepers”.

The MRPP presented a talk to Macmillan professionals on 11th November 2014 entitled “The

Challenges to Pharmacy of Providing Palliative Care to Elderly Patients in Remote and Rural

Settings”. The MRPP also facilitated sessions on palliative care case reviews within the community

pharmacies in the project area in the format of practice-based learning.

c. Patient & Public Awareness The MRPP undertook a number of activities to improve the understanding and awareness of patients

and carers with palliative needs, as well as the general public who could arguably become potential

future service users themselves. The MRPP initially planned a stand to be filled with patient

information paper resources for patients to access within the community pharmacy where the MRPP

was based. Paper resources were viewed as most appropriate as unreliable local broadband means

accessing electronic resources can be difficult and most resources of this nature were in similar

settings like GP Surgeries. An order for Macmillan patient information resources was made.

However, a stand suitable for the community pharmacy shop floor was not forthcoming so the

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MRPP prepared a different stand with materials, in the pharmacy staff room for staff to draw from

(if needed) when interacting with patients with palliative needs. The MRPP reported that some of

the resources were being used by pharmacy staff during follow up visits to the pharmacy. Since

August 2014, these stands are in two of the three pharmacies and also in one of the GP practice

waiting rooms. Staff have reported that all stands are regularly accessed by members of the public.

Leaflets were ordered by the MRPP in May and December 2014. Of the 77 leaflet-types available,

149 were taken by patients and healthcare professionals in total. The most popular leaflets were on

the following topics:

“Your Life: Plan Ahead Scotland” (8 copies accessed)

“End of Life” and “Gardening As A Way To Keep Active” (6 copies accessed each)

“Recipes from Macmillan Cancer Support”, “Signs and Symptoms of Cancer and “The Side

Effects of Cancer Treatment” (5 copies accessed each)

“Work It out for Carers” and “Controlling Cancer Pain” (4 copies accessed each).

The most popular leaflets accessed show that patients require information and support in everyday

activities as well as disease, symptom and pain related matters (a full list of all resources and copies

accessed can be found in Appendix 2).

The Highland Hospice operates a Day Therapy Health and Wellbeing service as part of the hospice

programme. These are 12 weekly sessions covering different topics mainly focusing on the

psychological and emotional aspects of palliative care. They help patients to empower themselves to

improve their quality of life as well as develop coping strategies suitable for dealing with their illness

trajectory. A modified format is now rolling out across the NHS Highland health board area as an

outreach programme. The MRPP has been involved in delivering the medicines and pain-focused

sessions of this programme.

In collaboration with a local GP, the MRPP set to explore health and medicines information literacy

issues. (It is accepted that patients struggle with understanding written medicines information for a

variety of reasons) Possible methods of addressing this issue were to be explored including: Using

pictorial illustrations of dosing and administration of medication; the Teach Back programme- which

encourages patients to repeat back the information they have heard to elicit if they understand

what they have been told about their medicines; information cards for patients- prompting them to

ask certain questions about their medicines; and follow-up home visits or drop-in clinics at the GP

surgery or pharmacy to discuss with patients their information needs.

29

The MRPP also consulted the Macmillan Cancer Support website (www.macmillan.org.uk) to see

what was written about the project area and the current service. On establishing that nothing was

present, Macmillan were contacted and the website updated. The MRPP also arranged publicity for

the new service in the local free press. An article about an MSP visit was treated as a first advert in

the free paper West Highland Free Press and monthly adverts were agreed from the beginning of

April to improve awareness. Flyers were also distributed in the medicine bags of patients with

palliative conditions collecting their medication from the Boots Pharmacy advertising the service and

drop-in clinics.

The MRPP provided a number of talks to the public at Living with Cancer Days sponsored by

Macmillan Cancer Support. These occurred on 6th February and 11th September 2014 and were

entitled “The Role of the Macmillan Palliative Care Pharmacist” “Getting the most of your

pharmacist”. The MRPP also gave two similar talks to the Scottish Women’s Rural Institute on 3rd

April and 3rd of November.

A local MSP spent almost 2 hours visiting the pharmacy on 1st March 2014 to discuss the service with

various Key Service Leads. The MSP also offered a debate in Parliament about Palliative Care. The

specific topic of the debate would be decided towards the end of 2014. A further visit by another

local MSP took place on 6th June 2014 and a further MSP visit is planned for January 2015.

In addition details of the project were disseminated and discussed in a number of professional and

academic forums, details of which can be found in Appendix 3.

Conclusions

Care Home staff felt that the Sunny sessions training they received were of great benefit in

increasing their awareness of palliative care and what it entails

The training addressed current needs and more training was welcomed

The MRPP was active in developing and delivering resources to improve the writing of CD

prescriptions

The MRPP was active in promoting various forms of up-to-date palliative care guidance to a

variety of healthcare professionals, ensuring all staff were implementing current relevant

practice

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The MRPP engaged with a variety of healthcare professionals in a variety of settings during

educational settings, promoting medicines-related palliative care information across a large

setting

Patients and the general public were also targeted with the increased availability of paper

resources within the less formal setting of the community pharmacy

All other public engagements, including patient contact and publicity in the press have

worked towards increasing the profile of what pharmacy services can offer, the MRPP role

and the project within the area and wider.

Future Directions

Enabling Practitioners

Care Home Staff

Ongoing: The development and roll out of additional Sunny Sessions training materials

Ongoing: Access to further learning resources beyond Sunny Sessions (e.g. The Current

Learning in Palliative Care and the NES Pharmacy Technician training pack)

Phase 3: Support staff in their knowledge of new medicines with medicines information

sheets

Phase 3: Explore a mechanism to make Sunny Session training a national resource.

Healthcare Professionals

Ongoing: Deliver tailored GP talks on request (e.g. symptom management i.e.

breathlessness, use of ‘specials’ etc.)

Ongoing: Maintain locality group pharmacy peer-review and training development

Phase 3: Improve access to all training through the use of webinars and other technology

Phase 3: Facilitate local multi professional team training

Phase 3: Explore potential for further distribution of the mouse mats, mugs and any other

educational materials across NHS Highland

Phase 3: Test the roll out of the Sunny Sessions care home training information packs to

other health/social care support workers (SVQ Level 2 and 3).

Enabling Patients & Carers

31

Phase 3: Adapt and test the roll out of Sunny Sessions training and make available to family

carers, patients and members of the public through established settings (e.g. Macmillan days

etc.)

Phase 3: Promote further MSP visit to the project area following MSP Rhoda Grant’s visit

Phase 3: Test currently developed materials i.e. “Ask 3” cards and medicines information

cards1

Phase 3: Explore use of twitter account and hashtag to enable non-direct contact with

patients (#SkyeLochPharm)

Phase 3: Explore access to medicines information materials in non-clinical settings e.g.

libraries.

ii. Integration of the MRPP into MPT

Aims

To identify the level of integration of the MRPP into the local palliative care service

To Identify areas where the MRPP could potentially extend their contribution to the service

Results Twelve participants were recruited from Methods 1 and 2 (see “Methods” section for short

descriptions).

a. MRPP Key Clinical Services Delivered & Reflections

Eleven oral history sessions were recorded between 17th January and 13th June 2014. The MRPP

was asked to detail their recent activities and an unstructured conversation would ensue. Two major

clinical activities appeared to dominate each oral history session: Gold Standard Review (or

Framework) meetings (GSRs); and drop-in clinics. In addition, a summary account of other clinical

activities undertaken by the MRPP is provided.

Gold Standard Review meetings (GSRs)

1 Ask 3 cards are being developed by the Project Lead based on the ASK ME 3 project in the United States of America. These and patient medicines information support cards and are planned to be distributed via the outreach Health & Wellbeing Course and via Community Pharmacies in the first instance.

32

GSR meetings are attended by a variety of healthcare and social care professionals (depending on

the area) involved in patient care. Decisions are made about a patient’s care in the various settings.

The MRPP attended GSR meetings in the following locations: Portree (n=5), Broadford (n=3), Glenelg

(n=2) and Dunvegan (n=1). Glenelg, Carbost and Dunvegan GP Dispensing Practices did not have

GSR meetings prior to the introduction of the MRPP role, which in part was stimulated through the

MRPP appointment as a focus for engagement with the GPs. The MRPP attended all meetings with

the exception of two areas; Carbost and Kyle. Details of discussions at the GSR meetings can be

found in Appendix 4.

The MRPP reflected that the GSR meetings facilitated the following:

A discussion about patients moving between care settings: being able to trace the movement of

patients can help other professionals in other settings who may also have queries about these

patients, resulting in a more “joined-up” service for the patient

Healthcare professionals ability to plan and manage patient care, as well as raising awareness of

the role of pharmacy within the service

The creation of a useful platform for healthcare professionals to share information about

patients from a safety perspective, as patients sometimes provide variable information about

their symptoms and treatments to different healthcare professionals.

It was thought that the GSR meetings may help to address the issue of GPs not placing some

patients, especially elderly patients onto the Palliative Care Register (an issue identified in Phase 1).

The MRPP commented that over time, the range of healthcare professionals who attended the GSR

meetings increased. At the Glenelg meeting, attendees have built up a more standardised meeting

format, with the next step being to grade patients based on their current care status. A move to

standardising meeting structure further was seen as beneficial.

The MRPP reported that attending GSR meetings was on a few occasions challenging, due to

pressures in the community pharmacy. The MRPP foresaw staffing issues, timing of meetings which

were often at lunchtime, and travel time (up to 30-45 minutes) as potential barriers for pharmacists

being able to attend future GSR meetings. This is an important factor to be considered for future

roll-out of the service and the potential involvement of community pharmacists in GSR meetings.

Drop-In Clinics

33

An overview of the content of the drop-in clinic(s) can be found in Appendix 5. Clinics started in

September 2013 and occurred every fortnight until June 5th 2014. From 16th January 2014 a

Diabetes clinic was run concurrently on behalf of Boots and continues to run. The Community

Pharmacy saw this as an ideal opportunity for patients to ask questions or receive information about

their medicines, particularly as some patients may not like to ask questions in the GP surgery. Also,

having a private consultation room within the Pharmacy means patients can ask about their

medication with more privacy than at the pharmacy counter. Unfortunately, the clinics were not

well attended, despite local advertising. It was observed that patients generally made queries on any

given day. A regular daily facility was considered to be a better approach. Additionally, it could be

that some patients/carers who required information lived further afield. These patients may not visit

their local pharmacy at all and instead have their medicines delivered to their home.

The MRPP reflected that addressing palliative care needs should be integrated into the general

pharmaceutical activity to support patients. This could be incorporated as a structured framework

into the Chronic Medications Service (CMS) from community pharmacies. One possibility was to

establish a ‘chronic or long-term conditions clinic’ as an alternative. This arrangement could provide

a more comprehensive and better-utilised service rather than palliative-specific clinics. The MRPP

has liaised with the Pharmacist in the community pharmacy in Kyle to discuss piloting such a clinic;

she was motivated but felt that they required ‘significant support’. The Project Lead is developing a

framework to support MRPP rollout for pharmaceutical palliative care delivery from community

pharmacies.

Other Clinical Services

The MRPP discussed a number of other clinical services in operation. The MRPP provided a ward

pharmacy service in the Community Hospitals, although the majority role was in the Portree hospital

pharmacy, primarily because this community hospital is in the vicinity of the MRPP base. The MRPP.

made regular visits to update and restock the medicines cupboard, a generic technical pharmacy

role which increased hospital staff contact with direct pharmaceutical expertise. The MRPP also

advised on stock levels and provided help with new ordering scheme in Broadford hospital

pharmacy. A number of frequent issues were identified, including: medicines in bedside lockers not

belonging to patients; incomplete information on prescription Kardexes; and issues with

formulations or preparations of patient medications. Details of the hospital pharmacy work the

MRPP discussed can be found in Appendix 6.

34

The Nurse Medicine Manager for NHS Highland had performed medicine audits in Broadford and

Portree hospitals whilst the MRPP was on annual leave. The results of this audit were similar to the

MRPP audit which found issues associated with medicines safety and missing patient information on

Kardexes. The MRPP and the Project Lead met with the Nurse to discuss what could be done to

improve the situation. It was agreed the MRPP would check these at the time of clinical review and

let Charge Nurses in the hospitals know if there were any gaps/omission in patient information that

required completion.

It is possible that the lack of pharmacy input in the community hospitals has led to a lapse in quality

control towards medicines use and completeness of patient information on prescription charts. The

MRPP commented that over time, she was being more welcomed and accepted as part of the

hospital, and that staff were expecting to see her in the pharmacy on a regular basis. In order to

address these issues and work towards fewer medicines safety incidents in the future, the MRPP had

begun informally training nursing staff in medicines protocol to help address the issues with

medicines ordering/management. On a more specialist level, the MRPP was also offering informal

training to nursing staff on palliative care medicines, hoping to address some of the issues

highlighted about palliative medicines formulations and preparations.

The MRPP detailed 17 enquiries received from an array of individuals, including healthcare

professionals, patients and carers between 17th January and 13th June 2014. Table 3 summarises the

nature of the enquiries and any resolutions which occurred.

Table 3- Summary of Clinical Enquiries made to MRPP detailed in Oral History sessions

By whom? Issue(s) Resolution

GPs (n=11) Talking labels for patient’s medication Talking labels and other aides sourced Medicines unavailable (n=4) MRPP sourced medications (n=3)

MRPP was still resolving access issue (n=1) Additional medication for patient MRPP provided information on additional

medicines Concerns about long-term of use of medication

MRPP provided information on alternatives, maximum strengths and side effects

Enquiry about possibility of sharing stock between GP practices

MRPP approved of sharing medicines

Patients (n=2) Patients asked about side effects of treatment (n=2)

MRPP gave advice on both occasions

Carer (n=2) Family carer needed advice about family member’s medicines

MRPP facilitated in creation of a care package

Pharmacist (n=1)

Patient was having difficulty swallowing MRPP recommended a liquid formulation and alternative methods of administering

Nurse (n=1) Patient was experiencing side effects from chemotherapy

MRPP recommended patient be admitted to hospital for assessment

35

The MRPP had been invited to be a member of various working groups, including the Area

Pharmaceutical Committee and the Area Clinical Forum. The MRPP had attended a few meetings

during the time of the project. It seemed that her inclusion was perhaps a result of the project

profile, and further facilitated, the MRPP integration into the MPT network.

The MRPP and the Project Lead also facilitated the collection of data from the Highland Hospice

Phone Line on calls made about patients with palliative needs between March and July 2014. The

Phone Line operates 24/7 and is open to members of the public as well as healthcare professionals.

The aim of the audit was to serve as a continuation of the data collected during Phase 1, and to

identify if the nature of calls received and made had changed now that the MRPP post and the

project was in place. The MRPP and the Project Lead have both contributed to the advice given

during these telephone calls. Full details of the audit can be found in Appendix 7.

b. Feedback from Stakeholders A thematic analysis of the follow-up interviews with stakeholders identified three main

themes/issues:

MRPP Engagement with Health Professionals

MRPP Engagement with Patients

MRPP Role and Service Development

A number of sub-themes emerged in association with each theme/issue which are discussed below

and accompanied with participant quotes to illustrate particular findings.

Healthcare Professional Engagement

The MRPP engaged with a variety of healthcare professionals, and many participants mentioned the

value of the MRPP developing these relationships. It was initially challenging because the role was

placed within a pre-existing service, however the current MRPP was known to (some) of the

community prior to her assuming the position of MRPP. One of the main challenges was to become

integrated within teams and communities, which for a variety of reasons were perhaps not so open

to expanding their networks. Furthermore, challenging the pre-existing and somewhat traditional

view of a pharmacist’s role was also seen as a challenge, and overcoming this was key to the success

of the integration of the role moving forward:

36

“Having to meet so many different healthcare professionals, that she maybe hadn’t

been involved in before, working in so many different settings, making the

connections with all those professionals and building relationships…That is quite a

challenging activity to do and she’s managed that brilliantly…professionals and lay

people don't really understand what pharmacists do, and I think breaking down

those barriers have been absolutely great.” (KSL)

One participant commented that the MRPP was now regarded as part of the community, perhaps

due to the community-based nature of the post. As the MRPP was visiting and working in a number

of different care settings, this increased visibility worked some way towards further integrating the

role into the current service. This engagement with healthcare professionals could be categorised

into two sub-themes: the MRPP as a source of medicines information & support; and, the MRPP role

in Care Home staff training.

Medicines Information & Support

When asked about contact /involvement with the MRPP, or what aspects of her role were the most

beneficial, most participants reported that her knowledge of palliative care medicines was the most

helpful. Other Healthcare professionals saw her as a source of information, or at the very least, as a

guide to accessing information that they required. Many of the participants stated that the MRPP

had been particularly helpful in situations where sourcing a medicine was problematic:

“ [This patient’s] medicine was trying to keep sort of symptom control…[the MRPP]

was able to [phone] the company that was producing it ,as well as talk to other

pharmacists for advice for what other things we could try for him.” (GP)

The interviewees also noted that prior to the MRPP role, GPs or the Highland Hospice were often

their first port of call when seeking information about (palliative) medicines. This had now become

the MRPP who was a dedicated individual for contact:

I mean it has been helpful having her there, because I think we turn to her more

because before she was here… [we] used to ring the hospice. And I know the one lady

that we used to get in touch with there, they made her redundant. So her post was

taken away. So [the MRPP’s] filled a gap for us” (KSL)

37

The MRPP has also engaged effectively with healthcare professionals through activities in the

hospital pharmacy. The MRPP was active in the local Community Hospitals auditing and monitoring

medicines uses. A number of issues were identified and are detailed in Appendix 6:

“In the pharmacy in the hospital there are certain drugs that we have to have

available twenty-four-seven and there are other medications that we use as standard

medications so we have got to manage a stock…she assisted the nurse who’s got this

role in organising that…She also helped by scrutinising prescriptions within the

hospital and that’s a role a pharmacist in a hospital would normally take…to go

through the prescriptions and see what the doctors are ordering and point out you

know discrepancies or errors or suggestions given her particular knowledge on

medications.” (KSL)

As the community hospitals do not currently have a routine pharmacy presence, the MRPP’s input

into patient care via monitoring medicines and alerting nursing staff to errors or potential problems

in this setting was seen as beneficial not just for palliative patients but potentially all patients in the

hospital.

Care Home Training

Some participants said that they were aware of the MRPP’s input into the Care Home training and

felt positively towards this education initiative:

“She’s going round all the [care] homes at the moment doing a lot of education

which for me is hugely beneficial…we can prevent a lot of symptom management

problems later on and also get [the care homes] to contact us earlier when there is a

problem.” (Nurse)

This participant identified the secondary benefits the care home training would have, in that it

would not only benefit Care Home staff and residents, but could also potentially reduce Macmillan

Nurses workload in having to deal with medicines issues within the Care Homes which may be more

appropriately directed towards a pharmacist. Some participants were able to detail various activities

the MRPP had led on, or had taken part in. Although some had little direct contact with the MRPP,

they could still identify that the MRPP role was of benefit to the local service provision:

38

“So if you asked each of us [GPs] I think each of us would say, “I don’t see her very

much”, but collectively…there's been positive merits from all of my colleagues

about her involvement.” (GP)

Patient/Carer Engagement

As well as engaging with healthcare professionals, the MRPP’s engagement with patients and carers

was also highlighted. Comments were made about the MRPP engagement with patients and carers,

both directly and indirectly.

Direct Engagement

Most participants commented on the MRPP’s direct involvement with patients and her role in terms

of guiding and supporting patients with palliative needs and their medicines. One participant felt

that as the MRPP role was based in the community, it meant that care was more accessible:

“[The MRPP] talks about more than just medicines…I think it is something that's

missing [elsewhere] to be honest with you I really do, I believe it's that personal care,

where a healthcare professional can go into a patient's home and really look after

them in a rounded way, but have the expertise of the medicines that will help them

through their condition and help them understand how to take them.” (KSL)

Participants commented that the MRPP had been a great source of support to patients & carers with

palliative needs. This direct patient contact was seen as extremely valuable and should be

continued:

“You have the opportunity to see patients that you wouldn't normally see that don't

come and seek you out, you see them by chance because they're in collecting their

medicines and that gives you the opportunity to have a chat with them, and I think that's

the key thing.” (KSL)

Some participants gave specific examples of where the MRPP had directly helped a particular patient

with their medicines, both in terms of improving access and sharing information on how to take

them. One participant, a family carer, detailed how the MRPP helped her while caring for her

husband:

39

“[The MRPP] phoned up and made an appointment …she was quite helpful in looking

carefully at the medication [my husband] was on and making suggestions and it was

really suggestions on the dosage…that was helpful because when you're a carer on your

own, you can't start mucking about with medication… [the MRPP’s] input was good in

that it gave me the confidence that I was doing the right thing and that I could also

contact her if I was anxious about anything.”(Carer)

Participants also referred to an array of care settings the MRPP had interacted with patients,

including patient’s own homes, care homes, hospitals and even in the street. Some commented that

the MRPP was now well known in the community, had forged relationships with the MPT and was

both personally and professionally known to many patients and family carers.

Indirect Engagement As well as having direct interaction with patients and family carers, the MRPP also impacted on

patient care, namely, the joining up of care between settings, through her involvement with the

Gold Standards Review (GSR) meetings in the area. The main benefit realised was the breadth of

patient visibility, i.e. when patients moved between care settings, the MRPP was often one of the

few healthcare professionals who could “follow” these patients as they move from location to

location, and could therefore promote a more joined-up service:

“[The MRPP’s] following patients around regardless of where they are. What has

been a really interesting development, which I don't know I expected, had maybe

hoped for, but hadn’t actually expected, is that she has been seen as a kind of a

coordinator.” (KSL)

Another benefit realised was the perceived support the GSR framework had received. The MRPP’s

presence at meetings may have encouraged more regular and more formalised meetings, but the

MRPP has also been responsible for establishing meetings in areas where previously there had been

none:

“I really think [MRPP involvement with GSR meetings] has helped engage with

professionals…[who] maybe wouldn't have talked to each other previously… it

would appear that the system wasn't maybe as robust as it appeared on the

outside... You know, she has managed to engage with some of the practices where

previously it had been quite challenging.”(KSL)

40

The MRPP has also directly engaged with patients and their carers through a multitude of other MPT

meetings and liaison teleconferences with a number of healthcare professional groups. Promoting

GSR meetings, facilitating their coordination and communication between healthcare professionals

and being able to track the journey of palliative care patients all had an indirect but positive impact

on the patient and their medicines needs.

MRPP Role in Future Service Development

Comments and suggestions made by participants about the ideal characteristics of the MRPP role as

it develops were identified. Sub-themes to emerge from this were; the Delivery Format and Focus of

the MRPP Role; Patient & Carer Support; and Integration with and Support of the MPT, as illustrated

in Table 4.

Table 4- Suggestions for MRPP Role in Future Service Development

Theme / Sub-Theme Explanation Quote

Delivery Format of MRPP Role

MRPP Role Shared by Community Pharmacists

The MRPP role was not necessarily seen as belonging to one person, but as a collection of responsibilities/tasks that could be shared among local Community Pharmacists on a part-time basis.

“I would imagine maybe the community pharmacists having their own specialisms- there might be a pharmacist who has a real passion for asthma, there might be another pharmacist who has a real passion for hypertension.” (KSL)

Generalist vs Specialist Balance

The MRPP had an impact on a general level in the Community Hospitals, and as a community pharmacist with a generalist background, a broader approach to medicines might be a valuable approach.

“I think [the MRPP] could be potentially involved in more stuff within our hospitals but a lot of the issues within the hospitals and pharmacology are not just around palliative care. So for me it would be maybe having this role that has a slightly broader remit rather than just the palliative side of things.” (KSL)

Patient/Carer Support Bridging the Gap

between Healthcare Professionals

The community-outreach aspect of the MRPP role was seen an invaluable as it bridged a gap between community based staff like Nurses and clinic-based staff like GPs, with a specific emphasis on medicines.

“I felt that once [my husband] had been diagnosed, it moved completely out of the medics locally…[my husband] only saw the GP twice...and I do feel that if it hadn't been for people like [the MRPP] and the Macmillan nurse and the other nursing staff that were coming in, I really would have been very much on my own.” (Carer)

Providing Information and Support

Providing patients and carers with advice, support and information relating to medicines, administration, formulations, symptoms and side-effects appeared to be an important part of the MRPP role moving forward.

“[The MRPP has] the opportunity to see patients that you wouldn't normally see that don't come and seek you out, you see them by chance because they're in collecting their medicines and that gives you the opportunity to have a chat with them, and I think that's the key thing.” (KSL)

41

Integration in and Support of MPT

As well as in the Care Homes, training in other care settings with other healthcare staff (including nursing staff, new care home staff and untrained dispensing staff) was suggested as potential avenues the MRPP could help in.

“Well, as I say, the one thing that sprung to mind would be a bit of training for us, you know with imparting some of her knowledge to us certainly about specifically about palliative care.” (Dispensing Staff)

Further Development of the Role across NHS Highland

Participants commented on the infrastructure and resources that need to be in place for the MRPP

role to be successful. In the current project, there was a delay to adequate IT support for the MRPP,

resulting in limited or sub-optimal access to computers, telephones and other electronic or paper

resources. Ensuring the MRPP role is paired with adequate and accessible technology and resources

is key to the job role. Relevant CPD and training for the role was also seen as important, as was a

personal enthusiasm for the speciality:

“As I say, just the fact that she has been so willing to embrace, you know, the

continued professional development side of the role, has been absolutely incredible,

so I do think an awful lot of what we have achieved has been down to the

individual.” (KSL)

Some participants also highlighted the importance of the environment in which the MRPP role

would be operating. As discovered in Phase 1, rural working and living poses unique challenges and

having a service that can adequately react to and pre-empt these difficulties is helpful. Some also

highlighted that small rural communities can be hard to penetrate, and that excellent interpersonal

and networking skills are essential.

Conclusions

The MRPP engaged in a number of key clinical tasks during Phase 2, including attendance at,

promotion of, and creation of Gold Standards Review Meetings in the area. This enabled the

MRPP to facilitate a more joined-up service for patients. Less successful activities included

trying to establish a community pharmacy drop-in clinic

The MRPP’s other clinical tasks revolved mainly around providing a pharmacy presence in

the Community Hospitals which was identified as an important service need. The MRPP

input has identified a number of opportunities for improvement

The MRPP role should involve dealing with requests from a variety of healthcare

professionals on a regular basis

Patients/carers welcomed the additional support provided through the post and the

42

accessibility within a different setting

Feedback from stakeholders was positive. All felt that the MRPP role was accessible, needed

and appreciated. The MRPP role was seen as beneficial in terms of providing excellent

medicines information and support, as well as facilitating education and training

opportunities

The format and future of the MRPP role was discussed, with many saying that the tasks and

responsibilities could be shared between local Community Pharmacists who could provide

both generalist and specialist services if employing a single individual was not appropriate.

Future Directions A number of areas where the MRPP has integrated the role, as well as opportunities for further

integration into the current service were identified. Common tasks or themes included the

integration into the GSR meetings, opportunities for enhancing pre-existing and potential new

engagement opportunities, and prospects for improving access to patient information.

Gold Standards Review Meetings

Ongoing: Attend GSR meetings to provide information and insight into palliative medication

related issues in patients

Ongoing: Raise issues at a local level at GSR meeting from Highland Hospice calls

Phase 3: Explore how Community Pharmacists can contribute to GSR meetings through the

use of technology

Phase 3: Develop Top Ten Tips guide for healthcare professionals for conducting GSR

Meetings.

Further Engagement Opportunities

Ongoing: Raising ethical issues in the quarterly Palliative Care Model Schemes Newsletter

starting Nov 2014, with feedback request & answers in next quarterly newsletter

Ongoing: Provide continued advice and support to Macmillan Nurses relating to palliative

care medicines

Phase 3: Conduct a follow-up audit of CD prescribing

Phase 3: Support Community Pharmacists across the project area in developing and hosting

their own drop-in clinics, independent prescribing clinics and/or providing teach-back

experience for patients’ improved understanding of medicines.

43

Access to Patients’ Medicine Information

Phase 3: Implement a system where access to patient hospital admission and discharge

information, including Immediate Discharge Letter (IDLs) as well as more advanced

information for Community Pharmacists is arranged.

5. Phase 3- Service Development & Sustainability Model Drawing from the evidence gathered throughout the project and discussion with the Steering Group

a service development and sustainability model for community pharmacy palliative care services was

created (Figure 6).

Figure 6: Phase 3 Service Development and Sustainability Model

The Start-Up Step- The MRPP role will be evolving and fluid depending on the area’s specific needs.

This step is focused mainly on scoping the current service, establishing the needs of the community,

Step 1:

Start-Up Phase

Step 2: Development

Phase

Step 3: Maintenance

Phase

44

forging relationships and building the profile and awareness of the role. Visibility is key. The MRPP

attendance at forums such as the area GSR meetings is critical.

The Development Step- The MRPP role is mainly focused on facilitating the multi-professional team

(including the Community Pharmacist) to educate and upskill with a view to providing specialist

services in the future. The MRPP will be active in developing and providing new educational

programs, as well as promoting pre-existing resources. The MRPP will continue to attend GSR

meetings but should be scoping how local Community Pharmacists can be engaged with this process.

The MRPP will also provide support in other pharmacy settings (i.e. Community Pharmacies,

Community Hospitals, General Hospitals, Dispensing Practices etc.) where appropriate and needed.

This Phase also involves the set up and testing of the new service delivery models devised from

Phase 1 within Community Pharmacy.

The Maintenance Step- This step sees the balance of roles and responsibilities shift from the MRPP

to local Community Pharmacists so they become a local champion. This allows Community

Pharmacists to work generally but also develop and maintain a specialist Palliative Care interest. The

Community Pharmacist will be supported in establishing and running their own IPCs. For example, an

early development has been a new clinic at Broadford Medical Centre commenced on 23rd

September 2014 with a chronic and palliative pain focus. During this step, the role is focused on

maintaining the service through learning and support. The MRPP will facilitate (both directly and

through the Community Pharmacist) better access to and use of medicines & pharmacy services for

patients, including but not exclusive to: developing a system where palliative patients have a named

pharmacist; encouraging automatic sharing of admission information and discharge letters between

hospital settings and community pharmacy settings; facilitating in removing incentives to limit the

passing on of unfillable prescriptions to other pharmacies; and conducting and facilitating other

pharmacy staff in visiting patients who have recently been discharged from hospital back to the

community.

More job-focused roles and responsibilities can be found in the Resource Toolkit accompanying this

report. Some limitations to success have been identified which need to be anticipated. In order to

ensure success of the critical Start-Up Step, the MRPP must engage (and be supported in engaging)

in relevant training/education. It would also be of benefit for the MRPP to identify what resources

would be useful for the role at this time (e.g. hard copies of books and guidelines, equipment,

devices, technology etc.). Lack of these and other essential resources can have a limiting effect on

45

the progression of the role. Another potential limitation is the lack of appropriate infrastructure and

support. Therefore, ensuring there are adequate communications methods, as well as funding,

staffing and managerial support are critical at this early time.

As the Development Step involves a great deal of education and training, the MRPP must have the

ability (and resources needed) to develop, produce and disseminate any materials. Good

communications technology is also essential, as is time to travel between care settings and members

of the MPT. The Maintenance Step is more resource-heavy in terms of the Community Pharmacist.

In order for them to engage in regular training, engage more with patients and conduct successful

IPCs, it is critical that Community Pharmacists are allowed the time and are supported both

financially and professionally by their employer to do so.

6. Conclusions “Prescription for Excellence: A Vision and Action Plan” published by the Scottish Government in 2013

set out a strategy whereby all patients, regardless of their age and setting of care, should receive

high quality pharmaceutical care from clinical pharmacist independent prescribers. The strategy is to

be delivered through collaborative working between patients, carers and all members of the direct

and wider MPT. Alongside this, the Healthcare Quality Strategy provides an additional palliative-

specific direction of travel for NHS Scotland. This is contextualised for palliative care through “Living

and Dying Well: A National Action Plan for Palliative and End of Life Care in Scotland”, published in

October 2008, which sets out a single, cohesive and nationwide approach to ensure the consistent,

appropriate and equitable delivery of high quality and person-centred palliative care (based on

neither diagnosis nor prognosis but on patient and carer needs).

The Highland Palliative Care Network was a multi-agency group which was dissolved during 2013-14

along with the Highland Living and Dying Well Strategy Implementation Group and replaced in 2014

by the Highland Palliative & End of Life Care Quality Improvement Group. These groups served

clinical leadership functions and service monitoring function, which were respectively replaced as

part of a health board review of clinical networks. The loss of clinical focus as a result is currently

being slowly addressed. The project has provided an element of stability for the Skye and Lochalsh

area for clinical palliative care support during this additional change. The project was endorsed by

Highland Hospice and the outreach area palliative care specialty doctor links with the MRPP and

inclusion in the outreach day therapy service by a local practitioner to assist in consistent

communication and provision of palliative care to complex patients to enable them to remain closer

46

to home to receive care. Recognition that administration time within the project team would have

been hugely beneficial and enables some of these types of barriers such as accessing printing,

equipment etc to have been followed up more efficiently including general project administrative

support. Challenges with post holder changes and the significant periods without support from key

service areas such as financial support, Macmillan development support etc. made information

finding more challenging and time-consuming than expected.

Evaluation of the project has provided an opportunity to observe, shape and record

comprehensively the development of the MRPP role, and how it impacts and expands the role of the

community pharmacist within a palliative care managed care network across a diverse mix of

primary care settings within a rural area. The evaluation output, delivered in two parts, has focused

on:

Characterising the current service provision, including community pharmacy services, across the

Skye, Kyle & Lochalsh area, identifying current practice, key issues and gaps in current service

through qualitative and quantitative methods (Phase 1 report)

Building on the work from the Phase 1 baseline evaluation by recording and assessing the

implementation and impact of the activities and resources developed to improve clinical services

for patients and carers. This was done with a focus on: exploring and testing education, training

and awareness methods; investigating and building on the integration of the MRPP within the

MPT; and evolving an evidence based model of community pharmacy-based palliative care.

For NHS Scotland, the evidence from the project presents for the first time a conceptualised clinical

practice model for community pharmacy palliative care services in a rural and remote area, building

upon experiences in NHS GG&C, a highly populated urban environment (5). The model aligns with

existing key health policy, namely “A Route Map to the 2020 Vision for Health and Social Care” (2),

“Living & Dying Well” (3), “The Healthcare Quality Strategy” (6) and the current pharmacy policy

“Prescription for Excellence” (1). Adoption of this model will impact on maximising the use of

community pharmacists’ professional competence in planning and delivering specialist clinical

services while maintaining a generalist role. The model provides detail of the key roles and

responsibilities important to support the safe and effective use of medicines for patients and their

carers, but provides this in a format that enables flexibility for the deployment of these functions

depending on local business planning, service delivery frameworks and community setting.

47

References 1. Prescription for Excellence: A Vision and Action Plan: Scottish Government; 2013. Available from: http://www.scotland.gov.uk/resource/0043/00434053.pdf. 2. A Route Map to the 2020 Vision for Health and Social Care: Scottish Government 2013. Available from: http://www.scotland.gov.uk/Resource/0042/00423188.pdf. 3. Living and Dying Well: a national action plan for palliative and end of life care in Scotland Edinburgh: Scottish Government 2008. Available from: http://www.scotland.gov.uk/resource/doc/239823/0066155.pdf. 4. Bennie M, MacRobbie A, Akram G, Newham R, Corcoran ED, Harrington G. Macmillan Rural Palliative Care Pharmacist Practitioner Project: Mapping of the Current Service & Quality Improvement Plan University of Strathclyde, 2013. 5. Bennie M, Akram G, Corcoran ED, Maxwell D, Trundle J, Afzal N, et al. Macmillan Pharmacist Facilitator Project- Final Evaluation Report. Macmillan Cancer Support: University of Strathclyde, 2012. 6. The Healthcare Quality Strategy for NHSScotland: Scottish Government 2010. Available from: http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf 7. WHO. World Health Organisation Definition of Palliative Care 2010 [17th December 2014]. Available from: http://www.who.int/cancer/palliative/definition/en/ 8. Review of Palliative Care Services in Scotland: Audit Scotland; 2008. Available from: http://www.audit-scotland.gov.uk/docs/health/2008/nr_080821_palliative_care.pdf. 9. O'Dowd A. Palliative care in Scotland is too focused on cancer, says national report. British Medical Journal. 2008;337(a1428). 10. Gibbs M. End-of-life palliative care is needed by others besides cancer patients Pharm J. 2009;283(543-544). 11. Davies E, Higginson IJ. The Solid Facts: Palliative Care. Copenhagen: WHO Eurpoe, 2004. 12. GP Practice Details: Information Services Division 2014. Available from: http://www.isdscotland.org/Health-Topics/General-Practice/Workforce-and-Practice-Populations/Practices-and-Their-Populations/. 13. NHS Highland Areas 2014 [19th Devember 2014]. Available from: http://www.nhshighland.scot.nhs.uk/OurAreas/Pages/Welcome.aspx. 14. Wikipedia. Skye 2013 [05/11/2013]. Population, area and population density of the Isle of Skye]. Available from: http://en.wikipedia.org/wiki/Skye. 15. Highland Health and Social Care Services: NHS Highland; 2012. Available from: http://www.nhshighland.scot.nhs.uk/OurAreas/HHSCS/Pages/welcome.aspx. 16. Highland Health and Social Care Partnership: NHS Scotland; 2012 [15/01/2015]. Available from: http://www.chp.scot.nhs.uk/index.php/highland-health-and-social-care-partnership. 17. Yardley S, Dornan T. Kirkpatrick's levels and education 'evidence'. Medicl Education. 2012;46:97-106. 18. Adam J, Mackay C. Opioid Conversion Chart: NHS GG&C; 2006. Available from: http://www.palliativecareggc.org.uk/uploads/file/education/GPs/Opioid%20switch%20chart.ppt. 19. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review. . J Am Med Inform Assoc. 2008;15(5):585-600. 20. Stewart J. Investigating the Prevalence and Nature of Controlled Drug Prescribing Errors identified in Community Pharmacies. : Thesis submitted for degree of MSC Clinical Pharmacy, University of Strathclyde; 2013.

48

Appendix 1- Controlled Drugs Audit

Aims

To identify the prevalence and nature of errors associated with the prescribing of Controlled

Drugs and how these are managed

Results

CD Audit

Community Pharmacy Audit of Controlled Drugs Prescriptions

Through discussions with the Project Lead and the Steering Group, a need was established for an

audit of Controlled Drug prescriptions dispensed from the 3 community pharmacies in the area.

Informal discussions amongst the community pharmacists highlighted a possible issue with GP

writing CD prescriptions correctly and which needed to be returned to the GP for review and

alteration.

A data collection form previously developed for a similar audit in NHS GGC in 2012 was used for this

study.

The audit form consisted of three sections. Section 1 captured the characteristics of the

prescription, i.e. date/time of presentation, prescriber, etc. Section 2 was concerned with the

medication. Sections 1 and 2 were completed for all eligible prescriptions. The remaining sections

(3-6) were completed if an error/issue/discrepancy was associated with the prescription. Section 3

set to define any legal discrepancies and/or omissions, whilst section 4 covered therapeutic or

clinical errors issues. Sections 5 and 6 determined how the issue was resolved. (See Project Toolkit

for audit form and accompanying materials).

The MRPP distributed the audit forms to the 3 community pharmacies and 4 dispensing GP

practices. All prescriptions for Schedule 2 and 3 Controlled Drugs received from 1st November 2013

to 30th April 2014 (inclusive) were eligible except those for supervised substitution therapy e.g.

methadone and stimulant medication. The MRPP collected the completed audit forms throughout

the data collection period and posted them to the research team. The data was entered and

analysed on Microsoft Excel.

49

Table 1- General Characteristics of Prescriptions

Community Pharmacy (n) Dispensing Practice (n)

CD Rx dispensed N = 683 341 342

CD items dispensed N = 695 352 343

Rx from… a.GP (GP10) 322 (94%) 339 (99%)

b. Hospital (HP10) 10 (3%) 0

c. Non-medical prescriber 1 0

Details missing (a-c) 8 3

Prescription is d. Computer generated 324 (95%) 332 (97%)

e. Handwritten 17 (5%) 0

Details missing (d-e) 0 10

Prescription is f. Urgent 35 (10%) 3

Details missing (f) 1 4

g. For pall care 23 (7%) 32 (9%)

Details missing (g) 167 180

h. From OOH prescriber 0 0

A total of 661 (97%) prescriptions were generated by GP’s, 10 (1.5%) by hospital prescribers and one

from a non-medical prescriber. One tenth of the prescriptions (n=35) presented at the community

pharmacies were urgent in nature. The question asking if the prescription was for a palliative care

patient were poorly completed and left largely unanswered.

Prevalence of Prescription Errors

Twenty one prescriptions pertaining to 24 items were found to have some kind of issue which could

potentially affect the dispensing process. Twenty five ‘issues’ were ultimately identified/associated

i.e. some prescriptions had more than one issue. The rate of ‘issues/problems’ was therefore 3.5%

(25/695). Nine of the 21 prescriptions were handwritten i.e. 53% of all handwritten prescriptions.

All of the ‘problematic’ prescriptions were identified/presented to the community pharmacies.

Community Pharmacy 1 (N=157) reported seven issues/errors, rate prevalence of 4%, Community

Pharmacy 2 (N= 51) reported eight issues/errors, a rate prevalence of 16% and Community

Pharmacy 3 (N= 133) reported a six errors/issues, a rate prevalence of 4.5%. Six of the ten hospital

prescriber prescriptions had an issue/error associated with it (60%) and all were hand written.

50

Nature of Controlled Drug Prescription Errors

Most issues (n=13, 52%) were caused by discrepancies associated with the legislation around CD

prescribing. The most prevalent legal error was the failure to specify the form of the drug (n=5,

38%). One prescription by a hospital prescriber had three legal errors, including no defined dose or

form, and the absence of the total quantity in words and figures. On four occasions the prescribed

item was not in stock- strictly speaking this is not an error but is included in the audit as it resulted in

a delay in the supply of medication to the patient. Eight issues (32%) were clinical in nature and had

the potential of harming the patient if the pharmacist had not intervened.

Table 3- Nature of Errors/Issues identified from CD prescriptions dispensed in community pharmacies (n=352)

Number of Rx N= 21 (6%) GP Rx n=15 Hosp Rx n=6

Total errors/issues N= 25 (4 out of stock) 17 8

Legal Errors 13 (54%) 7 6

Formulation not specified 6 3 3

Dose not specified 5 4 1

Total quantity not specified in words AND figures

2 1 1

Clinical Issues 8 (31%) 6 2

Unable to confirm previous opioid dose 4 4 0

Unusual strength / dose prescribed 3 1 2

Inappropriate strength of midazolam prescribed

1 1 0

Item not in stock 4 (15%) 4 0

The majority of errors were found in the prescribing of tablets. However, when analysed as a

proportion of the total amount of that particular formulation, morphine sachets and injections

appear to have the most issues associated with them.

51

Table 4- Breakdown of CD formulations as a proportion of total amount prescribed

Formulation Type N= 352 Error/issue per formulation

Sachet 3 2 (67%)

Other injection 11 5 (45%)

Midazolam injection 7 3 (43%)

Tablets 164 10 (6%)

Oral liquid 18 1 (5%)

Patches 94 3 (3%)

Capsules 51 1 (2%)

Unknown 4 0

Methods of Resolution

Most of the prescriptions (13, 62%) with issues were dispensed after contact had been made with

the prescriber. Only one instance occurred where the pharmacist chose to amend the prescription

themselves as permitted within legislation. On three occasions (14%) it is not known what was done

as the details were missing and on 4 occasions (19%) items were out of stock/ordered.

Contributing factors to challenges experienced are that the hospitals route of pharmaceuticals

supplies should be through the hospital pharmacy service in Raigmore Hospital, Inverness. Contract

purchasing within the hospitals encourages the use of morphine sulphate injection whereas on

discharge to the community, diamorphine hydrochloride injection is the preferred option. Hospital

staff writing prescriptions to be dispensed in the community may be unaware of the difference and

request products less readily available in the community, resulting in delays in medication supplies

to patients. Greater awareness of these issues to facilitate rapid discharge must be in place for

hospital prescribers using the community pharmacy medicines supplies route.

Time to Resolution

Ten (55%) errors were resolved in 15 minutes or less. Of these, two prescriptions were urgent in

nature. Five (28%) prescription errors took up to one hour to resolve; two of these were urgent.

Only one prescription error (5%) took up to 24 hours to resolve but was not urgent in nature. Two

items (11%) were not in stock and both were urgent.

Conclusions

52

The six month audit found an extremely low rate of issues/errors associated with the prescribing of

CD prescriptions. The reported error rate of 4% was lower than that of a comparable study of CD

prescriptions presented to community pharmacies in NHS Greater Glasgow and Clyde (NHS GG&C)at

12.5% (19). However, the GGC study analysed more than 3 times as many CD prescriptions and had

over ten times the number of participating locations. The chance of finding errors was therefore

greatly increased. Whilst, the rate of issues/errors was similar for community pharmacy No 1 and 3

at 4%, the number rose significantly for Community Pharmacy 3 at 16%. This requires further

investigation.

Hospital prescribers had a high rate of issues/errors associated with their prescriptions (60%) and all

these had been handwritten. Whilst e-prescribing is not without disadvantages, these results suggest

the use of computer generated prescriptions for CDs by hospitals could help to reduce prescribing

errors. A systematic review found that 23 out of 25 studies showed a significant risk reduction in

errors when e-prescribing systems were used (20). However, of all the included studies, none

focused specifically on CD errors, thus further research is required to identify the absolute benefit of

electronically prescribing controlled drugs within hospitals or in rural areas where a

hospital/community interface is being used for prescribing/dispensing medicines. Hospital and

community prescribing/dispensing systems would benefit from being compatible for these purposes.

The majority of errors/issues were associated with failure to meet the statutory CD prescription

writing requirements. The most frequently reported legal error was the omission of the drug

formulation, followed by omission of dose. It also appears that the pharmacists were choosing to

dispense against the original prescription, rather than returning it to the prescriber for amendment.

This is likely to have been done to avoid delay/inconvenience to the patient. Future developments

should capture how often the patient/carer had to make contact with the pharmacy or another

healthcare professional about their prescription which could assist in clarifying the level of

inconvenience and potentially distress caused to patients or carers.

The number of clinical errors, although relatively small in number, was still found to be a high

proportion of all issues (31%). These were also mainly due to the pharmacists’ being unable to

confirm the patients’ previous opioid dose

(http://www.nrls.npsa.nhs.uk/resources/?entryid45=59888), which is essential to being able to

judge the appropriateness of the prescribed dose. This highlights the need for community

pharmacists to have access to patients clinical notes or better sharing of clinical information

between prescribers’ and pharmacists’.

53

Development work enabling community pharmacists to access the IDL from hospital (occurring in

Phase 3) will be evaluated to determine whether this impacts on improved hospital/community

interface communication about medicines.

It is not unknown whether the number of forms returned is a true representation of the number of

CD prescriptions presented and ultimately dispensed. Ideally the number could have been cross

referenced with entries in the CD register. However, Schedule 3 CDs are exempt from entry in the

CD register and would have required another method of validation which was considered too time

consuming. The high pressure working environment and increasing workload of community

pharmacists’ may reflect the poor response rate to some questions on the audit form.

There is evidence from the steering group meeting discussions that few pharmacists or dispensing

practice assistants knew when a patient was considered to have palliative needs. As a result,

appropriate pharmaceutical care interventions could not have been anticipated. Including the

question about the palliative status of patients in the audit prompted staff to engage with practices

more to establish the patient status leading to a pattern of changing response rates over the period

of the audit. The process of audit therefore may have influenced pharmaceutical care provision and

multiprofessional communications.

54

Appendix 2- Macmillan Information Leaflet Usage

Of the 77 leaflet-types available, 149 were taken by patients and healthcare professionals in total. This table details the leaflets where more than 1 copy was taken (39 topics, 117 copies taken).

Table 1- Macmillan Information Leaflet Usage May 2014-January 2015* (n> 1)

Leaflet Title Total Ordered (n) Taken (n)

Your Life: Plan Ahead Scotland 10 8

Gardening As A Way To Keep Active † 9 6

End of Life 6 6

The Side Effects of Cancer Treatment 6 5

Signs and Symptoms of Cancer: What To Be Aware Of 6 5

Recipes From Macmillan Cancer Support † 5 5

Controlling Cancer Pain † 6 4

Work It Out For Carers* 6 4

How Are You Feeling? : Coping With The Emotional Effects of Cancer 6 3

Making Treatment Decisions 3 3

Keeping Warm Without Worry 3 3

Self-Employment & Cancer † 5 3

Step-by-step Guide To Making A Will 3 3

Caring For Someone With Advanced Cancer 6 3

Ask About Your Cancer Treatment † 9 3

Assessment and Care Planning For People With Cancer 3 3

Are You Worried About Prostate Cancer? 3 3

Controlling The Symptoms of Cancer † 6 3

Managing Breathlessness 3 3

Understanding Radiotherapy 6 3

Life After Cancer Treatment 3 3

Building Up Diet 3 3

Financial Guidance Series: Insurance* 6 3

Financial Guidance Series: Sorting Out Your Affairs* 6 3

It All Adds Up: Managing Money Day-to-Day* 6 3

Cancer, You and Your Partner 3 2

Cancer Genetics: How Cancer Sometimes Runs in Families 3 2

Going Home From Hospital 3 2

Weight Management After Cancer Treatment 2 2

Allogenic (donor) Stem Cell Transplants 2 2

Coping With Advanced Cancer 3 2

Coping With Fatigue 3 2

Are You Worried About Ovarian Cancer? 3 2

Understanding Rectal Cancer 3 2

Understanding Chemotherapy 3 2

When Someone Close To You Has Cancer 3 2

Bone Health 3 2

What To Do After Treatment Ends: Ten Top Tips 3 2

Get Active, Feel Good 6 2 *Most leaflets were received on 21st May 2014, with the exception of those asterisked, which were first received 1st Dec 2014 †These leaflets were first ordered on 21st May and re-ordered on 1st Dec 2014

55

Appendix 3- Other Academic, Professional & Public Dissemination of Project

Information

Poster presentation at the University of Strathclyde Institute research day (31st March

2014)

Oral presentation at the New Directions in Palliative Care Conference on 2nd Oct 2014

(Awarded best oral poster presentation prize)

Poster presentation at the SPPC conference (17th September 2014)

Poster and oral poster presentation at the NHS Highland Research Conference (7th

November 2014) (Awarded best oral poster presentation prize)

Project submitted for the RPS Pharmacy Leadership Awards 2014.

Finalist in Scottish Pharmacy Awards partnership working category 12th Nov 2014.

Oral presentation to Macmillan Study Day in Inverness on 11th Nov 2014

Poster abstract submitted to EAPC conference in Copenhagen 8th to 10th May 2015

Articles in Mac Voice

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Appendix 4- Method 2 Gold Standards Review Details from Oral Histories

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Appendix 5 – Method 2 Drop-In Clinics Details from Oral Histories

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Appendix 6- Method 2 MRPP Hospital Pharmacy Work

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Appendix 7- Highland Hospice Phone Line Audit

Aim

To explore how the Highland Hospice Phone Line is used and by whom, and to compare

these results with Phase 1 Highland Hospice Audit data.

Results

In Phase 2, 32 calls were received from patients from the beginning of March to the end of July 2014

concerning roughly 20 patients.

Table 1- Highland Hospice Phone Call Information Phase 1 data versus Phase 2 data

*Although 32 calls were made in Phase 2, multiple calls were received about the same patients, hence n=20 **Phase 2- Patient spoke to hospice during a call with Macmillan Nurse

A full detailed list of all calls in this audit can be found in Table 2. As in Phase 1, most calls were

made during working hours but more so in Phase 2 (64% versus 94%). Significantly fewer calls were

made out-of-hours. In Phase 1, GPs were the predominant user of the Phone Line, in Phase 2 these

numbers dropped dramatically, instead Macmillan Nurses were now the predominant users of the

Highland Hospice Phone Line, accounting for 69% of the calls. Unlike Phase 1, the phone line was

now being used by Pharmacists, Hospital staff and a patient. As some calls were made by hospital

staff, not all calls in Phase 2 were made about patients based in the community (compared with

100% of Phase 1).

Demographic Information Phase 1 (March-June 2013)

(n=11)

Phase 2 (March-July 2014)

(n=32)

When were the calls made?

During Work Hours Out-of-hours Unknown

7 (64%) 4 (36%)

-

30 (94%) 1 (3%) 1 (3%)

Who made the calls? Macmillan Nurse

GPs Pharmacist Patient’s Relative Hospital Patient**

2 (18%) 8 (73%)

- 1 (9%)

- -

22 (69%) 4 (13%) 2 (6%) 2 (6%) 1 (3%) 1 (3%)

Where was the patient based?*

Community Hospital Unknown

11 (100%) - -

25 (78%) 2 (6%)

5 (16%)

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Time Caller Nature of call Outcome/Advice Given

1 Work Hours

Macmillan Nurse

Called about a patient in the community known to the hospice. The patient was experiencing a high volume and frequency of urination.

Hospice checked their medication list and noted that they were not on an anti-urination medication. Offered advice on herbal medicines but noted that it may be related to hormones or disease progression. A urine test was recommended.

2 Work Hours

Macmillan Nurse

Called about a patient in the community known to the hospice. The patient was experiencing swelling of the neck and pain related to their diagnosis.

Hospice advised an oral opioid solution as well as a pain relief patch.

3 Work Hours

Call 1: Macmillan Nurse

Patient was based in the community and known to the hospice. The Macmillan nurse called to enquire about this patient’s syringe pump contents.

Discussed patient’s medications.

Call 2: GP The GP called as the patient had a sudden onset of breathlessness although on oxygen, and thought it may be anxiety-related

Hospice advised the GP to optimise pain relief and use Oramorph for breathlessness (and may then need a laxative), as well as an anti-anxiety medication if non-pharmacological interventions were not working.

4 Work Hours

Call 1: Macmillan Nurse

Patient was based in the community and known to the hospice. The Macmillan Nurse called as the patient had pain in their collarbone.

The Hospice advised that it may be a post-syringe driver abscess. They recommended a review of medicines.

Call 2: MN The patient was experiencing hiccups

The Hospice advised the increase of medication which the Macmillan Nurse initially suggested.

Call 3: Macmillan Nurse

The patient was experiencing hiccups, shortness of breath and retching.

The Hospice recommended a syringe pump with an anti-nausea medication.

Call 4: Macmillan Nurse

Patient had increasing pain.

Macmillan Nurse was to discuss pain with patient on next visit.

5 Out-of-hours

Hospital Patient was based in a hospital and was not known to the Hospice. The patient had painful radiotherapy burns to upper thighs and labia – painful. The hospital felt they may have been infected. Topical and oral treatments were not working. The patient was allergic to some medications. Two doses of over the counter pain relief had been taken that day.

The Hospice suggested oral pain relief, a topical solution, and a medicine for bacterial infections (if needed) and if necessary a stronger form next. They advised to leave the area uncovered.

6 Work Hours

Relative The patient was based in the community and was known to the Hospice. The patient wanted to stop taking antidepressant. The patient also had pain when getting into bed and a previous change in pain medication made them sleepy.

The Hospice advised they take their antidepressant on alternate days for 2 weeks before stopping. For the pain, the Hospice advised oral pain relief also.

Table 2- Highland Hospice Phone Line Audit Calls March-July 2014

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7 Work Hours

Pharmacist The patient was based in the community and known to the Hospice. The patient had nausea and hiccups.

The Hospice advised an increase anti-emetic in a syringe pump.

8 Work Hours

Pharmacist The patient’s location was unknown but they were known to the hospice. The patient had nausea and was taking an anti-emetic.

The Hospice discussed the patient’s background with the Pharmacist and discussed their options.

9 Work Hours

GP The patient’s location was unknown but they were known to the hospice. The patient had ear pain but was not really using their opioids. The patient had taken ibuprofen and 2 weeks of an anti-inflammatory.

The Hospice recommended a number of pain relief options.

10 Work Hours

Macmillan Nurse

The patient was based in the community. They were experiencing nausea - stimulated by food and taste. Tramadol had made them toxic and feverish, and their ant-emetic made feel disorientated.

The Hospice discussed the use of other anti-emetics.

11 NA GP The patient was based in the community. They were experiencing nausea and vomiting. The patient was frail and unable to take oral medication. They were on a fentanyl patch, Oramorph and an anti-emetic.

The Hospice advised subcutaneous ant-emetic plus opioid pain relief over 24 hours, and to potentially add other pain relief if necessary.

12 Work Hours

Macmillan Nurse

The patient was based in the community. They were on medication to control vomiting which was working reasonably well. However they were developing extrapyramidal symptoms with marked hand/face tremor worsening. An anti-emetic was previously ineffective.

The Hospice and Macmillan Nurse talked through options possibly with increased ant-emetic dose.

13 Work Hours

Macmillan Nurse

The patient was based in the community. They had severe leg pain, no background of opioid use, and had tried codeine/tramadol which caused nausea and vomiting. They were not happy to use NSAIDs.

The Hospice and Macmillan Nurse discussed options including opioids as required, starting at a low dose.

14 Work Hours

Call 1: Unknown The patient was based in the community and was known to the Hospice. The patient had a diagnosis of breast and bone cancer and was on a longstanding corticosteroid, as well as a variety of other medicines.

Some medications were increased.

Call 2: GP Similar query about the patient’s treatment. Medications were reviewed and altered.

Call 3: Macmillan Nurse

The patient was very sleepy and wanted to reduce drug sedative effects.

The Hospice suggested checking bloods and recommended altering their medications slightly.

Call 4: Macmillan Nurse

The patient had pelvic pain when walking.

They were recommended pain relief and hospice admission.

Call 5: Macmillan Nurse

Nurse had query about patient’s haemoglobin levels.

Hospice advised that they did not need a blood transfusion and levels were a result of disease progression.

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Call 6: Relative The patient had increasing lymphedema due to a possible IVC obstruction. The Hospice recommended medication.

15 Work Hours

Call 1: Macmillan Nurse

The location of the patient was unknown. The patient was experiencing a lack of coordination and mobility. They also had a strong salty taste.

Their medication was first reduced then increased. They also received radiotherapy.

Call 2: Macmillan Nurse

Follow-up of this patient.

Patient was admitted to Broadford Hospital.

16 Work Hours

Hospital The patient’s location was unknown. The patient had radiotherapy burns.

The Hospice suggested that a pain relief may be added to a gel only if the skin was broken. Diprobase was recommended if the skin was intact. The hospital was sent a topical opioid information sheet by email.

17 Work Hours

Macmillan Nurse

The patient was based in the community. The patient had experienced recent fits on an anticonvulsant. Tried another medication with no difference. The patient could not to swallow.

Hospice recommended subcutaneous medications.

18 Work Hours

Macmillan Nurse

The patient was based in the community and was known to the hospice. The patient was currently bedbound.

The Hospice recommended a medication.

19 Work Hours

Call 1: Macmillan Nurse

The patient was based in the community. They had cancer as well as hernias. Vomiting was well controlled with anti-emetic yet they were agitated with abdominal pain and loose bowels. Medication had previously not helped.

The Hospice recommended a number of medications.

Call 2: Macmillan Nurse

The patient was experiencing black faeces associated with upper gastrointestinal bleeding.

The Hospice advised that they be checked for blood clotting and a number of medication alterations were advised.

20 Work Hours

Call 1: Macmillan Nurse

The patient was based in the community. The Macmillan Nurse had made previous enquiries to MRPP about patient’s unmet needs. The patient had a ‘bubbly chest’ and could not lie flat or on their side.

The Hospice discussed options with the Macmillan nurse, including an increase in some medications.

Call 2: Macmillan Nurse

A request for the patient to be admitted to the hospice was raised. The patient had been stented, had poor compliance, poor appetite, PTSD, poor memory, and nausea.

The patient was placed on the waiting list. The MRPP had raised the hospice advice at the local GSF meeting day before as she had been concerned at an apparent lack of intervention in this deteriorating patient.

Call 3: Macmillan Nurse

The patient had severely deteriorated. The nurse had not seen them for 2 weeks. Fluid had been drained from their abdomen. The patient expressed a wish to die in the hospice but may not have been fit to travel and there was no bed available.

The patient remained on the waiting list.

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