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Trust Board Meeting

7 July 2016 Paper Reference: TB(16-17) 61

Report Title: Medicines Optimisation Annual Report 2015-16

Executive Summary:

This report describes progress in 2015/16 with the Trust journey towards improved medicines optimisation for service users.

It describes some medicines management performance indicators, key achievements and challenges in medicines optimisation in the past year and progress with the objectives in the Medicines Optimisation strategy (one of the strategies underpinning the Quality Strategy), which was approved by the Board in July 2014.

The Quality and Safety Assurance Committee has received two detailed reports on Medicines Optimisation since July 2015.

Action Required: For information.

Link to Strategic Objectives: We will provide consistent high quality safe services that represent value for money

Risks: This is a retrospective report

Quality Impact: This is a retrospective report

Resource Implications: This is a retrospective report

Legal/Regulatory Implications: CQC outcome 9. TDA medicines optimisation domains NHS LA NHS England/MHRA patient safety alerts Medicines Act and associated Regulations Misuse of Drugs Act and associated Regulations Other legislation applicable to medicines

Equalities Impact: The report is based on the Trust Medicines Optimisation strategy 2014-2018

Groups Consulted: Drugs & Therapeutics Committee (including service user & carer reps), SWL MH Clinical Quality Review Group.

Author: Dianne Adams, Chief Pharmacist

Owner: Dr Emma Whicher, Medical Director

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Medicines Optimisation Annual Report 2015-16

Date: Jun 2016 Status: Final Current Version: V1.0 Transparency : Public Commissioned by: Medical Director Distribution & approvals history Version Distributed to Date Action required / taken 0.1 tracked changes 0.2 Senior Pharmacy team 21.6.16 comment 0.3 Medical Director 28.6.16 comment 1.0 Board 29.6.16 information

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Foreword “Medicines remain the most common therapeutic intervention in healthcare. We must all work hard to ensure that individual patients get as much benefit out of medicines as possible, and resources are used wisely and effectively. Pharmacy Services are contributing to the wider patient care, effectiveness and patient safety agenda, through technological advances and medicines optimisation approaches, and also through more traditional medicines management mechanisms, which all support the whole medicines pathway and improving outcomes for patients”

Dianne Adams Chief Pharmacist “We are really pleased to be asked to write the foreword for the Medicines Optimisation Annual Report 2015-16 and excited about the direction the Trust is taking, in empowering patients to be more involved in their treatment with medicines.

Medicines are an absolutely vital component in all aspects of the care we provide and the effective prescribing and safe management of medicines is something which almost all of our service users and their carers can relate to. We are really encouraged by the Medicines Optimisation strategy which has been developed, in individualising care based on patient need. This is something which will really enable us to improve patient outcomes at the same time as improve the value we get from our investment into medicines.

We are also excited by our innovative use of technology and are delighted by the development and launch of the physical monitoring ‘app’ for service users to access via their mobile phones and devices, and by the planned implementation of the new electronic prescribing and medicines administration system before March 2017 across the whole Trust.

Furthermore we are really pleased that the innovative 2015/16 ‘Medicines & Physical Health Reconciliation’ CQUIN was successfully achieved, not only earning income for the Trust but also improving quality and safety of prescribing & monitoring for patients when they are discharged or have an annual review conducted by our community adult services staff.

We hope that in 2016-17 the whole multidisciplinary healthcare team will continue to work closely together to deliver improved care in relation to medicines. We would like to take this opportunity to recognise the hard work and dedication of all those involved in delivering the visions in the medicines optimisation strategy and thank them for their continuing commitment to safe high quality care, as well as their achievement of ‘Psychiatric Team of the Year’ from the Royal College of Psychiatrists.”

Best wishes,

David Bradley Dr Emma Whicher Chief Executive Medical Director

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Executive Summary Medicines Optimisation is the quality use of medicines that aims to produce the best outcomes for patients and enables recovery, which should help ensure that patients and the NHS get better value from the investment in medicines. It focusses on:

– outcomes rather than process – patients rather than systems – being led, rather than delivered by pharmacists – the whole medicines pathway – choosing the right medicine to achieve the outcome the patient wants

This report describes progress in 2015/16 with our journey towards medicines optimisation.

Key achievements in medicines optimisation in the past year include

• Improved patient safety, through better management of incidents • Improved patient experience through improved community patient survey results and

encouraging medicines-related Real Time Feedback results. • Using information technology to support patients with their medicines • Supporting patient access to medicines through timely implementation of NICE technology

appraisals guidance • Improved working in multi-disciplinary teams to deliver safe and effective medicines

management • Maximising effective use of resources • The 15/16 medicines & physical health reconciliation CQUIN, worth £580k to the Trust

income was successfully achieved. • The Trust prescribing budget underspent and the Medicines CIP was achieved. • The Medicines Safety Officer position has now been made substantive.

Key challenges in medicines optimisation in the past year were:

• To try and improve reporting rates of errors by community team staff and doctors. • To develop a non-medical prescribing strategy, to improve access to medicines for service

users and achieve efficiency savings. Changes in senior nursing structures have impacted on progress with this.

• The community patient survey showed that 66.4% of users say they are definitely or to some extent are involved in decisions about medicines to be prescribed. This is within the lower 20% of trusts and the recommendation ‘’to seek ways to improve participation of service users in decisions about their medication, paying attention to establishing what level of involvement in decision-making the patient would like’’ has been made in response. This may include healthcare professionals reviewing their consultation style and adapting this to the needs of the individual service user.

In summary, 2015/16 saw significant progress with medicines optimisation, resulting in improved patient experience and patient safety, but there is still room for improvement.

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Introduction This report describes the Trust’s approach to medicines optimisation in 2015/16, including how medicines management is supporting the Trust to meet its medicines optimisation objectives.

Did you know? • The Trust spent £2.37m on the supply of 125,000 medicinal items to patients, which were dispensed either in Trust (95,000) or community (27,500) pharmacies or via homecare (2,500) in 2015-16. The average cost of each item was £18.96.

• The Trust employed 37 Pharmacy staff, 30 of whom were registered Pharmacy professionals (Pharmacists and Pharmacy Technicians) in 2015-16.

• Clozapine was supplied to an average of 652 patients per month. 74 clozapine assays (blood levels) were undertaken each month on average.

• 616 medication queries from healthcare professionals (including primary care) and 78 queries from service users and carers were answered by the Medicines Information Service.

• 577 out-of-hours calls from healthcare professionals across all health sectors of South West London were handled by the Mental Health Pharmacist on-call service (weeknights 5pm-9am, weekends and Bank Holidays).

• 85% (1494 out of 1753) of newly admitted patients had a level 2 medicines reconciliation completed within 72 hours by Pharmacy Services.

• The Trust received four formal complaints concerning treatment with medicines. Additionally, pharmacy services received one complaint and five compliments.

• 50 quality improvement audits, with the aim of driving up standards to improve patient care, clinical effectiveness, compliance and patient safety, were completed. Trust staff have also participated in 3 POMH-UK audits • Pharmacy Services staff delivered over 63 hours of formal teaching or group sessions with service users and carers.

• 721 medication incidents were reported by Trust staff.

• Prescribers receive advice to change 1300 medicines per month from Pharmacy Services staff on average. These recommendations have a high acceptance rate by clinicians.

Achievements Commissioning for Quality & Innovation (CQUIN) in Medicines In 2015-16, a medicines CQUIN was designed with the aim of implementing, measuring and embedding into practice the reconciliation of the medicines that patients are taking on discharge from community mental health teams (CMHTs) or at Care programme approach (CPA) reviews. It also set out to ensure that any required physical health monitoring is carried out and documented appropriately.

Improved documentation sent to primary care by care co-ordinators aids the ability of primary care clinicians (GPs) to provide the review a patient requires specifically for their condition and treatment. The Trust is the first in the country to address this area of medicines risk.

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233 care co-ordinators from 27 community teams were trained by Pharmacy staff, using either Skype or face-to-face sessions, depending on the staff’s location or choice. The accuracy and quality of community discharge summaries and annual review documents dramatically improved after the training. The quality of documents is now equivalent to those produced by doctors associated with inpatient teams. The CQUIN also required the Trust to test a process of telephoning service users 5 days post-discharge from an inpatient ward to ensure that service users have all the necessary information to allow them to understand their medicines, side-effects and to encourage adherence, along with an evaluation of the telephone call and what impact this has on patient care.

The post-discharge call was additional to the 3 or 7 day follow-up call that patients routinely receive from inpatient wards or Home Treatment Teams (HTTs) post-discharge. On average, it took 40 minutes per patient of Pharmacy Services time to complete the call and all service users who were contacted required the pharmacy staff to make an intervention or provide further information. The call from pharmacy services has a clear benefit to patients. However, the resource implications of implementing this long term are significant. A process has

recently been set up to refer service users for a ‘medicines use review’ (MUR) with community pharmacists upon discharge. It is hoped that this will provide service users with the same quality of service on discharge as Trust pharmacy staff calling patients. The CQUIN was fully met and achieved an income of £580k for the Trust in 2015-16.

Publications & Awards Pharmacy Services staff have been busy with audits and innovative ways of working. Some of these initiatives were shared with other organisations at learning events, submitted as conference posters or as articles to peer-reviewed journals. One poster was shortlisted at the Royal Pharmaceutical Society annual conference in 2015 and four posters were submitted to the College of Mental Health Pharmacy Annual Conference in 2015, one of which won second prize. Four audit posters were also displayed at the Royal College of Psychiatry International Congress in 2015. One article by the Medication Safety Officer (MSO) was published in ‘Clinical Pharmacist’ journal. The MSO & the pharmacist who led the development of the physical monitoring app presented at the national Medication Safety Officer WebEx event on the role of the improvements in medicines safety & development of the Physical Monitoring App.

The Trust Drugs & Therapeutics Committee (DTC) was the winner of the Royal College Psychiatric Team of the Year award in Nov 2015.

The judges said:

“This Committee is a dynamic multidisciplinary team, driving a Trust-wide programme of evidence-based, cost-effective prescribing. The team is a hub for audit, education and technological innovation.

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“This is an exemplary service, drawing on the expertise of psychiatry, pharmacy, service users, and carers to translate the scientific evidence-base into the best standards of clinical care, setting a standard for other services to emulate.”

The DTC has also been shortlisted for the Team of the Year in the Pharmacy & Medicines optimisation category of the HSJ Value in Healthcare Awards 2016, to be awarded on 24th May 2016.

The ‘Total Quality Management to Improve Medicines Safety in Mental Health’ entry submitted by the Medication Safety Officer has been shortlisted in the Patient Safety in Mental Health category of the HSJ Patient Safety Awards, to be awarded on 5th July 2016. Trust Medicines Optimisation Strategy A medicines optimisation strategy, one of the clinical strategies which underpin the Trust Quality Strategy, was approved by the Trust Board in July 2014. The strategy includes seven high level themes or visions. Progress in 2015-16 with the objectives underpinning them is described below. In addition, there is a detailed action plan, developed through consultation with service users, carers and Trust healthcare professionals of all disciplines. Responsibility for implementation of the strategy is shared by the Medical Director, the Director of Nursing & Quality and the Chief Pharmacist. 1 We will continue to build on and maintain the excellent progress that has already been

made. • Pharmacy Services completed level 2 medicines reconciliation on 85% of newly admitted

patients within 72 hours in 2015-16.

• The Trust remains amber-rated (between 75 and 99% compliance) in the annual audit of the safe and secure handling of medicines (including controlled drugs) and community prescriptions (known as FP10s).

2 We will improve the cost-effective use of medicines

• Pharmacy Services, the Trust’s Drugs & Therapeutics Committee and the South West London Mental Health Interface Prescribing Forum have been working to ensure that the £2.37m annual expenditure on medicines is managed as efficiently as possible, thereby maximising the benefits patients receive from their medicines and reducing waste.

• The Trust took the decision to use paliperidone depot as the long acting atypical antipsychotic injection of choice. Savings elsewhere have continued to allow the Trust to

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absorb the increased cost of this medicine, even though the Trust budget for medicines in 2015-16 was 5% smaller than in 2014-15.

This has been delivered through a range of initiatives:-

Innovative purchasing through links with regional purchasing consortia and good management of stock purchased by Trust pharmacy staff (high stock turn and continued search for good value medicines).

Ensuring clinical engagement in decisions regarding product selection. Ensuring primary care engagement in purchasing decisions has derived benefit for

CCGs, as partner organisations and commissioners of our services. Under the influence of the SWL Mental Health Interface Prescribing Forum, the CCGs

continue to review their use of mental health medicines. CCGs have used the forum to identify efficiencies across the sector making significant steps forward in quality and reducing spend e.g. by reducing the expensive & potentially dangerous long-term use of temazepam.

The Trust also leads the way by advising commissioners (practices) on cost-effective prescribing of mental health medicines, as a result of which the local CCGs achieved some of the highest Quality, Innovation, Productivity and Prevention (QIPP) savings in mental health medicines in the UK.

Also, by ensuring we follow local CCG physical health recommendations and savings plans we can also make some savings e.g. by using less expensive combination inhalers.

Where there is a paucity of evidence for the use of extended release products, the Trust specifies that immediate-release products should be used, which are cheaper e.g. quetiapine & venlafaxine, unless a patient has a strong preference.

Switching to cheaper brands e.g. Xenidate® instead of Concerta®. CAMHS patients’ prescriptions are being switched by CCGs and in Trust clinics.

Where patients are stabilised on mental health medicines, prescribing is transferred to GPs in accordance with shared care guidelines.

It is not appropriate for Trust prescribers to undertake prescribing of physical health medicines for outpatients and hence these have been referred back to patients’ GPs for regular prescriptions to be dispensed in patients’ usual community pharmacies. This ensures the GP has oversight of a patient’s physical health care treatment ensuring safer prescribing of physical healthcare medicines.

The Trust achieves one of the highest Pharmacy stock-turns of any London Trust which minimises the Pharmacy medicines stockholding and means that we do not have money invested in ‘dead’ stock.

Prescribing expenditure is routinely monitored and reported to prescribers and directorate managers to improve budgetary control.

The Informatics team has suggested using in-house (JAC) prescribing data and later matching the prescribing system with FP10 (Drug Tariff) costs. The identification of the cost of medicines down to patient level will thus be possible. The implementation of financial reporting will therefore be incremental as e-prescribing rolls out.

The mental health formulary (for South West London) is the approved list of medicines for prescribing by clinicians, agreed by the Trust Drugs & Therapeutics Committee and monitored by Pharmacy services. The Trust has a robust process for handling non-formulary requests for patients and amendments to the formulary. 78 non-formulary requests were received in 2015/16 and 65 requests were approved.

Better compliance with the formulary has resulted in the Trust being one of a small number of Trusts to reduce its medicines spend in 2015-16 (by 5%), while still managing to invest in new psychiatric medicines.

Prescribing is audited on a monthly basis and variation from the Trust medicines formulary is reported directly back to prescribers with a view to improving formulary compliance, which contributes to the cost-effective use of Trust spend on medicines. The use of non-formulary medicines is also audited annually and showed further improved compliance with the formulary in 2015-16.

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Each medicine prescribed on hospital prescriptions is individually screened by Pharmacy staff to ensure that it complies with South West London formularies.

• The Trust Drugs & Therapeutics Committee is responsible for ensuring the implementation

of NICE technology appraisals guidance relating to medicines. Information about this, and the Trust formulary, is available on the Trust website for commissioners and the public to access. The Committee leads on prescribing issues for mental health and substance misuse for South West London.

• Trust policies have been updated, implemented and audited where appropriate to be in line with national guidelines, standards and recommendations.

• The Trust has a centrally run (by the SPUH dispensary team) medicines returns process. An audit of returned medicines was completed in September 2015. 1103 items were returned to the pharmacy department over 4 weeks, the majority from inpatient settings and HTTs. New dispensing processes (‘One stop dispensing’, where medicines are sent to the ward/team as original packs of medicines labelled with directions) have been implemented to try and reduce unused returned medicines.

3 We will reduce the risks associated with use of medicines

• A ‘medicines reconciliation at discharge’ process has been introduced at the point where the Pharmacist checks the inpatient discharge prescription (the TTA, ‘To Take Away’). This important safety intervention ensures that information about changes in medicines, medicines being stopped or started or those that have particular monitoring requirements since admission are included in the communication sent to GPs.

• In June 2012 the Department of Health published its findings on the abuse of patients and overuse of psychotropic medicines in those with learning disabilities at the Winterbourne View Hospital. It summarised the required actions of organisations in relation to medicines. This included: to have systems and policies in place to ensure that reviewing medicines

requirements for each individual is done safely and in a timely manner to carry out regular audits of medication prescribing and management, involving

pharmacists, doctors and nurses.

• This, and the subsequent publications below, have shown that the level and quality of use of psychotropics in people with learning disabilities needs to improve nationally. A report was produced combining recommendations from these publications: Prescribing of psychotropic drugs to people with learning disabilities and/or autism

by general practitioners in England (Public Health England) Winterbourne View Medicines Programme Report (NHS Improving Quality) Second Opinion Authorised Doctor (SOAD) information (CQC) NG11: Challenging behaviour and learning disabilities: prevention and interventions

for people with learning disabilities whose behaviour challenges (NICE) POMH-UK Topic 9b Antipsychotic prescribing in people with a learning disability re-audit (POMH-UK)

• The following conclusions were drawn: Service users with a learning disability are being prescribed antipsychotic and

antidepressant medicines at rates higher than expected, given the prevalence of psychotic and depressive illnesses.

Nationally, 58% patients prescribed antipsychotics and 32% patients prescribed antidepressants have no relevant diagnosis; the assumption is that, in these cases, psychotropics are being prescribed for the management of behaviour that challenges.

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At present, it is not known how many people with a learning disability in South West London are being prescribed medicines for challenging behaviour and whether they are being reviewed appropriately.

• The Department of Health has tasked NHS organisations to review prescribing in this

population. NICE published a clinical guideline in May 2015 that includes several recommendations about the prescribing of antipsychotics to people with learning disabilities.

• A number of actions were agreed as the Trust response to the above publications: The Trust will promote use of the physical health handbook for people with learning

disabilities The Trust will make available a medicines and physical health check awareness e-

learning package for patients, families and carers. The Trust will pilot a physical health check hub based in the new outpatient centre

at Springfield University Hospital. The Trust will develop prescribing guidance for use in the Trust. The Trust will work

with primary care to develop prescribing guidance for use in primary and secondary care.

The Trust will offer support to primary care in developing audit templates and GP practice search templates to allow GPs to improve the quality of care they provide to people with learning disabilities.

The Trust will have a register of those on antipsychotics for challenging behaviour in learning disabilities to ensure review and allow audit.

Community Learning disability teams will offer support to primary care if appropriate for the annual physical health check. GPs should communicate this to the Trust annually as per NICE guidance.

Community Learning disability teams will request the GP summary sheet before an annual review of every patient.

All doctors to ensure they have access to the patient’s Summary Care Record and electronic pathology reporting systems.

A clinical lead for Learning Disabilities is to be identified who should be the lead for the sector.

The Trust should work with commissioners to explore opportunities for improving community services for people with a learning disability in order to increase capacity for positive behavioural support (as per the service for behavioural and psychological symptoms in dementia in Sutton).

The Trust will work with health and social care stakeholders to improve quality of life for people with learning disabilities.

• The Trust audits controlled drugs each quarter and the Accountable Officer for CDs

(Director of Nursing & Quality) submits a quarterly CD occurrence report to the NHS England Accountable Officer for Controlled Drugs. Handling of controlled drugs according to Trust standards remains variable. There have been a number of incidents related to controlled drugs, some have led to increased stringent monitoring, for extended periods of time, of supplies of controlled drugs.

• The Trust encourages the reporting of medicines errors and incidents in an attempt to learn from them and to reduce the risk of recurrence. The number of incidents reported by Trust staff is comparable with other Trusts of this size. High levels of reporting are indicative of a positive safety culture. 721 medicines incidents were reported by Trust staff in 2015-16. 92% were near-miss or no harm incidents, 8% were low harm incidents. 50% were reported by Pharmacy staff, 32% by inpatient nurses, 12% by community nurses and 5% by doctors.

• Administration errors made by nurses remain the most common process error reported, followed by dispensing errors made by pharmacy staff (both volume related). The most common drugs involved are clozapine and antipsychotic depot injections. As well as

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medicines e-learning, a practical medicines management competency assessment tool has been developed and trialled for nurses (one is already in place for pharmacy staff). A learning event on medicines safety for junior doctors was held in January 2016.

• The Medication Safety Officer (MSO) reviews every medicines incident to ensure appropriate and accurate documentation and learning and actions are taken to try to mitigate the risk of the incident happening again either locally (within a service) or Trust-wide (where appropriate). The MSO analyses and reports quarterly on themes and learning from medicines incidents.

• The Trust uses ‘Risk Alerts’ as a means of highlighting preventable risk to all staff. Three medication-related risk alerts were issued in 2015/16: October 2015 Look alike, Sound alike (LASA) risk alert. Medicine names can look or

sound like other medicines causing confusion and patient harm. The risk alert highlights medicines that have been confused and outlines what prescribers and nurses can do to minimise this risk.

November 2015 FP10 risk alert which highlights the responsibility of the team consultant in the governance of FP10s, following a series of recent incidents involving unlogged, lost/stolen FP10 prescriptions.

November 2015 Depot prescriptions risk alert which was released following a series

of depot antipsychotic prescription chart incidents.

• Since March 2016, a monthly learning bulletin has been published, including information from medicines errors. The March issue included a reminder to all staff, following an administration error, that liquid medicines must be administered using purple oral syringes and how to order these. It also highlighted that where a complex dose calculation is involved, a second nurse or other registered professional may independently check it.

• The Trust also ensured that action was taken in response to NHS England Patient Safety Alerts. Of those issued in 2015-16, three were deemed relevant to medicines and were acted upon by the Trust: Patient Safety Alert 2015/007 Stage 2: Antimicrobial stewardship

The alert was jointly issued by NHS England and Public Health England (PHE) to highlight the challenge of Antimicrobial resistance (AMR) and to signpost providers to the toolkits developed by PHE to support the NHS in improving antimicrobial stewardship in both primary and secondary care. Actions agreed include

o A Doctor, Nurse and Pharmacist have been nominated as leads for the Trust.

o A referral system was set up from pharmacists to the infection prevention & control (IPC) Nurse for all anti-infectives prescribed, who then reviews all anti-infectives prescribed to ensure appropriate treatment is carried out.

o Routine audit of anti-infectives is undertaken by Pharmacy Services and the junior doctors to assess Trust practice.

o The electronic prescribing system will be set to prompt prescribers to review prescribing information.

o The Trust has access to and follows locally developed anti-infective guidelines.

Patient Safety Alert 2015/009 Stage 2: Support to minimise the risk of distress and death from inappropriate doses of naloxone

Whilst naloxone use can be life-saving in respiratory depression and respiratory arrest, the previous Stage One Alert highlighted that use of naloxone in patients where it is not indicated, or in larger than recommended doses, can cause a rapid reversal of the

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physiological effects for pain control, leading to intense pain and distress, and an increase in sympathetic nervous stimulation and cytokine release, precipitating an acute withdrawal syndrome. The new ‘Stage 2: Resource’ alert highlights a number of resources now available to help providers ensure their local protocols and training related to naloxone reflect best practice. These resources have been developed in response to a previous Patient Safety Alert issued in November 2014 to raise awareness of the risk of inappropriate doses of the opioid/opiate antagonist naloxone.

Actions agreed include

o Guidance produced for those involved in medical emergencies in the Trust. o Medical emergency training to confirm it is included in the syllabus.

PSA/W/2016/001 Stage One: Risk of severe harm or death when

Desmopressin is omitted or delayed in patients with cranial diabetes insipidus Cranial diabetes insipidus is a rare disorder of the pituitary gland characterised by an inability to produce antidiuretic hormone (ADH), resulting in the production of large volumes of dilute urine – if left untreated this can lead to life-threatening dehydration and hypernatraemia. Treatment is with a synthetic form of ADH known as desmopressin, which is considered a life sustaining medication. Following reports of patient safety incidents caused by an omission or delay in the provision of desmopressin, actions agreed included

o ensuring stock is available in Pharmacy and in all three Trust EDCs o awareness raised with staff by adding to the list of high alert medicines

(TMC appendix).

• MHRA yellow card app A new free smartphone (Apple and Android) app for reporting side effects to the Yellow Card Scheme has now been launched for healthcare professionals, patients, or carers to report any suspected side effects directly.

4 We will proactively provide independent & balanced information in a suitable format or language to service users, their carers, family & friends (where appropriate) which empowers them to participate in medication treatment decisions • Pharmacy services have been engaging with carers’ and service users’ groups to better

understand issues where the Trust needs to improve how to help service users to better take their medicines, in line with the principles of medicines optimisation. Their feedback has been used to inform the medicines optimisation strategy delivery plan.

• Real Time Feedback (RTF) 46 responses were received from service users in eight different community teams to six RTF medicine-related questions in the first half of 2015-16. Of those that responded more than 50% service users agreed they had been involved in the choice of the medication they were prescribed and had the purpose of the prescribed medication explained to them. 100% had been informed how to get further information about medicines and had been given information about the medicine in a way it could be understood. In the second half of 2015-16, 555 responses were received concerning medicines, from eighteen different community teams and 11 inpatient wards, a significant increase over the previous 6 months. More than 60% of service users in the community had been involved in the choice of the medication they are prescribed, and had the purpose explained. This was lower in inpatient wards (41% choice, 46% purpose). 52% of carers on inpatient wards felt that they had been involved in choosing the medicines prescribed to the person they care for. 80% of patients in the community and 58% of inpatients knew how to obtain further

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information about their medicines. 72% of patients in the community and 35% of inpatients stated that the side effects of their prescribed medicines had been clearly explained. One of the visions in the Medicines Optimisation Strategy is to improve discussions between service users/carers and professionals. A range of actions were included in the action plan to tackle this.

• Montgomery Judgement The law on informed consent changed following a March 2015 Supreme Court judgment. Doctors must now ensure that patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives, following the judgment in the case Montgomery v Lanarkshire Health Board. This is a marked change to the previous “Bolam test”, which asks whether a doctor’s conduct would be supported by a responsible body of medical opinion. This test will no longer apply to the issue of consent, although it will continue to be used more widely in cases involving other alleged acts of negligence. The overriding importance of this judgement is for clinicians to record that information has been given to the patient, with an opportunity to discuss the treatment and ask questions about it. The Trust’s medicines leaflets have been updated with information required to be given to patients to comply with the Montgomery Judgement. The Trust is looking at a number of ways to make it possible for Trust staff to routinely document actions to demonstrate compliance with the judgement.

• Information on what service users can expect in relation to medicines and the pharmacy service is included in the ward welcome pack given to newly admitted patients.

• Service users also have access to Pharmacy Services staff during the process of medicines reconciliation on admission, ensuring service users, carers and family members are offered the opportunity to discuss their medicines and are given advice to help them with taking their medicines.

• Pharmacists provided advice for the Living with a diagnosis of Psychosis and Schizophrenia Recovery College courses in all boroughs in the Autumn 2015 and Spring 2016 terms

• Pharmacists are available through ward based drop-in clinics at weekly time slots for one-to-one meetings with patients to discuss matters relating to their medicines. The clinics are advertised with a poster on the ward and information for ward staff to promote the service. Service users who would like more information on their medicines can request an appointment with the pharmacist through their nurse or be referred by another member of the MDT.

• Service users & clinicians have access to a wide range of leaflets, including easy-read leaflets for children and young people and pictorial leaflets for deaf patients or those with intellectual disability.

• The Trust subscribes to Choice and medication which is an online resource not only for service users and carers, but also for healthcare professionals, to access online information about mental health medicines and resources on how to choose medicines to treat various illnesses & substance misuse issues. It is also accessible via a link on the Trust website.

• The Medicines component of the Community patient survey showed that in the last 12 months: 77% of service users had been prescribed medicines, less than the average across

the country. 43% had been prescribed a new medicine and 83% had been receiving medicines for longer than 1 year.

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66% service users prescribed a new medicine said they had understood the information given to them definitely or to some extent.

85% service users said they had had their medicines reviewed, which is within the top 20% of trusts.

66.4% of users say they are definitely or to some extent are involved in decisions about medication to be received. This is within the lower 20% of trusts and the recommendation ‘’to seek ways to improve participation of service users in decisions about their medication, paying attention to establishing what level of involvement in decision-making the patient would like’’ has been made in response. This may include healthcare professionals reviewing their consultation style and adapting this to the needs of the individual service user.

5 We will ensure that medicines optimisation is high on the Trust’s agenda and that the

Trust Board is assured about the safe and effective use of medicines by the Trust The Trust has two medicines committees responsible for medicines optimisation and for providing assurance to the Board on medicines governance:-

• The Drugs & Therapeutics Committee (DTC) is a multidisciplinary committee chaired by consultant psychiatrist Dr Helen Miller which focusses on prescribing governance (approves the introduction of new drugs, implementation of NICE guidance, prescribing policies etc.) and acts as the reference group for electronic prescribing & medicines administration. There is both a user and a carer representative on the committee.

• The Safe Medication Practice Committee (SMPC) is a multidisciplinary committee chaired by chief pharmacist Dianne Adams and focusses on medicines management and administration, develops and approves procedures relating to medicines, monitors medication safety (including the review of medication errors and incidents), oversees the safe and secure handling of medicines, including controlled drugs, and audits compliance with the Trust’s Medicines Code (the medicines ‘bible’) and other Trust policies.

• Twice yearly reports on medicines optimisation are made to the Quality & Safety Assurance Committee and one report was made in 2015/16 to our commissioners via the Clinical Quality Review Group.

• An annual report is also made to the Board and published on the Trust website.

• There are excellent working relationships with primary care commissioners in CCGs through the SWL MH Interface Prescribing Forum, a group which has been in existence for 14 years. This aims to minimise problems for service users at the interface between primary & secondary care and has been responsible for the development of shared policies and guidelines which are available to the commissioners and the public on the Trust website.

6 We will ensure that we employ and deploy the most appropriate skill mix in the workforce to maximise the safe and effective use of medicines • The Medication Safety Officer role, including being a member of a new national medication

safety network, support local medication error reporting and learning and acting as the main contact for medicines between the Trust, NHS England and the MHRA, has been substantively established.

• Medicine champions (nurses with a special interest in medicines optimisation) have been identified in every ward and team and a checklist of tasks has been developed.

• Calls to the out of hours pharmacy service continued to increase by 10% from an average

of 40 calls a month in 2014-15 to an average of 44 per month in 2015/16 with the majority being on Saturdays, often due to new admissions out of hours. The emergency drug cupboards stocks have been reviewed and now reflect the increased demand for physical health medicines for patients admitted out of hours.

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• The Pharmacy Service was independently reviewed by Hambleton Medical in December 2015, which resulted in 15 recommendations:-. Investment in MMTs More Pharmacist support to community teams Emphasis on adherence Raise hoarding of medicines by patients with GPs HTTs support Increase EIS support Look at implications of bed closures on pharmacy Re-deploy part of one B6 technician post to EPMA Out of hours brown bag scheme EPMA require pharmacy resource post implementation Register premises with GPhC Dispensing for discharge Raise the profile of the pharmacy service to strengthen recruitment Education and better explanation of DTC decisions Business venture proposal recommendations Hambleton Medical said: ‘’The Pharmacy service at SWLStG’s MH Trust is very impressive. There are very few pharmacy organisations which are comparable in terms of governance, have balanced cost effectiveness with innovation and who have such comprehensive and robust quality systems in place. In our very broad experience (over 80 reviews) almost no other organisation has rapidly transformed, as this one has, to achieve this high level of practice. Most impressive is the engagement of the wider organisation with the policies and procedures that ensure optimisation of medicines practice. The engagement of the nurses in relation to the key medicines governance items was particularly impressive and reflects well on both professions. Internally, pharmacy is very well managed with good use of skill mix and powerful systems to ensure adequate training, learning from mistakes and adoption of best practice. It has a strong direction which is well described. The Drugs and Therapeutics Committee at this Trust is fulfilling its obligations to the Board in an exemplary fashion and the strict controls relating to medicines management have benefited the Trust and its patients well. Some do not always appreciate the controls and we came across some slight criticism of the constraints that this placed on other professions. It may be that some more effort is needed to explain the reasons and more importantly the results and benefits of the systems that have been put in place.’’ An action plan has been prepared, to implement some of the recommendations of the review. Recruitment and retention of pharmacy staff continues to be a challenge. In common with other MH Trusts, this is believed to be due mainly to the high turnover of staff in London, particularly more junior staff. Further to the inclusion, in 2014, of a pre-registration student pharmacy technician in the Pharmacy Services structure, in order to help improve recruitment and succession planning for pharmacy technicians, 16/17 will see the inclusion of the Trust’s first pre-registration pharmacist, with a view to doing likewise for pharmacist succession planning.

• Pharmacy Services staff have also taught others about Trust policies concerning prescribing and medicines management:

All new staff at Trust corporate induction All new junior doctors 1-1 sessions with all new consultants Development and maintenance of bespoke e-learning packages for:

o Inpatient nurses,

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o Community nurses o AHPs, healthcare assistants, social workers, psychologists and support

workers (also suitable for carers) o Rapid tranquillisation (for all staff). o Diabetes

Regular slots at ward managers meetings, academic meetings and acute care fora. Community medicines management meetings Medicines bite size sessions for nurses on inpatient wards Pharmacy students from two London universities undertake their dissertation projects

with supervision from senior Trust pharmacists. Pre-registration pharmacists from a local acute Trust spend time as part of their training

with Pharmacy Services. Trust Pharmacists teach on two undergraduate courses (pharmacy and nursing) at a

London University and on the Royal College of Psychiatrists MRCPsych Years 1 & 2 courses.

7 We will be innovative & forward-thinking in order to generate income for the Trust

• Physical health (was lithium) monitoring app

The physical health monitoring app (funded by the SWL AHSN) was launched in December 2015, with high profile marketing such as on the Bipolar UK website, an interview with the Deputy Chief Pharmacist and the pharmacist who worked with the app developer on London Live TV , Radio Wandsworth, national press and various magazine and digital reviews. The app replaces the lithium purple book and can be used to:

Record lithium treatment & levels Set health check reminders via the calendar Record health check results Record mood and sleep using the diary function Store emergency information & contacts Learn about lithium treatment from a bank of FAQs

It is free to download, has no in app purchases, is password protected, has no advertisement or industry funding. The app has been downloaded 1200 times and its current feedback rating is 5* rated. The app can be accessed from the Apple and Android stores, free of charge. For further information see the website: http://www.physicalhealthmonitoring.com/

• The Trust is commissioned to provide specialist MH prescribing advice for one session a week to its 5 South West London CCGs. The session provides the sector with a pharmacist to lead on efficiency, safety and clinical effectiveness of prescribing for mental health, learning disabilities and substance misuse.

• The Pharmacy Service has also been providing input to GP practices in Sutton (via Sutton UPLIFT service) for one day a week since August 2015 and in Kingston since October 2012 to try and reduce the use of high risk and high cost MH medicines, by focussing on patients seen only in primary care, to review those patients and reduce the risk of harm from their medicines thereby preventing referrals.

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• Our business strategy is to generate income for the organisation, as finding funding for new

work streams while maintaining current service provision to teams and patients is a challenge. A number of business cases have been developed to enable this.

Challenges There have been a few key challenges during the past year. Errors & Incidents A quarterly medicines incident report is reviewed by the Trust Safe Medication Practice Committee, the aim being to ensure that Trust procedures are followed, and to identify areas where a change in procedures may result in improved patient safety. Reporting of incidents is as expected for a Trust this size, more work is to be done to improve reporting by community teams and by doctors. Non-medical prescribing The Trust will continue to strive to develop a strategy to support independent non-medical prescribing in 2016/17, which will improve access to medicines for patients, as well as achieving efficiencies.

Looking Forward Medicines Optimisation It is hoped that the Montgomery judgement will act as a tool to enable all healthcare professionals to ensure that service users and carers are given the opportunity to ‘Ask about Medicines’, which will help empower them to participate in the decisions to take medicines for their conditions.

Efficiencies In line with the efficiencies demanded by the whole NHS for the foreseeable future, the prescribing and pharmacy budgets are also subject to efficiencies, by making savings without compromising service quality or through additional income generation. These efficiencies form part of the challenge in the medicines optimisation strategy for 2014-18.

Electronic Prescribing Although the implementation date for the new electronic prescribing and medicines administration (EPMA) software was delayed from its original November 2015 date, it is currently anticipated that the Trust will be fully EPMA-enabled by March 2017.

This will have many benefits, both in terms of improved medicines safety and clinical and cost-effectiveness as well as streamlining many work processes for clinical staff, thereby releasing staff time to deliver more clinical care to patients. The new system will replace all paper based prescribing and administration record-keeping and will support the Trust and clinicians to transform the processes needed in the coming years.

E-learning A doctor’s e-learning package will be published in the summer of 2016 with the intention of reducing risks associated with prescribing. The DTC supports the addition of this to statutory and mandatory training requirements for all doctors. Clozapine Point of Care Testing The Clozapine Point of Care Haematological Testing (POCHI) of blood results and full physical health monitoring at clozapine clinics project is well underway. This means service users will only visit once to have their routine blood monitoring and receive the supplies of medicines. This new service will help to minimise the risks of prescribing clozapine and to improve the patient experience, as well as improving staff efficiency. Implementation commenced in the Sutton Clozapine Clinic (Jubilee East Health Centre) in April 2015. Queen Mary’s Hospital clozapine clinic is due to commence in April 2016.

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Physical Health Monitoring (previously Lithium) app Having gone live for lithium monitoring in 2015, the app framework is now being worked up with the developer to include physical monitoring for all psychotropic medicines. This will help to address the challenge of ensuring our patients are treated in accordance with NPSA and NICE standards. The Medicines & Healthcare Regulatory Agency is also meeting with Pharmacy Services to discuss collaboration on the app. CIH Inspection Following the CIH full inspection of the Trust in March 2016, the CQC found a few pockets of non-compliance with medicines management standards. These are being promptly addressed with the wards and teams concerned. The full CQC report will be published in due course. June 2016 Pharmacy Department Morrison Building (9) Springfield University Hospital 61 Glenburnie Road London SW17 7DJ