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Palliative Care Pharmacy Project Report
Palliative Care Community Pharmacy Services: Building
capacity and strengthening skill mix within community pharmacies
February 2020
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Contents
1. Palliative Care Pharmacy Project Background ................................................................ 4
2. Project Aims and Objectives ...................................................................................................5
2.1 Project Governance and funding ..........................................................................................5
2.2 Palliative Care Pharmacy Project Team ............................................................................. 6
3. Palliative Care Pharmacy Project Financial Performance ............................................ 7
4. Project Methodology and Outcomes ................................................................................ 8
5. Further Work ............................................................................................................................... 17
6. Service sustainability challenges ........................................................................................ 18
7. Lessons Learned ....................................................................................................................... 19
Appendix 1: Palliative Care Pharmacy Project Objectives and status ................................ 20
Appendix 2: Community Staff Survey Results ............................................................................ 31
Appendix 3: Survey Monkey Responses June/July 2019....................................................... 34
Appendix 4: Meetings attended to raise awareness of project ............................................ 36
Appendix 5: Information sharing from Palliative Care Register Meeting to Regular Community Pharmacy ........................................................................................................................ 38
Appendix 6: Community Pharmacy Palliative Care Patient Information Form ............. 39
Appendix 7: Resources developed during project ...................................................................40
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Document Control Version Date Status
(draft, approved, signed off)
Author Change Description
6.0 04/09/2019 Draft Lynn Sproat, Karen Menzies, Diane Lamprell
Updated Draft
8.0 12/12/2019 Draft Lynn Sproat, Karen Menzies, Diane Lamprell
Initial draft updated following comments from Project Oversight Group
9.0 22/02/2020 Approved Lynn Sproat, Karen Menzies, Diane Lamprell
Layout and design
Approval Approved for submission to Oversight Group, Roisin Kavanagh, Interim Director of Pharmacy
Date:
Oversight group sign off to proceed with distribution
Date:
Distribution List
Name Organisation Job title / Dept.
For further information on the project please contact Karen Menzies, Specialist Palliative Care Pharmacist. Tel 01292 269200 or email: [email protected]
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2. Palliative Care Pharmacy Project Background Access to medicines in the last days and weeks of life is still a source of significant stress to patients, families and health professionals. Hospice UK document ‘No Painful Compromise’ 2017 states:
• Dying peoples’ pain is reported to be consistently not as well-managed at home compared to other care setting such as hospice inpatient units, care homes and hospitals.
• Prescribing is identified as both the second main barrier and the most important enabler for effective pain management.
• While seven of 10 healthcare professionals can access seven-day extended-hour pharmacy services which dispense pain medicines, for a person at the end of life, many find it a difficult process.
Anecdotal evidence of gaps in prescribing and supply of medicines at end of life in Ayrshire and Arran is described below. These situations significantly impact on patient and carer distress and sub-optimal symptom control. “If the local palliative care pharmacy does not stock the drug you require, on this occasion levomepromazine sub cut then travelling to Kilmarnock took a family member away for 2 hours as they were left waiting in a pharmacy for over an hour to have this script filled. Can palliative prescriptions take priority?”
“Nobody is standing in your pharmacy on a Saturday afternoon getting ACP sub cutaneous drugs unless their lives are difficult!”
“Ampules of oxycodone can be like gold dust! I visited one palliative care pharmacy to be told they could order this for much later that day. This was no use for 2 reasons 1.due to toxicity the syringe driver switch needed to be made to alleviate toxicity symptoms 2. A later filling of the script would mean that the out of hours nursing team would need to re-do the syringe driver the night team could not attend until after 8pm and I was asking for this drug at 1030am.” Pharmacists are generally ‘out of the loop’ as information on diagnosis, prognosis and patients’ needs are rarely shared with the Community Pharmacist. The needs of people requiring palliative care would be greatly improved with greater integration of Pharmacists within existing Multi-Disciplinary Teams such as GP Practice Palliative Care Register meetings. Community Pharmacists are in an ideal situation to provide greater care, support and clinical services to people living with and dying of a life limiting disease and their families if they have this information and are involved in the planning of anticipatory care.
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1. Project Aims and Objectives
The joint NHS Ayrshire & Arran and Ayrshire Hospice project was designed to increase capacity of Community Pharmacies to provide good palliative care to their patients.
Within the scope of Primary Care, the project aimed to:
• Increase awareness and access to generalist and specialist pharmaceutical support when looking after the needs of palliative care patients and their carers.
• Improve the effectiveness of the 40 Community Pharmacies currently in the Adult Palliative Care Network and strengthen skills within the 59 Ayrshire Community Pharmacies not currently in the network.
The main objectives of the project were to:
• Establish baseline data on the number, frequency and effectiveness of GP practice Palliative Care meetings.
• Improve Palliative Care training and awareness.
• Create a list of Pharmaceutical Palliative Care information resources and provide a governance mechanism for regular systematic review of Pharmaceutical Palliative Care information resources.
• Improve access to and awareness of the 40 Palliative Care Network Pharmacies.
• Establish a cohort of pharmacists with specialist interest in Palliative Care to provide leadership and support to staff providing Palliative Care.
• Increase the number of Pharmacists attending Palliative Care MDT meetings.
• Increase the frequency of Palliative Care meetings and improve information sharing with Community Pharmacies following these meetings.
• Develop and roll out Just in Case (JIC) Anticipatory Prescribing Scheme.
• Reduce the chance of patients being transferred to hospital due to medicine issues and so keep patients in their preferred place of care.
Appendix 1 provides details of the actions taken to achieve the project objectives and indicates the status of these objectives.
2.1 Project Governance and funding
Governance and ownership of the project at a senior level of NHS Ayrshire & Arran were required from the beginning of the project to ensure that the project outcomes could be embedded and sustained in the normal day to day work of Ayrshire and Arran healthcare professionals. A Project Oversight Group was therefore formed consisting of: senior members from Pharmacy, General Practice, Nursing and the Hospice; the Project Lead and Project Pharmacy Advisor.
The Project Oversight Group was responsible for monitoring: project progress, project expenditure against the project budget and helping to resolve any
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professional issues identified. The Project Oversight Group also provided overarching support and direction to the Project Team. The Project Team reported to the Oversight Group, and consisted of the Project Lead, the Pharmacy Advisor, and the 3 Community Pharmacy Palliative Care Champions (one from each of the three Ayrshire and Arran Health and Social Care Partnerships HSCPs). The Oversight Group reported to the Clinical Effectiveness Group at the Ayrshire Hospice and the NHS Ayrshire & Arran Palliative Care Steering Group. A restricted Pharmacy fund of up to £55,000 was approved by NHS Ayrshire & Arran Pharmacy Endowment Fund in September 2017 however, the project start date was delayed until April 2018. The project funding enabled recruitment of three Community Pharmacists from East, North and South Ayrshire HSCPs enabling testing of alternative models of care to increase and sustain generalist palliative care pharmacy services within Community Pharmacies. An additional £10,000 was provided by the Pharmacy Champions fund to support provision of Pharmacist Coordinator/Advisor sessions.
2.2 Palliative Care Pharmacy Project Team
Project Owner:
Gail Caldwell, Director of Pharmacy, April 2018 to Dec 2018.
Roisin Kavanagh, Director of Pharmacy, January 2019 to September 2019.
Project Oversight Group:
Margaret Wilkie, Patient Services Director, Ayrshire Hospice
Craig Stewart, Associate Nurse Director
Hugh Brown, GP and Cancer and Palliative Care GP Lead
Karen Menzies, Specialist Palliative Care Pharmacist
Diane Lamprell, Project Pharmacy Advisor
Project Team:
Project Lead- Karen Menzies, Specialist Palliative Care Pharmacist
Project Pharmacy Advisor - Diane Lamprell
South Ayrshire Pharmacy Palliative Champion - Jane Rorison, Oggs Pharmacy, Ayr
East Ayrshire Pharmacy Palliative Champion - Julie Stark, Morrisons Pharmacy, Kilmarnock
North Ayrshire Pharmacy Palliative Champion - Lyndsay Wilson, Boots Pharmacy, East Road, Irvine
Project Managers:
Karen Tarn, April 2018 to December 2018
Lynn Sproat, From April 2019
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3. Palliative Care Pharmacy Project Financial Performance
Total budget for Palliative Care Pharmacy project was £65,000. Project total spend amounted to £57,516.03 with one invoice outstanding. At project end £6,928.97 currently remains unspent. The Oversight Group have agreed the remainder of the budget can be spent on the Pharmacy Advisor continuing on an adhoc basis to complete outstanding actions and to fund a showcase training event during 2020.
The following table shows the Palliative Care Pharmacy project expenditure:
Table 1: Estimated and actual project costs
Expenditure Estimated Cost (£) Actual cost (£) 3 x 0.2 WTE Pharmacist sessional payment of £225 for 46 weeks
£31,050 £28,914.89 one invoice for Julie Stark June outstanding
1 x 4 hours per week, 0.11 WTE, Band 5 Pharmacy Technician support for 46 weeks
£3,420 £3,420
0.2 WTE Band 6, Hospice Pharmacist backfill for 46 weeks
£8,010 £8,010
3 x Certificate in Palliative Care (3 x £800)
£2,400 £510 – attendance at conferences
Staff educational resources (3 x £50 Palliative Care Formulary) (2 x Syringe driver book)
£200 £209.20
Travel expenses x 4 staff £800 Included in invoices
1 x 0.2 WTE Pharmacist Coordinator/advisor sessional payment of £225 (part fund for 46 weeks)
£5,350 + £3,770 (contingency agreed by oversight group) +£10,000 from champions fund Total = £19,120
£17,006.94 till end October 2019
Total £55,000 Ayrshire & Arran Pharmacy Champion Funding
£10,000
Revised Total £65,000 £58,071.03 Budget remaining £6,928.97
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4. Project Methodology and Outcomes
1: Surveys created, implemented and data collected.
The project team created and implemented a number of surveys.
A baseline survey was issued in July 2018 to GPs, Practice Managers, Practice Pharmacists, Community Pharmacies, District Nurses, Hospices Community Nurses and Practice Nurses (79 respondents) Some of the key themes from this survey were:
• Information not always being accessed which can affect patient care
• Difficult to access prescribers to make changes to incorrect scripts
• Community Pharmacies don’t have access to eCS – can compromise ability
to provide good care
• Teams don’t have a good awareness of how to contact each other and what
each other’s roles are
• If Prescribers have to handwrite prescriptions – there is a lack of awareness of
legal requirements
• Just in Case (JIC) meds are often not being put in on time and prescribed on
administration chart so they can be given OOH
These themes influenced the direction of the project to look at training and resources for how to write legal controlled drug prescriptions, raise awareness of roles and help to build relationships, improving communication with Community Pharmacies about patients on Palliative Care Registers and provision of JIC medicines.
A GP practice staff pilot training session and evaluation after the session was carried out in April 2019. (4 respondents) Results from the evaluation showed:
• 100% of respondents were aware of the difference between a palliative care network pharmacy and a non network pharmacy
• 100% of respondents had noticed a benefit to their GP practice since attending the training.
• 100% of respondents felt that this training had improved patient outcome or service.
• 100% of respondents indicated that the training had encouraged them to improve communication with Community Pharmacies.
This feedback helped to shape the training which was later rolled out to 35 of the 55 GP practices in Ayrshire and Arran.
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Evaluation results from two palliative care network training days showed (79 respondents):
• 99% of respondents indicated that they strongly agreed or agreed that the palliative care network training day was relevant to their training requirements.
• 99% of respondents indicated that the palliative care network training day promoted insight and understanding.
• 97% strongly agreed or agreed that the palliative care network training day was useful.
A Community Pharmacy staff baseline survey carried out November 2018 showed (47 respondents):
• 76% of respondents would allow a patient or carer to be prioritised if their prescription was for an urgent palliative care medicine.
• 85% of respondents indicated that if a prescription was illegally written they would attempt to get the prescription corrected.
• 93% of respondents indicated that quality of service to palliative care patients was very important to their Community Pharmacy.
• 68% of respondents were aware of JIC medicines.
• 93% of respondents indicated that they knew where the nearest palliative care network pharmacy was located.
This survey will be repeated in April 2020.
Appendix 2 details responses from community teams in regards to any issues staff experienced in accessing palliative care medicines in the last year. 2: Improvement to palliative care training Prior to introduction of the Palliative Care Pharmacy project only 2 training sessions on palliative care medicines were held for Network Community Pharmacists on an annual basis. The project has provided an increased level of staff training and has delivered 40 training/awareness raising events as detailed in Appendix 4 over the 15 months of the project.
The Project Team identified a number of key stakeholders and meetings and met with these key stakeholders to progress the main elements of the project by raising project awareness, building relationships and providing education to different groups of health and social care professionals.
1. Practice Manager meetings were attended by members of the Project Team to raise awareness of the project and to obtain feedback about the processes for dealing with palliative prescriptions within practices. Attendance at these meetings highlighted an exciting opportunity to train GP practice staff through the Medicine Management Service Locally Enhanced Service (MMS LES). 54 of the 55 GP practices took part in the MMS LES. As part of this service GP practices had to commit to attending training session, and give details of the:
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• Number of patients on palliative care list
• Number of patients with read code for JIC medicines - 8BMM-1
• Practice protocol for dealing with palliative care prescriptions
The initial training session involved an overview of palliative care, palliative community pharmacy network and a workshop to brainstorm how to improve the prescription process for palliative patients, and should ensure patients: are recorded on the palliative list and receive ongoing review at GP practice palliative meetings where a pharmacist should be included in the team. The follow up session on 17 September 2019 explored the protocols developed by GP practices to improve their provision of palliative care services to patients and carers and gave some training on symptom control in palliative care and common medicines used. The completed protocols will be submitted to the prescribing support team in March 2020 and enable good practice to be shared amongst practices. Training resources for GP practice staff will be uploaded onto Athena to enable sharing of training material with other practices who didn’t attend sessions.
Feedback from a GP practice about a recent incident when a patient was not involved in discussion about JIC medicines being issued has resulted in the practice carrying out a significant event analysis and ensuring they have a more robust process in place. This GP practice took part in the training sessions so they had a greater awareness of what should have happened and what to do to prevent this happening again.
2. Attendance at Senior Prescribing Advisor Meetings allowed the Project Team to raise awareness of the project and the revised JIC Bag Scheme with the large team of Practice Pharmacists. There are Pharmacists in every GP practice in Ayrshire so involving this team in the project helped to ensure sustainability of many aspects of the project. Developing stronger links between the community pharmacists and practice pharmacists helped with the roll out of JIC and the sharing of information on palliative patients to community pharmacies.
3. Training of Pharmacists at Royal Pharmaceutical Society training event, GP Practice Pharmacists training session, Network training days, Local Pharmacy Group meetings and individual visits to community pharmacies. Training was specifically designed to raise awareness of the patient/carer issues, and those of other healthcare professionals, what to do if the prescription process for palliative medicines is flawed or delayed and clinical subjects such as anticipatory prescribing and symptom management. Training covered awareness raising of the resources available, such as the Community Pharmacy Network, and the JIC Bag Scheme for anticipatory prescribing. Training resources for Community Pharmacists and their staff have been created and uploaded to NHS Ayrshire & Arran Community Pharmacy website: https://www.communitypharmacy.scot.nhs.uk/nhs-boards/nhs-ayrshire-arran/.
Training sessions for Community Network Pharmacies are currently being reviewed. These training days are expensive costing around £8,000 a session for
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payment of locum fees. It is hoped to use Project Echo in 2020 to provide training to the Community Network Pharmacies. This will be more economical but also will aim to improve learning outcomes and build a stronger network: https://www.hospiceuk.org/what-we-offer/clinical-and-care-support/project-echo.
4. Attendance at Care Home Forums helped to identify issues being experienced by care homes with palliative care prescriptions/medicines. It also allowed the Project Team to: raise awareness of the revised JIC Bag Scheme and how Community Pharmacies can help in palliative and end of life situations regarding medicines. Note: Care Homes and Care at Home are both areas that would benefit from further work in the future.
5. District Nurses were found to be a key stakeholder group for the project
therefore members of the Project Team attended both senior and operational nursing meetings which allowed identification of specific issues around palliative care medicines and the prescription process. This resulted in a more informed approach to the drafting of the JIC prescription flow charts and encouraged the building of relationships between District Nurses and Community Pharmacists and an increased appreciation of each other’s roles and how this can directly affect patient care. Training material for the revised JIC Bag Scheme was also provided and cascaded to the District Nursing teams.
6. Out of Hours Services: The Palliative Care Champion for North Ayrshire attended
a session at Ayrshire Unscheduled Care Service (AUCS) to identify issues specific to out of hours’ services around the palliative care medicines and prescription process. As the service is currently under redesign, it was not possible during the time of the project to follow up on the initial meeting. Although there were several key issues which were actioned or handed over to other teams such as updating the palliative medicine stock kept in AUCS centres. Note: This is an important area, and would benefit from further work in the future.
3: Improved awareness of Palliative Care Medicines and service Awareness of palliative care medicines and the palliative care pharmacy service has improved. The Community Palliative Network leaflet has been shared with practice staff, district nurses, GP’s, Care Homes and Out of Hours services both in hard copy and electronically. Resources developed during the project have also highlighted the network and prescribing issues around palliative medicines. These were distributed to all GP practices and Community Pharmacies and at different meetings and training events. These resources can also be found on the NHS Ayrshire and Arran Community Pharmacy Website. https://www.communitypharmacy.scot.nhs.uk/nhs-boards/nhs-ayrshire-arran/palliative-care/
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Repeating the initial survey monkey with a wide range of community staff (83 respondents) interestingly showed that: ‘What influences your choice of community pharmacy?’, the response ‘Good relationship with community pharmacy’ increased from 18% to 52%. Staff awareness of the Scottish Palliative Care Guidelines which underpin all the information resources developed during the project has been raised with links provided to the Guidelines website in order to ensure ongoing access to the most recent version of the guidelines. The Scottish Palliative Care Guidelines have been used as the “gold standard” for all healthcare professionals and have been incorporated into the revised JIC Bag scheme. www.palliativecareguidelines.scot.nhs.uk 4: Palliative Care Information governance has been agreed within existing governance structures The NHS Ayrshire & Arran Palliative Care Steering Group has overall responsibility for the governance around the use of the most up-to-date version of the Scottish Palliative Care Guidelines within NHS Ayrshire & Arran and for the implementation of the JIC Bag Scheme. The Project Team has increased access to other groups of professionals who can receive updates via regular bulletins during the course of the project The Palliative Care Steering group and the ADTC are responsible for the accuracy of the palliative care information available NHS Ayrshire and Arran Intranet site, AthenA. Agreement has been gained from the Palliative Care Acute Clinical Governance Group to work together to ensure that the contents of the AthenA palliative care section is accurate and up-to-date. Discussion is ongoing to identify an administrator for this section of AthenA to ensure information is kept up-to-date. 5: Distribution of Pharmaceutical Palliative Care information has been improved The project has produced and distributed palliative care information resources to health care professionals. The resources are available on the Ayrshire & Arran Community Pharmacy website and will be added to the Athena Palliative Care site. A list of resources developed through the project can be found in Appendix 7. Community Palliative Care Resource Folder was delivered out to all Community Pharmacists in January and a copy will be given to all GP Practice Pharmacists. This contains details of the network and other useful palliative care information.
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6: GP staff awareness and access to Palliative Care Network Pharmacies has improved
The July 2018 baseline survey showed that 78% of survey respondents were aware of the Palliative Care Network Pharmacies. The end of project survey July/Aug 2019 showed improvement with 92% of respondents being aware of the Palliative Care Network Pharmacies. All GP practices have been provided with information listing the contact details for the Palliative Care Network Pharmacies both electronically and hard copy and the information is available on the Athena Palliative Care website. This information has been highlighted to GP practice staff as part of their ongoing training. 7: For duration of the project a cohort of pharmacists with specialist interest in palliative care was established providing leadership and support to staff providing palliative care
The project enabled recruitment, employment and training of three Palliative Care Pharmacy champions, one for each HSCP area. The champions worked as part of the community teams providing leadership and support to staff who provide palliative care to patients, and supported service improvement work. These pharmacists were all working in community pharmacies within their project HSCP area and continue to do so. This ensures they are able to continue to develop links in these areas and support pharmacy colleagues. 8: Increased number of Pharmacists regularly attending GP Practice Palliative Care register meetings At the start of the project Pharmacists regularly attended two GP Practice Palliative Care meetings with one Pharmacist attending Dalmellington GP practice meetings and one pharmacist attending Catrine GP practice meetings. Throughout the project it was recognised that it is not practical for Community Pharmacists to regularly attend GP practice palliative care meetings. The Director of Pharmacy, as a member of the Project Oversight Group arranged for the GP Practice Pharmacists to include in their remit, attendance at GP practice palliative care meetings and subsequent sharing of relevant information with the patient’s Community Pharmacist. At the end of the project Pharmacists were regularly in attendance at 41 out of 55 GP Practice palliative care meetings. Qualitative review of the benefit of this increased pharmacy involvement in palliative care meetings will be carried out in early 2020. 9: Improved information sharing by staff following GP Palliative Care meetings
Data from project surveys show a slight improvement in information sharing following GP Palliative Care Register meetings.
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The baseline survey showed: 20% of survey respondents (n=79) did pass on information gained to colleagues following GP Palliative Care Register meetings.
The end of project survey showed only a slight improvement in palliative care information sharing with 23% of survey respondents indicating that they did pass on information gained to community pharmacy colleagues following Palliative Care meetings. Ongoing training with GP practice pharmacists and attending prescribing huddles to raise awareness of the importance of this role will be provided by the Specialist Palliative Care Pharmacist, Community Pharmacy Advisors and Project Pharmacy Advisor.
The three Palliative Care Community Pharmacy Champions visited GP Practices and Community Pharmacies to identify palliative care prescription/medicines issues and to raise awareness of the project. From their discussions at the start of the project with GP Practices and Community Pharmacies it was established that GP palliative care meeting schedules were inconsistent, there was little involvement of a pharmacists at these meetings and very little information sharing was taking place with patients’ Community Pharmacies. The South Palliative Care Community Pharmacy Champion therefore piloted training sessions with some GP practices. These training sessions were then adapted and included in the GP Practice Medicines Management Service Local Enhanced Service (MMS LES) 2019 provided to 54 out of the 55 GP practices.
Qualitative review of the benefit of sharing information with Community Pharmacists will be carried out in early 2020. Carer’s story Carer felt a carers communication book would have helped, often medicines delivered with poor/no instructions so no one was sure exactly what they were for at times. Language on Rx e.g. sublingual – do carers know what that means? Pharmacy deliveries meant no pharmacist input – should pharmacists be phoning to discuss if delivering. DN’s were overstretched. Lack of communication meant pharmacy didn’t know patient had a stomach tube so inappropriate medicines supplied with little advice. Better communication would have helped this.
Community Pharmacist patient story
I attended a practice Gold Standards meeting at a local GP practice. I was there to promote the new palliative care project. Whilst I was there one of my patients who attends the Community Pharmacy was on their list. As this was unknown to me it was quite a shock as the patient wasn't even on any medicines to signify that he was palliative. All of the staff were informed after the meeting I attended and a note was added to the patient’s record to notify any staff of this patient’s status. Within 5 months this patient deteriorated and passed away. It was mentioned by his friend who collected all of his prescriptions that we were courteous and understanding whenever they were in the shop and she thanked us for all of our help. She also
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informed me that it was helpful to know I was there to ask for help. I felt it benefited our practice as his prescriptions were always prioritized when he was in and I always checked he was ok when he was in the pharmacy. I think knowing when a patient is palliative is a huge benefit to Community Pharmacy. Communication is definitely key with palliative care.
10: A robust process for provision of JIC medicines to patients has been established
The project identified improvement was required to the process for provision of JIC medicines. Following a scoping exercise by the project Pharmacy Advisor elements of the successfully introduced NHS Wales, Just in Case Bag Scheme: www.wales.pallcare.info were adopted and the following changes were made to the existing NHS Ayrshire & Arran JIC Box Scheme:
• An easily identifiable orange JIC Bag has been introduced rather than a box.
• The earliest expiry date of the medicines inside the bag is now noted on the outside of the bag.
• Contents of the new JIC bag includes: NHS Ayrshire & Arran Medicines Administration Record, Symptom Control Guidelines (from Scottish Palliative Care Guidelines), Community Pharmacy Network leaflet, and a patient leaflet (attached to outside of the bag).
• A Community Pharmacy Service agreement was developed, to dispense the JIC medicines into the bag with associated paperwork and to note and add the earliest expiry date to the outside of the bag.
The NHS Ayrshire & Arran Palliative Care Steering Group assumed responsibility for the ongoing clinical governance associated with the new JIC guideline developed by the Project Team.
JIC process training materials have been provided to GP practices, Practice Managers, Practice Pharmacists, Community Pharmacists, District Nurses and Hospice Community Nurses. The Project Team delivered training on the JIC medicines scheme during visits to: GP practices, Community Pharmacies, District Nurse and Hospice Nurse meetings, Area Pharmacy Group meetings, the Royal Pharmaceutical Society local forum, the Practice Pharmacist training day, GP practice staff training at the 2019 Medicines Management Service Local (MMS) Local Enhanced Service and also to various GP trainee training sessions.
The new JIC Medicines Bag scheme was launched across Ayrshire and Arran in April 2019. A total of 153 JIC bags have been supplied from April to September 2019 with the number increasing on a monthly basis. Provision of JIC medicine bags is anticipated to grow to between 600 and 800 bags annually.
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An issue has been identified with some JIC prescriptions not being clearly identified as JIC scripts with medicines not being dispensed as such. Awareness of this issue will continue to be raised by the Prescribing Team Huddles and the Community Pharmacy Advisors. The data on the number of JIC bags in use is partly reliant on Community Pharmacies claiming for the service. Data on the number of patients being coded for JIC medicines can also be collected as a single code is now in use.
The Area Pharmacy Contractors Committee agreed that the cost of the JIC bag service could be paid from the Community Pharmacy Palliative Care Model Scheme budget.
11: Improved patient access to JIC medicines
Community Pharmacist patient story: A patient was being discharged from community hospital. In addition to their normal medicines supply JIC medicines were arranged with the GP prior to the patient’s discharge. The pharmacists were able to ensure the opioid equivalent dose was correct as the patient was already on an oral morphine dose. Both a 24-hour syringe driver dose and s/c prn dose were included on the patient’s JIC Kardex. The patient’s medicines were supplied to the family home on the day after discharge. The District Nurses were informed and 13 days after discharge/supply (on a Saturday) the syringe driver was commenced by the out of hours District Nurse Service. The patient was reviewed by ADOC over the weekend and opioid dose titration changes were made. A further supply of morphine and hyoscine were provided on the following Monday morning with a JIC bag being used. The patient passed away in the afternoon of that day. The family were able to stay with the patient the whole time with no requirement for medicines to be sourced before the driver was commenced.
Further qualitative data will be collected and reviewed early 2020 on the patient/carer benefits from improved access to JIC medicines for publication in 2020.
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5. Further Work The project team would recommend the following be addressed to further improve Palliative Care medicines management: Required Action Reason to Continue/Pursue
Action Owner
1. Development of
Palliative Care medicines management e-training module
To deliver practice staff Palliative Care medicines Management training over time and ensure staff are up-to-date
K Menzies
2. Project Echo – Hub and spoke Palliative Care network for shared learning
To deliver Community Pharmacy staff Palliative Care training over time and ensure staff are up-to-date
Hospice/ K Menzies
3. GP Palliative Care Medicines Management training
To deliver GP and GP trainees Palliative Care medicines Management training over time and ensure GPs are up-to-date
Hospice/ K Menzies
4. Out of Hours staff Palliative Care Medicines Management training and review of prescribing processes
1.To deliver out of hours’ staff Palliative Care Medicines Management training over time and ensure staff are up-to-date
2.To monitor and support Out of Hours Palliative Care prescribing processes
Hospice/ K Menzies
A Thomas
5. Qualitative review of benefits of sharing information with Community Pharmacies from palliative care register meetings
Assess impact on patients/carers of community pharmacies having this information and improved access to JIC medicines.
K Menzies with involvement of Scottish Health Council
6. Showcase event to be organised in early 2020
To showcase the outcomes of the project and share learning and resources and with community and hospice teams.
K Menzies D Lamprell M Wilkie
7. Process map a typical Palliative Care patient journey to develop a practical checklist of Palliative Care pharmaceutical service actions required when a Palliative Care patient is identified
To identify current barriers within Palliative Care patient journey to provision of high quality Palliative Care pharmaceutical service for patients.
K Menzies
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6. Service sustainability challenges
The project team has identified a number of areas of work that may prove challenging in regards to maintaining a quality Palliative Care Community Pharmacy service and has provided suggested solutions and ownership to sustain the service.
Challenge Sustainability Solutions Owner at End of Project
1. Lack of support to continue JIC bag process may lead to inconsistent use
Project team have ensured wide spread training and key champions within the community teams such as Hospice Community Nurses and Practice staff to facilitate ongoing development of this project.
K Menzies
2. Loss of Palliative Care Pharmacy champion support leads to reduced awareness and interest in Palliative Care Pharmaceutical issues
The project team feel we have invested in solutions and processes which are sustainable such as using Practice Pharmacists and training practice support staff. We have also ensured governance through robust structures. The Project Pharmacy Advisor will continue to be employed with the underspend from the endowment funding to further embed the JIC service.
K Menzies/A Thomas
3. Failure to sustain community palliative care pharmacy provision due to lack of continued intensive support
The investment in time to establish relationships with key stakeholders and good leadership in palliative care services should ensure palliative care is kept as a key priority by NHS Ayrshire & Arran.
K Menzies
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7. Lessons Learned
The project began in April 2018 with Project Owner, Project Lead, Independent Pharmacy Advisor and two Palliative Care Pharmacy Champions; it initially proved difficult to recruit a North Palliative Care Pharmacy Champion. The East Palliative Care Pharmacy Champion was unable to continue with the project after 2 months, resulting in further re-recruitment to this post. This delayed the full project start until all staff were recruited by September 2018.
Initially the project budget did not take into account the Independent Pharmacy Advisor. The Pharmacy Advisor post was found to be essential to the success of the project. £10,000 of Pharmacy Champions money was agreed to cover the majority of the funding of this post. No administration support was provided for the project and the backfill by the rotational pharmacist although beneficial did not free up much time for the Specialist Pharmacist to be as involved in the project. The Pharmacy Advisor was therefore very useful in co-ordinating the champions and took the lead with the JIC project. The JIC element of the project ended up being more time consuming than first thought.
During the project there was a change of Project Owner and a change in Project Manager resulting in the project being without a Project Manager for several months which increased the need for handover of project aims. Provision of a single Project Manager and implementation of a single set of project management methods and tools would have benefited the project.
Creation of a Project Oversight Group was very useful as this group provided project governance and acted as a sounding board advising the Project Team on how to engage with other professionals. The Project Oversight Group also helped to facilitate engagement with professional staff.
Budget management was challenging at the beginning as it involved Endowments, Community Pharmacy, NHS Finance and Hospice Finance departments. Processes were implemented after key personnel were identified and linked to the project.
Initially the project team invested a lot of time engaging with key stakeholders. At the time it appeared that the project was not moving forward but it became evident that investing time in stakeholder engagement was instrumental in enabling the changes implemented by the project to be sustainable.
The Project Team found it difficult to engage with GPs who are key project stakeholders. Some relationships have been built with GP sub-committee representatives and GPs who are involved in organising training for GPs. Moving forward the Specialist Palliative Care Pharmacist will be linked in with GP trainee training days and GP protected learning time enabling provision of palliative care training to these groups in conjunction with the Hospice Education team.
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Appendix 1: Palliative Care Pharmacy Project Objectives and status
Objective 1: Establish baseline data on the number, frequency and effectiveness of GP practice Palliative Care meetings.
Action Status Achieved 1.Collect and collate information on Palliative Care meetings
Baseline data collected on: • Number of practices who hold Palliative Care meetings
and meeting frequency
• Number of pharmacists attending GP practice palliative care meetings
• Effectiveness of GP practice palliative care meetings
• Awareness of Palliative Care Network.
This information has been shared with GP and DN leads to influence improvements in Palliative Care meetings. Out with scope of this project.
2. Multi-disciplinary survey
Multi-disciplinary survey completed May to July 2018 to provide baseline data and to identify Palliative Care issues: • Number of Palliative Care Pharmacy education sessions
provided to Primary Care staff (i.e. GPs, nurses, pharmacists)
• Availability and awareness of Just In Case bag process
• Availability of Palliative Care information to Community Pharmacies and other health care professionals
• Knowledge of process for supply of Palliative Care medicines
• Quality of Palliative Care pharmacy service
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Objective 2: Improve Palliative Care training and awareness: Training Action Status Achieved Future Steps 1. Agree and deliver Palliative Care network training dates for community and non-network pharmacists, Practice Support Pharmacists (PSPs) and District Nurses
October 2018 – Community Pharmacists Network Training day
12 March 2019 - Community Pharmacists Network Training day
27 May 2019 - Practice Support Pharmacist (PSP) training delivered
Ongoing Palliative Care Pharmacy training for Practice Support Pharmacists (PSPs) and Community Pharmacists (CPs) using Project Echo –trialling with Care Homes in East Ayrshire November 19.
2.Training sessions with GP practice staff to raise awareness of why and how to share Palliative Care information with Community Pharmacies and to embed Palliative Care Pharmaceutical training in Medicines Management Service Local Enhances Service (MMS LES) for 2019
Pilot training sessions held with 4 GP Practices South HSCP November - December 2018
Training session rolled out at Medicines Management Service Local Enhanced Service (MMS LES) session 27 June 2019.
Further in-depth training session to be delivered 17 September 2019 at request of GP practice staff.
3.GP Pharmaceutical Palliative Care training
Protected learning time for
GP Palliative Care training not established. Delivery of GP Palliative Care Pharmacy training course is still outstanding. Contact has been made with Dr Chris Black to organise evening training sessions in 2019/20.
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Objective 2: Improve Palliative Care training and awareness: Awareness
Action Status Achieved Future Steps 1.Develop Pharmaceutical Palliative Care e-learning module for practice staff
Palliative Care e-learning
module still to be developed.
2. Use bulletins i.e. Community Pharmacy bulletin, Prescribing Bulletin, Hospital Pharmacy Bulletin to improve Pharmaceutical Palliative Care awareness.
Prescribing Flash 93: Information on Palliative Care 'JIC' bags, Palliative Care prescribing guidelines and resources.
Community Pharmacy Bulletin May 2019: Just in case Anticipatory Prescribing flow chart
Community Pharmacy Bulletin May 2019: Palliative Care Bulletin
Prescribing Flash and Hospital and Primary Care Bulletins require to be developed to provide staff with information on the updates to the Palliative Care AthenA website once updated. Hospital pharmacy Bulletin detailing information on Palliative Care guidelines and JIC bags still to be distributed.
3.Establish Community Pharmacy Scotland NHS Ayrshire & Arran Palliative Care information section
Community Pharmacy Scotland NHS Ayrshire & Arran Palliative Care information section established: https://www.communitypharmacy.scot.nhs.uk/nhs-boards/nhs-ayrshire-arran/palliative-care/ Web site section includes contact details for specialist advice, Just In Case training material, useful web links and Palliative Care Network information.
4. Regionalise the NHS GG&C Palliative Care website to cover West of Scotland area
Meeting held with Gail Caldwell 01 June 2019.
Contact to be made with Paul Corrigan regarding governance to allow regionalisation of website.
5.Update to NHS Ayrshire & Arran Palliative Care AthenA information
NHS Ayrshire & Arran Palliative Care AthenA website updated to include links to:
• Palliative Care Guidelines • Palliative Care Formulary
• The Palliative Care Network leaflet
Palliative Care contact information JIC bag process and information
6.Promote use of clinical email box as tool to transfer Palliative Care Pharmaceutical information
Use of clinical email box for transfer of Palliative Care Pharmaceutical information promoted at training days and via various bulletins.
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Objective 3: Create a list of Pharmaceutical Palliative Care information resources and provide a governance mechanism for regular systematic review of Pharmaceutical Palliative Care information resources. Action Status Achieved 1.Develop a list of available Palliative Care Pharmaceutical information resources
List of Palliative Care Pharmaceutical information resources available at the start of the Palliative Care Pharmacy project compiled to inform need for resource improvement.
2. Develop Pharmaceutical Palliative Care information sharing models for urban and rural areas
Early stages of project Director of Pharmacy gave permission to utilise Practice Support Pharmacy Team to be the link between GP practice palliative care register meetings and Community Pharmacies. This negated the need for different urban and rural models which may have been difficult to replicate across the board.
3. Provide Palliative Care Network pharmacies with copies of the Syringe Driver book
Palliative Care Network pharmacies provided with copies of the Syringe Driver book and training on use of syringe drivers during April and October 2018.
4.Palliative Care Yellow Resource bags
Yellow bag palliative care resources issued to GP Practices and Community Pharmacies. Information includes resource cards with “Palliative care prescribing - Get it right first time!“ guidance on anticipatory medicines for use in last days or weeks of life/Conversion Chart for Strong Opioids in Palliative Care, magnets, pens and desk blotters with safe prescribing messages.
5. Resource folder and palliative care prescribing aid
Resource folder and palliative care prescribing aid developed and final draft at printers. Folder will be distributed to all Community Pharmacies and all Practice Support Pharmacists in January 2020. Prescribing aid will be distributed to all Prescribers, District Nurses and Community Pharmacists.
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Objective 4: Improve access to and awareness of the 40 Palliative Care Network Pharmacies Action Status Achieved Future Steps 1.Arrange training events to raise awareness of the Ayrshire Palliative Care Network
- Palliative Care Network training
held 12 March 2019 attended by 60 attendees including District Nurses, Community Pharmacists, PSPs and ANPs.
- Royal Pharmaceutical Society event 26 March 2019, open to all pharmacists and technicians.
- Nurse training to be arranged later in 2019.
-
2. Palliative Care champion visits to GP Practices
All GP practices received visits from Palliative Care Champions to raise awareness of Palliative Care Network and resources supplied.
3. Palliative Care Pharmacy project team to attend
4. Palliative Care Pharmacy project team to attend:
• Practice Support Pharmacist and District Nurse huddles
• District Nurse professional leads meetings
• Care Home Forums and Care at Home Forums
• NHS Ayrshire and Arran Palliative Care Network
• Practice managers Forum East, North, South HSCP
Palliative Care Pharmacy project team attended these meetings to raise awareness of Palliative Care Network, Palliative Care Pharmacy project and discuss Palliative Care Pharmacy issues. The Project was added as a recurring agenda item at NHS Ayrshire & Arran Palliative Care Network Group meetings. Practice managers Forum meetings East, North, South HSCP attended by Palliative Care Pharmacy project team to raise awareness of Palliative Care network and to discuss Palliative Care Pharmacy issues.
5. Raise awareness at conferences
Project lead spoke at two board wide conferences about the project and distributed resources. North Resource Centre 03 August 2019 and UWS Ayr Campus 17 August 2019.
Palliative Care Pharmacy project posters to be produced for national conferences in 2020.
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Objective 5: Establish a cohort of pharmacists with specialist interest in Palliative Care to provide leadership and support to staff providing Palliative Care Action Status Achieved 1. Recruit and train
Palliative Care Pharmacy Champions
Three Palliative Care Pharmacy Champions one for each HSCP area recruited and trained. Training of these staff included: Attending shadowing sessions at Ayrshire hospice, attending conferences, shadowed Community Palliative Care Nurses, completion of the NES Pharmacist in Palliative Care Pack and reading the National Strategy documents.
2. Embed Palliative Care pharmacy champions in local community teams
Three Palliative Care pharmacy champions established as part of community teams to support Palliative Care Pharmacy service improvement during term of project. The investment in time to establish links between Community Pharmacists, Practice Support Pharmacists, District Nurses and GP Practice Staff will have improved relationships and understanding of pharmacy issues so will aid with sustainability when the champions are no longer in post.
3. Rotational Pharmacist placement at the Hospice
Have had 3 rotations of Band 6 pharmacist through the hospice. The feedback has been very positive from the pharmacists involved and this has facilitated spread of palliative care knowledge back into acute sector.
Objective 6: Increase the number of Pharmacists attending Palliative Care MDT meetings Action Status Achieved 1. Baseline data
collected to establish number of Pharmacists attending Palliative Care meetings at start of project
At start of Palliative Care Pharmacy project on average two Pharmacists attending Palliative Care register meetings.
2. Establish Pharmacy leads support for PSP attendance at Palliative Care meetings
Agreement received October 2018 from Director of Pharmacy for Practice Support Pharmacists to attend Palliative Care meetings.
3. Encourage Pharmacist attendance at Palliative Care meeting
Pharmacist attendance at Palliative Care meetings promoted to GP practices. Number of Pharmacists regularly attending Palliative Care meetings has increased from 2, 3%, Community Pharmacists to 41, 84%, Pharmacists (mostly Practice Support Pharmacists)
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Objective 7: Increase the frequency of Palliative Care meetings and improve information sharing with Community Pharmacies following these meetings. Action Status Achieved Future Steps 1. Data collected on
frequency and effectiveness palliative care register meetings
This information has been shared with GP and DN leads to influence improvements in Palliative Care meetings. It has been decided by Oversight Group influencing frequency of palliative care register meetings is out with the scope of this project. Although this still remains a priority within the primary care transformation plan.
2. Increase frequency of transfer of information to Community Pharmacies after palliative register meetings.
Baseline survey July 2018: 80% did not transfer information to Community Pharmacies after palliative register meetings. Repeat survey July/Aug 2019: 77% % did not transfer information to Community Pharmacies after palliative register meetings.
Information to be reviewed in 6 months when Practice Pharmacists embedded in Palliative Care Register meetings.
3. Produce template and checklist for PSPs to share Palliative Care information with Community Pharmacists
Palliative Care Pharmacy information check list and template produced. This is being used to transfer information to Community Pharmacy clinical email box after palliative care register meetings. (See Appendix 5 for templates)
4. Improve relationship between DN’s, practice staff and Community Pharmacists
Relationships between DNs and practice staff has been improved:
• Baseline Survey, July 2018: 18% of respondents indicated that the relationship with community pharmacy staff influenced their choice.
• Repeat survey July/Aug 2019: 52% of respondents indicated that the relationship with community pharmacy staff influenced their choice.
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Objective 8: Develop and Roll out Just in Case Anticipatory Prescribing (JIC) Scheme - use of Just in Case bags placed in the homes of patients, who are in the dying phase, to support anticipatory prescribing and access to palliative care medicines. Action Status Achieved Future Steps 1.Develop Policy for use of JIC bags in Primary Care protocol
Policy established for the use of Just in Case Boxes in Primary Care A revision to the “Facilitating Anticipatory Care for Adults at End of Life: Guideline for the Use of Anticipatory Prescribing Just in Case Bags in Primary Care” was noted and approved at the meeting of the NHS Ayrshire and Arran ADTC in May 2019.
Discussion with GP sub-committee is ongoing in regards to JIC process concerns. JIC policy reworded to reflect practical capacity issues in community. Redrafted policy with GP subcommittee for approval at future meeting.
2. Just in Case Anticipatory Prescribing Pilot
Initial plan to pilot community
pharmacist independent prescriber involvement in anticipatory prescribing was abandoned when the former East Palliative Care Champion who is an independent prescriber, was recalled from the project by their employer. With the current lack of community pharmacy independent prescribers it was decided not to pursue this aspect of the project.
3.Agree JIC guardianship
Agreement at NHS Ayrshire & Arran Palliative Care Steering Group 23 November 2018 that JIC would be a standing item on the group’s agenda with the group overseeing and taking ownership of the JIC Scheme.
4.Create a multidisciplinary JIC Working Group
Short life working group established to implement JIC Bag scheme across Ayrshire and Arran. Group membership included representation from: Community Pharmacy, GP, Practice Pharmacists, Palliative Care Community Pharmacy Champions, District Nursing, Hospice Community Nursing, Practice Managers, Out of Hours Nursing and was chaired by the project Pharmacy Advisor. The group met formally twice: 23 January 2019 and 26 February2019, as well as via e-mail.
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The group does not plan to meet again as their task to implement the JIC Bag Scheme across Ayrshire and Arran has been accomplished.
Action Status Achieved Future Steps 5.Train GPs, District Nurses in JIC medicines process
Multiple methods used to train key stakeholder groups in anticipatory prescribing and the JIC Bag Scheme.
GPs: Community Pharmacy Palliative Care Champions visited all GP practices in their area, delivering information and training to practice staff and available GP’s.
The Hospice GP with a Special interest in Palliative Care delivered a session at ST3 GPs training session May 2019; arrangements have been made to include training in the ST1 GP training sessions after summer 2019.
JIC Bag Scheme and anticipatory prescribing information developed and issued to all GP practices.
GP Practice Staff: A Medicines Management Service, Local Enhanced Service (MMS LES) has been developed for practices to opt into for 2019/20, this includes a section on palliative care. Two training sessions are to be provided for GP practice staff, June and September 2019. GP Practices will be expected to submit information on: • Number of staff trained;
• Number of patients on palliative care list;
• Number of patients with JIC read code;
• Practice protocol for dealing with palliative care prescriptions.
District Nurses (DN): Lead nurses in the three Ayrshire and Arran HSCPs cascaded training slides and JIC Bag scheme flow charts to their DN team meetings.
Training provided at DN team leader meetings by the palliative care pharmacy project team.
JIC Bag Scheme training included
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in training sessions for the new Kardex.
GP Practice Pharmacists: as these pharmacists will participate in palliative care meetings in GP practices, they have received training on the JIC bag scheme via their huddles, and at a training event on 27 May 2019.
Community Pharmacists: Community Pharmacy Palliative Care Champions visited all pharmacies in their area providing information and training on the JIC Bag Scheme. Training was also delivered by the project team at:
- Two area pharmacy meetings on 04 September 2018 and 04 March 2019. Also at the
- Royal Pharmaceutical Society evening (26 March 2019); and
- Two network pharmacy palliative care training days (September and March 2019).
5.Develop and Publish JIC Bag Patient Information Leaflet (PIL)
Just in Case Bag Patient information leaflet: MIS19-028-GD published March 2019 and distributed to DN’s, GP’s, CP’s, published on the Community Pharmacy Scotland website and sent electronically to PSP’s and practice managers.
6. Develop and agree a local Service Level Agreement (SLA) with NHS Ayrshire & Arran Community Pharmacy.
Local SLA developed and agreed with NHS Ayrshire & Arran Community Pharmacy
06 February 2019.
Local SLAs issued from Primary Care – June 2019
7. Establish full sign up by the Community Pharmacists to the provision of the JIC Bag Scheme.
JIC Bags have already been provided by some Community Pharmacies to patients. Number of JIC bags issued is being monitored by Primary Care: 17 bags issued May 2019, 25 bags issued June 2019
Sign up to the JIC Bag Scheme has been transferred to the three Community Pharmacy Advisors to monitor and encourage participation in the Scheme, alongside the Specialist Palliative Care Pharmacist.
8. Include the JIC Bag Scheme in the monthly Community Pharmacy Local Services Claim Form.
Monthly Community Pharmacy Local Services Claim Form updated to include the JIC Bag Scheme from May 2019 to allow data to be collected on the number of JIC Bags provided and the extent of pharmacy involvement in provision
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of JIC bags.
9.Issue JIC Bags
• Initial supply of 500 JIC Bags containing PIL and anticipatory prescribing guidelines, were issued to Community Pharmacies in preparation for JIC scheme launch April 2019.
• Community Pharmacy Advisors issued with Community Pharmacy emergency supply of 10 JIC Bags each.
• In future the number of JIC bags issued will be measurable via EMIS from individual practices who use the new read codes following the MMS LES.
10.Publicise JIC
Community Pharmacy Bulletin May 2019: Just in Case Anticipatory Prescribing (JIC) Leaflet
Community Pharmacy Bulletin May 2019: Just in case Anticipatory Prescribing flow chart Community Pharmacy Bulletin May 2019: Palliative Care Bulletin Prescribing Flash 93: May 2019 provided information on palliative care 'JIC' bags, palliative care prescribing guidelines and resources. Also issued to hospital pharmacy teams in May 2019.
Hospital Bulletin to be sent out. Project lead to contact Tracy Love to agree issue date.
Additional Activity Objective 9: Keep Patient in Preferred Place of Care Action Status Achieved Future Steps 1.Develop business case for further project funding to continue Palliative Care Pharmacy project and submit to TLG
Business case submitted to TLG 11 April 2019 as part of Pan- Ayrshire Palliative Care Business Case
Funding for 1 year extension of Palliative Care Pharmacy project not approved.
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Appendix 2: Community Staff Survey Results During May to July 2018 community staff were asked to complete a baseline survey to establish information on: attendance at Palliative Care register meetings; awareness of the Community Palliative Care Network and leaflet; and availability of JIC medicines. The survey was repeated in July/Aug 2019.
Description Baseline Survey
End of Project Survey
% Improvement
Number of Respondents to Survey
79 100 Approx. 27%
Number of Pharmacists regularly attending Palliative Care register meetings
2 (1 pharmacist in Dalmellington, 1 Pharmacist in Catrine)
41 >2000%
Number of community staff aware of Community Palliative Care Network
55,70% 90, 92% 22%
Number of community staff not aware of Community Palliative Care Network
24, 30% 8, 8% 22%
Number of respondents indicating they were aware of Community Palliative Care Network Leaflet
54 68% of respondents
72, 74% 6%
Number of respondents indicating they were not aware of Community Palliative Care Network Leaflet
25 32% of respondents
25, 26% 6%
Number of respondents who confirmed JIC medicines available from their GP Practice for palliative care patients
(Responses – 39) 35, 90%
75, 82% -8% May be due to increased awareness of JIC Process but will monitor this over the next 6 months.
What influences staff choice of Community Pharmacy for Palliative Care prescriptions?
46% - Stock availability
18% - Relationship with Community pharmacist
18% - Proximity to base
69% - Stock availability
52% - Relationship with pharmacist
43% - Proximity to base
Number of respondents to survey willing to be contacted again in future to assess level of service improvements during the Palliative Care Pharmacy project.
15 N/A due to closure of project
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The following table lists Palliative Care Pharmaceutical Service issues and
suggestions for areas of good practice to improve Palliative Care Pharmaceutical service identified through the baseline survey May to July 2018.
Base line Survey End of project Survey Issues with Palliative Care Pharmaceutical service
• Poor stock/supply availability and specifically in the context of Islands;
• Poor JIC medicine Stock control e.g. stock insufficient to replenish syringe driver
• Poor completion of Palliative Care Prescriptions. Errors included: (wrong doses, drug not written up as a controlled drug)
• Lack of prioritization of palliative care prescriptions by community pharmacies
• Distance to community pharmacy with limited prescription collection and delivery services. Often if delivery service available usually only once a week.
• OoH access and number of locum pharmacists and doctors and not knowing patients
• OoH doctors no longer carrying palliative care medicine
• MDT communication particularly out of hours (interface of care and handover)
• ‘In an out of hours setting it is sometimes difficult to source some palliative care JIC medicines resulting in having to phone pharmacies in advance before advising patient's family on which pharmacy to attend. This includes pharmacies that are named palliative care pharmacies’
• ‘Sundays are problematic. Rarely have stock of common palliative medicines required for JIC or T34, therefore families need to travel to Kilmarnock if on a Sunday.’ - DN
• ‘We tend to go to Palliative drug carrying pharmacies who can respond quickly to patients' needs. Weekends can be problematic so more important for staff to ensure JIC meds being discussed and dispensed to ensure these are available in patient’s homes to allow staff to administer medicines timeously. End of life care should be seamless in nature with the full multi-disciplinary team being involved to make it seamless’ - DN
• ‘Staff not given priority when attending a pharmacy to collect drugs for palliative care patients. Staff often have to wait while routine prescriptions are dealt with. Staff do not wish to jump the queue but when you have a patient waiting for an end of life interventions - time is of the essence. ‘-DN
• One respondent indicated that: “Good experiences only from local pharmacy when accessing palliative medicines with no issues at all everyone helpful, knowledgeable, go the extra mile for their patients, nurses and provide a good service.’
Suggestions for areas of good practice to improve Palliative Care Pharmaceutical service
• ePCS should be started at point of prescribing anticipatory medicine
• Named coordinator available for
palliative care patients
• Use of a palliative care card as per
cancer card
• Awareness of use of anticipatory care plans and inclusion of anticipatory scripts
• A Sunday opening pharmacy should be added to the Palliative Care Pharmacy Network list in Irvine to prevent having to travel to get palliative medicines.
• Highlight to pharmacy staff to contact local DN’s to advise them they have a palliative script and it will be prioritised.
• Protocols need to be developed by individual practices on how to deal with
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Base line Survey End of project Survey • Provision of regular clinical updates
e.g. awareness of infusion doses v breakthrough doses; awareness of use of subcutaneous fluids in community can prevent admission
• Provision of alerts in regards to
problems with stock availability and
alternatives
• Named receptionist for palliative care
patients
• OoH doctors no longer carry palliative
care medicine
palliative prescriptions as part of training sessions.
• List of medicines updated carried by Out of Hours team updated to reflect Palliative Care Guidelines.
• WhatsApp group set up with Community Pharmacist Network, Specialist Pharmacist, Project Team and Hospice Community Nursing team to give information on stock shortages and a platform to source medicines amongst the network.
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Appendix 3: Survey Monkey Responses June/July 2019 The following provides details of responses from community teams in regards to any issues staff experienced in accessing palliative care medicines in the last year. Question: We would like to know of any issues you have experienced in accessing palliative care medicines in the last year; please summarised your experience below: Community team responses:
• In an out of hours setting it is sometimes difficult to source some palliative care just in case medicines which results in having to phone Community Pharmacies in advance before advising the patient's family on which Community pharmacy to attend. This includes those Community Pharmacies that are named palliative care pharmacies.
• We are a dispensing GP practice - we do not normally use Community Pharmacies
• No real issues raised. We did not see a need in our area for the JIC bags - sorry! Seems like a lot of work for minimal clinical benefit.
• No DNs available to give prn medicines between 7am and 9.30am. Out of hrs staff won’t come from their base during this time then in hrs staff are left to do insulins. It can take a few hours for DN to attend out of hours. No local Community Pharmacy service on a Sunday.
• Sundays are very problematic. Local Community Pharmacy rarely has a stock of common palliative care medicines required for JIC or T34, therefore families need to travel to Kilmarnock on a Sunday.
• Some pharmacies don't always have the medicines required and because they have half dispensed the prescription are disinclined to hand it back to allow access to other pharmacy.
• Service has improved as more use of JIC meds for anticipating need
• Sometimes locating larger dosage quantities can be difficult when using medicines in syringe drivers.
• We tend to go to palliative drug carrying Community pharmacies who can respond quickly to our patients' needs. In essence that is what they need but weekends can be problematic so it is more important to ensure JIC medicines are discussed and dispensed ensuring these are in the patient’s home to allow us to administer timeously. End of life care should be seamless in nature with the full multi-disciplinary team being involved to make it seamless.
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• Recent difficulties have occurred with Levomepromazine and Midazolam.
• Not given priority when attending local community Pharmacy when collecting drugs for palliative patient. We often have to wait while routine prescriptions are dealt with. Not wishing to jump the queue but when you have a patient waiting on end of life interventions time is of the essence
• Locally we do not have any choice of Community pharmacy. Community Pharmacy is not always well stocked with choice of drugs and usually you need at least 36 hours for an order to arrive or longer at weekends and public holidays. The local Community Pharmacy closes at 1pm on a Saturday and reopens at 9am Monday morning. This can be an issue hence we are very aware of stock and JIC medicines being available promptly.
• Good experiences only from local pharmacy when accessing palliative care medicines, no issues at all everyone is helpful, knowledgeable, go the extra mile for their patients. A good service.
• Delay in accessing medicines if going to local Community Pharmacy.
• Sometime issue getting some strengths of palliative care drug.
• Diamorphine amps have been an ongoing supply issue.
• Oxynorm injections 20mg were out of stock from our main wholesale. Alliance had it in stock but would not issue it as we do not have a full account. Phoenix could not even tell me if it was in stock or not as I do not have a full account. I phoned round a few pharmacies and managed to get a supply for the patient's husband to collect. This took me at least one hour out of my busy afternoon. The shop I work for is not a palliative care pharmacy and to be honest I found some of the large company network pharmacies unhelpful. Independent contractors actually understand and know what I am talking about!
• I'm based on Arran. Most issues are as the result of manufacturing problems or ferry issues. We try to plan ahead as far possible.
• Shortage of buscopan recently, now seems to be rectified
• Often drugs are out of stock. Local Community Pharmacy do not acknowledge the urgency of the required drugs, and do not endeavour to dispense medicines quickly. Patient’s relatives often have to try different pharmacies to obtain medicines.
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Appendix 4: Meetings attended to raise awareness of project The following tables list the number of awareness raising meetings and training events carried out during the course of the Palliative Care Pharmacy project. Type of Meeting Number of Meetings and Who Attended NHS Ayrshire & Arran Palliative Care Steering Group
3 held. Attended by Project Lead and Pharmacy Advisor
Oversight Group Meetings 4 held; attended by Project Lead plus Pharmacy Advisor
Project Team Meetings 4 held, attended by all Project Team members JIC SLWG 2 held, attended by Pharmacy Advisor and 1 Palliative
Care Pharmacy champion National Conferences 2 attended by members of Project Team
Prescribing Advisor Meetings 3 attended by members of Project Team (North, South, East areas)
Senior Prescribing Advisor Meetings 2 attended by Pharmacy Advisor Prescribing “Huddles” 3 attended by members Project Team (East HSCP area)
4 attended by members Project Team (South HSCP area) 1 attended by members Project Team (North HSCP area)
ADTC 2 meetings attended, one by the Project Lead and one by the Pharmacy Advisor
Area Pharmacy Group Meetings 2 attended by all members of the Project Team RPS Palliative Care event 1 attended by all members of the Project Team Area Practice Manager Meetings 2 attended by South and North Palliative Care
Champions GP Practice Meetings 37 attended by Palliative Care Champions Community Pharmacy Visits 51 visited by Palliative Care Champions and Pharmacy
Advisor Care Home Forums 4 attended by Palliative Care Champions and Pharmacy
Advisor Patient/Public Meeting 1 attended by South Palliative Care Champion AUCS 1 attended by North Palliative Care Champion
Community Kardex DN meetings 6 attended by Palliative Care Champions and Pharmacy Advisor
ACP Meetings 2 attended by East Palliative Care Champion District Nurse Professional Leads Meetings
2 attended by project Lead and Pharmacy Advisor
District Nurse Lead Meetings 2 attended by Pharmacy Advisor District Nurse area Meetings 1 (South HSCP) attended by Pharmacy Advisor
1 (North HSCP) attended by Project Lead and North Palliative Care Champion 2 (East HSCP) attended by Project Lead and East Palliative Care Champion
Community Pharmacy Ayrshire and Arran Contractor Meetings
2 attended by Project Lead
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Training Event Type Number of Events Network Community Pharmacy training 2 held (September 2018 and March 2019);
both attended by Project Team Practice Pharmacist training day 1 held (May 2019); attended by Project Team MMS LES 1 held (June 2019); session delivered by
Pharmacy Advisor and Palliative Care Champions. Second session in September 2019 delivered by Specialist Pharmacist
GP Staff training 4 delivered by South Palliative Care Champion (South HSCP)
CP staff training 3 delivered by South Palliative Care Champion (South HSCP)
Boots Information Evening 1 held ; session delivered by North Palliative Care Champion
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Appendix 5: Information sharing from Palliative Care Register Meeting to Regular Community Pharmacy
Information Checklist for GPCP/PSP at Practice Palliative Care Meeting: Addition of Patient to Palliative Care Register
Action Comments Has Patient been added to the Practice Palliative Care Register?
Ensure patient’s preferred Community Pharmacy has been added to the patient’s record in the practice.
Ensure the patient’s preferred Community Pharmacy has been notified via the secure Pharmacy Clinical Mailbox with the key information on the Community Pharmacy Palliative Care Information Form, including:
• Patient/Carer contact details
• Diagnosis
• Prognosis (if appropriate)
• Social Issues (lives alone, carer, etc.)
• DN contact details
• Hospice Nurse involvement/contact details
• Just in Case Medicines instigated? If so, ensure added to the patient’s eKIS. Ensure JIC medicines are reviewed regularly and updated appropriately after future meetings. Inform patient’s Community Pharmacy of any changes in medicines.
Does patient have an understanding of current medicines? Is there a requirement for input from the Community Pharmacist with information about medicines or services that the Pharmacy can provide to assist e.g. delivery, etc.?
Polypharmacy review required?
Check for information on any potential palliative medicine supply issues.
Is there a significant change in patient’s condition that the Community Pharmacist should be updated about?
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Appendix 6: Community Pharmacy Palliative Care Patient Information Form
The following patient from our GP Practice has recently been added to the Practice Palliative Care Register. Please treat the following information carefully and add appropriately to the patient’s PMR in the pharmacy to allow a more tailored service to be provided to the patient and their family at this difficult time. Any queries or issues please contact: Pharmacist Name: ………………………………………………………………………………………. Telephone or email: ……………………………………………………………………………………..
Patient Name
CHI Address
Contact Details of Patient or Carer
Patient: Carer:
Diagnosis
Prognosis (if appropriate)
Social Issues Lives alone / has carer/family involvement / family dynamics if appropriate.
District Nurse Patient known to DN Team: Yes / No Actively involved with patient: Yes / No If Yes which DN Hub:
Hospice Specialist Nurse involvement Yes / No If Yes : Name / Contact
Just In Case Medicines set up: Yes / No
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Appendix 7: Resources developed during project The following palliative care resources have been developed during the project and can be found on the Ayrshire & Arran Community Pharmacy website.
• Get it Right First Time! Improving Palliative Care Services Project Leaflet
• Desk Blotter – Opioid safety, sample controlled drug prescription, pharmacy network medicine list.
• Midazolam injection prescribing advice – A5 notepad and A7 post it notes
• Opioid conversion chart – produced as a mouse mat and A5 card
• Provide safe and effective palliative care – produced as a mouse mat
• Just in Case Medicines – produced as a mouse mat and A5 card
• Opioid safety card – produced as a thermos mug and pen pot
• Community Pharmacy resource folder
• Palliative Care prescribing aid/sample controlled drug prescription – produced as an A5 card
Many of the resources were developed from existing resources produced by NHS Greater Glasgow and Clyde with kind permission from Elayne Harris, Macmillan Area Palliative Care Pharmacist, and NES.
