The Community Pharmacy Wales response to The Health, Social Care and Sport Committee inquiry into

The use of anti-psychotic medication in care homes

Date: April 2017

Contact Details

Russell Goodway

Chief Executive

Community Pharmacy Wales

3^rd Floor, Caspian Point 2

Caspian Way

CARDIFF, CF10 4DQ

Tel: XXXXXXXXXXX

E-Mail XXXXXXXXXXXXXXXXXXXXXXXX

Part 1: Introduction

Community Pharmacy Wales (CPW) represents community pharmacy on NHS matters and seeks to ensure that the best possible services, provided by pharmacy contractors in Wales, are available through NHS Wales. It is the body recognised by the Welsh Assembly Government in accordance with Sections 83 and 85 National Health Service (Wales) Act 2006 as ‘representative of persons providing pharmaceutical services’.

CPW represents all 717 community pharmacy contractors in Wales. These include all the major pharmacy multiples as well as independent businesses. Contractors are located in high streets, town centres and villages across Wales as well as in the major metropolitan centres and edge of town retail parks.

CPW is pleased that the Committee is looking at the important issue of the prescribing, management and use of anti-psychotic medication in care homes. Even with the one to one support provided to residents in a care home, the frail elderly remain a vulnerable group of patients. As the demands of an ageing population continue to grow and NHS funding comes under greater pressure the temptation to turn to medication as a cheap and convenient solution to the management of behavioural and psychological issues in people living with dementia, will become even more significant over time.

Part 2: Specific comments relating to the Terms of Reference for the Inquiry

CPW has been asked to submit information relating to the specific terms of reference of the inquiry.

Item 1: The use of anti-psychotic medication in care home settings, and the ways in which its inappropriate use could be reduced.

CPW is concerned that, as the anti-psychotic problem has grown, it has coincided with a decrease in the commissioning of community pharmacy care home support services and a decrease in pharmacist input into the management of medicines in care homes in general.

CPW fully supports the principles contained in Your Care, Your Medicines that:

“Patients with supported living needs, whether living independently in their own homes or in a care home setting, must benefit from access to the pharmacy team to help manage their medicines effectively and to maintain their health and wellbeing.’’

The effective prescribing and use of medicines remains the backbone of modern healthcare and CPW believe that, as pharmacists are the experts in medicines, pharmacists should be involved in all situations where medicines are prescribed, supplied and administered irrespective of the residential status of the patient.

Over a number of years CPW has witnessed the steady decommissioning of Community Pharmacy Care Home Support Services and this removal of much needed support has coincided with the Care and Social Services Inspectorate Wales (CSSIW) policy decision to no longer directly employ pharmacists within the team.

Against a background of growing evidence of medication errors in care homes, and inappropriate use of antipsychotic medication, CPW is extremely concerned that at the very time care homes require greater support in managing medicines, the support available to care homes from community pharmacy teams has virtually disappeared.

CPW would ask the Health, Social Care and Sport Committee to review this situation as a matter of urgency and to ensure that all care homes receive regular community pharmacist advice and input into medicines management processes and medicines administration training for their staff..

Item 2: The availability of data on the prescribing of anti-psychotics in care homes, to understand prevalence and patterns of use.

CPW is not aware of the data sources relating to the prescribing and use of anti-psychotics in care homes but suspects that data may not be simple to access. CPW would suggest that care home support services are commissioned from community pharmacy for all care homes and that the CPW template service is amended to include a more detailed review on the use of anti-psychotics and the capture and sharing of relevant data on prescribing and use.

If there is a will in either Welsh Government or its health boards for a specific anti-psychotic medication support service from community pharmacies, CPW is happy to work with partners on the design of the service.

Item 3: Prescribing practices, including implementation of clinical guidance and medication reviews.

All care homes will receive their medication from a community pharmacy of their choice and it is common for the majority of pharmacies supplying care homes to offer some level of medicines management support to care homes. This arrangement however is a private arrangement between the care home and the supplying pharmacy and as a result the nature of the support provided will vary considerably and there is no standardisation of the support provided.

CPW would recommend that, irrespective of the supply arrangements between community pharmacies and care homes, NHS Wales ensures that a more structured and formal community pharmacy care home support service is commissioned from the supplying pharmacy. In this way regular structured visits would take place, the relationship between the care home staff and the pharmacy team would be allowed to develop over time and medicines management and prescribing in areas such as anti-psychotics would be routinely monitored.

Item 4: Provision of alternative (non-pharmacological) treatment options.

There are several types of cognitive therapy that could benefit people with dementia such as cognitive stimulation activities, group-based activities, reminiscence therapy and cognitive rehabilitation. While it is important to explore alternative therapies either as first line treatments or as adjuncts to medication, these services will need to be provided by experts in these services and are outside of the skills and expertise of community pharmacists to provide.

Item 5: Training for health and care staff to support the provision of person-centred care for care home residents living with dementia.

CPW fully recognises that while a structured review of medicines management processes will help to reduce less than optimal care of dementia, the real gains will be made by improving the knowledge and expertise of the health and care staff involved in the management of the patient and the provision of their medication on a daily basis.

Community pharmacy teams were widely involved in the training of health and care staff in medicines administration, however this now happens on an adhoc basis following the decommissioning of the care home service.

It is for this reason that CPW has included the training of health and care staff as one element of their template service.

CPW stands ready to work with health or social care providers to tailor a pharmacy service to meet their specific needs which could well include more focused training on the management of people with dementia.

Item 6: Identifying best practice, and the effectiveness of initiatives introduced so far to reduce inappropriate prescribing of anti-psychotics.

NICE guidelines recommend that the prescribing of anti-psychotic medication should be reviewed every three months. CPW understands that this is not currently the case in the majority of situations. In response, CPW would recommend that a three monthly audit of the use of anti-psychotic medication is undertaken by the supplying community pharmacy as part of the care home support service. This change would ensure that regular reminders are in place when a patient requires a review. In addition data from pharmacy care home visits would then be available to stakeholders on a national basis to support national quality standards.

Item 7: The use of anti-psychotic medication for people with dementia in other types of care settings.

The Discharge Medicines review Service has been amended so that it now covers the discharge to and from any care setting. This change has not been widely recognised and CPW would recommend that a community pharmacy DMR is built into the care pathway for all transfers of care.

The sound medicines management support and person centred care, encompassed in the community pharmacy care home service, can be tailored to meet the needs of any individual care setting as the pharmacists knowledge and skills are transferrable. Pharmacists as the experts in medicines should be the professionals that undertake all medicines management interventions.

Part 3: Conclusion

CPW would recommend that the Health, Social Care and Sport Committee ask the Welsh Government to ensure that arrangements are put in place for all care homes to receive a regular, structured, audit and advice visit, from the community pharmacy that supplies their medication and that a three-monthly audit of anti-psychotic prescribing is part of that review.

CPW agree that the content of this response can be made public.

CPW welcomes communication in either English or Welsh.

For acknowledgement and further Contact: