A qualitative exploration of how pharmacy professionals in primary care utilise planned protected development time.

Background: With patients developing more complex healthcare and medicine needs, it is imperative pharmacy professionals enhance their knowledge and skills to enable an advanced level of pharmaceutical practice, improving service provision and supporting patient care. The UK Royal Pharmaceutical Society (RPS) is urging employers to incorporate protected time within the working week to facilitate this development. Currently protected development time (PDT) is not well established within the pharmacy profession and there is little qualitative data available about the utility of this. Objective: To explore how pharmacy professionals in primary care currently utilise planned protected 'development time' and their perception of this. Methods: One-to-one semi-structured interviews were conducted between February and March 2023 via Microsoft Teams® with pharmacists, pharmacy technicians (PTs) and pharmacy support workers (PSWs), working in a large Health board area in Scotland who had established PDT since August 2021. Interview recordings were transcribed verbatim and analysed using an inductive thematic framework approach. Results: Interviews were conducted with 13 participants (12 female); 6 pharmacists, 5 PTs and 2 PSWs. Five core themes were derived from the data: logistics, competing priorities, methods for development, inequalities and benefits. Participants utility of PDT was variable, most focused on self-development to improve clinical knowledge however, supporting the development of others often taking precedence. Disparities in utility and inequity of protection from service delivery were highlighted. All participants befitted from PDT reporting a self-assessed improvement in confidence and competence. Conclusion: The experience of participants who had PDT was typically perceived as positive including supporting development and improving wellbeing however, it fostered inequalities which needs addressing. Educational input is required to provide direction for development across all four pillars of professional practice; clinical practice, leadership, education and research, promoting advanced practice. Further research is required to assess the impact of PDT on health outcomes of the local population.

Public perceptions and experiences of the minor ailment service in community pharmacy in Scotland

BACKGROUND: The Minor Ailment Service (MAS) in Scottish community pharmacy allows eligible people to gain improved access to care by providing free treatment for self-limiting conditions. OBJECTIVE: To determine the perceptions and experiences of individuals using MAS and to quantify the potential impact on usage of other healthcare services. METHODS: A cross-sectional survey was conducted of patients accessing MAS across Scotland during June and July 2018. Questionnaire items included reasons for choosing treatment through MAS, which other services they may have accessed had MAS not been available, experiences of consultation, overall satisfaction, and perceived effectiveness of treatment. Those accessing MAS were given a study pack including an information sheet, pre-piloted questionnaire, and pre-paid return envelope. Participants had the option to consent to an optional one-week follow up questionnaire that focused on perceived effectiveness of treatment after seven days and any further access to healthcare services such as general practice, emergency departments or repeat pharmacy visits. RESULTS: There were 1,121 respondents to the initial questionnaire. Most reported 'convenient Location' as the main reason for their access to community pharmacy (n=748; 67.1%). If MAS had not been available, 59% (n=655) of participants reported that they would have accessed general practice for treatment of their minor ailment. Experience of consultations was also rated highly with all ten outcome measures scoring 'Excellent' overall. Satisfaction was reported positively with most participants reporting full satisfaction with the overall experience (n=960; 87.2%). At one-week follow up, 327 participants responded, over 85% (n=281) did not require further access to care to treat their minor ailment and 99.7% (n=326) said they would use MAS again. CONCLUSIONS: Positive perceptions and experiences of those using MAS demonstrate a highly regarded service in terms of satisfaction and experience of consultation. The capacity for MAS to impact on the use of higher-cost healthcare services is evidenced through the number of participants who reported these services as a point of access to care should community pharmacy not be available. This national evaluation demonstrates MAS to be a positively experienced service and outlines the factors determining access for treatment of minor ailments

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Public perceptions and experiences of the minor ailment service in community pharmacy in Scotland.

BACKGROUND: The Minor Ailment Service (MAS) in Scottish community pharmacy allows eligible people to gain improved access to care by providing free treatment for self-limiting conditions. OBJECTIVE: To determine the perceptions and experiences of individuals using MAS and to quantify the potential impact on usage of other healthcare services. METHODS: A cross-sectional survey was conducted of patients accessing MAS across Scotland during June and July 2018. Questionnaire items included reasons for choosing treatment through MAS, which other services they may have accessed had MAS not been available, experiences of consultation, overall satisfaction, and perceived effectiveness of treatment. Those accessing MAS were given a study pack including an information sheet, pre-piloted questionnaire, and pre-paid return envelope. Participants had the option to consent to an optional one-week follow up questionnaire that focused on perceived effectiveness of treatment after seven days and any further access to healthcare services such as general practice, emergency departments or repeat pharmacy visits. RESULTS: There were 1,121 respondents to the initial questionnaire. Most reported 'convenient Location' as the main reason for their access to community pharmacy (n=748; 67.1%). If MAS had not been available, 59% (n=655) of participants reported that they would have accessed general practice for treatment of their minor ailment. Experience of consultations was also rated highly with all ten outcome measures scoring 'Excellent' overall. Satisfaction was reported positively with most participants reporting full satisfaction with the overall experience (n=960; 87.2%). At one-week follow up, 327 participants responded, over 85% (n=281) did not require further access to care to treat their minor ailment and 99.7% (n=326) said they would use MAS again. CONCLUSIONS: Positive perceptions and experiences of those using MAS demonstrate a highly regarded service in terms of satisfaction and experience of consultation. The capacity for MAS to impact on the use of higher-cost healthcare services is evidenced through the number of participants who reported these services as a point of access to care should community pharmacy not be available. This national evaluation demonstrates MAS to be a positively experienced service and outlines the factors determining access for treatment of minor ailments.

A Qualitative Study Investigating the Barriers to the Implementation of the 'Sepsis Six Care Bundle' in Maternity Wards.

Background: In 2014, the Sepsis Six Care Bundle (SSCB) was introduced into a Scottish health region to improve patient outcomes. Poor compliance was demonstrated with the SSCB across different specialities. This study explored determinants of non-compliance with the SSCB in maternity wards. Methods: In-depth interviews were conducted with midwives in a single Scottish health region. Convenience sampling was used to recruit interviewees. The interviews were digitally recorded, transcribed verbatim, entered into NVivo software, and analysed using thematic analysis. Results: Thirteen face-to-face interviews were completed and lasted an average of 33 min. Three main barriers were identified to SSCB implementation; the difficulty of diagnosing sepsis, the suitability of the SSCB in a maternity setting as part of the pre-conditions phase, and the lack of staff training as part of the pre-implementation phase. Conclusion: The findings emphasize the importance of adapting improvement initiatives with sufficient preparation of staff in the rationale use to the context of care bundles.

Administration of a long-acting antipsychotic injection to a child while managing contraindicated polypharmacy interactions and transition between services.

Second-generation antipsychotics are used to treat a variety of psychiatric symptoms and illnesses as well as the behavioural aspects of various neurodevelopmental disorders. However, there is reluctance in using second-generation long-acting injectable antipsychotics in child psychiatry services. We present a case of a 12-year-old child whose presentation and medication regime warranted the use of aripiprazole long-acting injection against a backdrop of potential CYP P450 enzyme interactions as a consequence of polypharmacy. The case also describes the difficulties encountered working across different health sectors and agencies and highlights the ongoing need for skills-based Continuous Professional Development for Child and Adolescent Mental Health Services-based nursing staff.

Benzodiazepine and z-hypnotic prescribing from acute psychiatric inpatient discharge to long-term care in the community.

BACKGROUND: Benzodiazepine and z-hypnotic prescribing has slowly decreased over the past 20 years, however long-term chronic prescribing still occurs and is at odds with prescribing guidance. OBJECTIVES: To identify the pattern of benzodiazepine and z-hypnotic prescribing in psychiatric inpatients at discharge and 12 months post-discharge. METHODS: Retrospective observational longitudinal cohort study of patients admitted to two adult psychiatric wards between June and November 2012 (inclusive) who were discharged with a prescription for a benzodiazepine or z-hypnotic drug. Routinely collected prescription data available from NHS Scotland Prescribing Information System was used to identify and follow community prescribing of benzodiazepine and z-hypnotics for a 12 month period post-discharge. Data were entered in Excel® and further analysed using SPSS 23. Ethical approval was not required for this service evaluation however Caldicott Guardian approval was sought and granted. RESULTS: Eighty patients were admitted during the study period however only those patients with a single admission were included for analysis (n=74). Thirty per cent (22/74) of patients were prescribed a benzodiazepine or z-hypnotics at discharge; 14 of whom received 'long-term' benzodiazepine and z-hypnotics i.e. continued use over the 12 month period. Seven patients received a combination of anxiolytics and hypnotics (e.g., diazepam plus temazepam or zopiclone). Long-term use was associated with a non-significant increase in median benzodiazepine or z-hypnotic dose, expressed as diazepam equivalents. CONCLUSIONS: One in three patients were prescribed a benzodiazepine or z-hypnotics at discharge with 1 in 5 receiving continuous long-term treatment (prescriptions) for 12 months post-discharge. As chronic long-term B-Z prescribing and use still remains an issue, future strategies using routine patient-level prescribing data may support prescribers to review and minimise inappropriate long-term prescribing.

Benzodiazepine and z-hypnotic prescribing from acute psychiatric inpatient discharge to long-term care in the community

Background: Benzodiazepine and z-hypnotic prescribing has slowly decreased over the past 20 years, however long-term chronic prescribing still occurs and is at odds with prescribing guidance. Objectives: To identify the pattern of benzodiazepine and z-hypnotic prescribing in psychiatric inpatients at discharge and 12 months post-discharge. Methods: Retrospective observational longitudinal cohort study of patients admitted to two adult psychiatric wards between June and November 2012 (inclusive) who were discharged with a prescription for a benzodiazepine or z-hypnotic drug. Routinely collected prescription data available from NHS Scotland Prescribing Information System was used to identify and follow community prescribing of benzodiazepine and z-hypnotics for a 12 month period post-discharge. Data were entered in Excel® and further analysed using SPSS 23. Ethical approval was not required for this service evaluation however Caldicott Guardian approval was sought and granted. Results: Eighty patients were admitted during the study period however only those patients with a single admission were included for analysis (n=74). Thirty per cent (22/74) of patients were prescribed a benzodiazepine or z-hypnotics at discharge; 14 of whom received'long-term' benzodiazepine and z-hypnotics i.e. continued use over the 12 month period. Seven patients received a combination of anxiolytics and hypnotics (e.g., diazepam plus temazepam or zopiclone). Long-term use was associated with a non-significant increase in median benzodiazepine or z-hypnotic dose, expressed as diazepam equivalents. Conclusions: One in three patients were prescribed a benzodiazepine or z-hypnotics at discharge with 1 in 5 receiving continuous long-term treatment (prescriptions) for 12 months post-discharge. As chronic long-term B-Z prescribing and use still remains an issue, future strategies using routine patient-level prescribing data may support prescribers to review and minimise inappropriate long-term prescribing

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Developing a Model for Pharmaceutical Palliative Care in Rural Areas-Experience from Scotland.

Palliative care is increasingly delivered in the community but access to medicines, particularly 'out of hours' remains problematic. This paper describes the experience of developing a model to deliver pharmaceutical palliative care in rural Scotland via the MacMillan Rural Palliative Care Pharmacist Practitioner (MRPP) project. The focus of the service was better integration of the MRPP into different care settings and professional teams, and to develop educational resources for the wider MDT including Care Home and Social Care staff on medicine related issues in palliative care. A variety of integration activities are reported in the paper with advice on how to achieve this. Similarly, many resources were developed, including bespoke training on pharmaceutical matters for Care Home staff. The experience allowed for a three step service and sustainability model for community pharmacy palliative care services to be developed. Moving through the steps, the key roles and responsibilities of the MRPP gradually shift towards the local Community Pharmacist(s), with the MRPP starting from a locality-based hands-on role to a wider supportive facilitating role for local champions. It is acknowledged that successful delivery of the model is dependent on alignment of resources, infrastructure and local community support.

Benzodiazepine and z-hypnotic prescribing for older people in primary care: a cross-sectional population-based study.

BACKGROUND: Overall prescribing of benzodiazepines and z-hypnotics (B&Zs) has slowly reduced over the past 20 years. However, long-term prescribing still occurs, particularly among older people, and this is at odds with prescribing guidance. AIM: To compare prescribing of B&Zs between care home and non-care home residents ≥65 years old. DESIGN AND SETTING: Cross-sectional population-based study in primary care in Scotland. METHOD: National patient-level B&Z prescribing data, for all adults aged ≥65 years, were extracted from the Prescribing Information System (PIS) for the calendar year 2011. The PIS gives access to data for all NHS prescriptions dispensed in primary care in Scotland. Data were stratified by health board, residential status, sex, and age (65-74, 75-84, and ≥85 years). To minimise disclosure risk, data from smaller health boards were amalgamated according to geography, thereby reducing the number from 14 to 10 areas. RESULTS: A total of 17% (n = 879 492) of the Scottish population were aged ≥65 years, of which 3.7% (n = 32 368) were care home residents. In total, 12.1% (n = 106 412) of older people were prescribed one or more B&Z: 5.9% an anxiolytic, 7.5% a hypnotic, and 1.3% were prescribed both. B&Zs were prescribed to 28.4% (9199) of care home and 11.5% (97 213) of non-care home residents (relative risk = 2.88, 95% CI = 2.82 to 2.95, P<0.001). Estimated annual B&Z exposure reduced with increasing age of care home residents, whereas non-care home residents' exposure increased with age. CONCLUSION: B&Zs were commonly prescribed for older people, with care home residents approximately three times more likely to be prescribed B&Zs than non-care home residents. However, overall B&Z exposure among non-care home residents was found to rise with increasing age.

Profiling psychotropic discharge medication from a children's psychiatric ward.

Background Community prescribing of medication to treat psychiatric illness in children is increasing. However, details about medication prescribed at discharge from psychiatric inpatient services for children are scarce. Objectives Characterise the nature of psychotropic medication prescribed on discharge from a children's psychiatric ward over a 15-year period. Method Retrospective analysis of discharge summary letters of all discharges occurring between Jan 1997 to Dec 2012. Results 234 children (152 males and 82 females) were discharged with 117 (50%) prescribed psychotropic medication at discharge. 133 medicines were prescribed (stimulants n = 49, antipsychotics n = 31, antidepressants n = 22, mood stabilisers n = 1, other ADHD medication n = 11, melatonin n = 10, benzodiazepines n = 7, other n = 2). Risperidone was the most popular antipsychotic at a mean daily dose of 1 mg (range 0.25-4 mg). Fifty per cent were given an unlicensed medicine or a licensed drug was used in an unlicensed manner, of which risperidone was the most common (n = 14). Sleep disturbance and tics were most often treated using unlicensed/off label medication (n = 10). Conclusion Psychotropic medication is routinely used in inpatient children's services, with the majority of use confined to stimulants and atypical antipsychotics. Much of the antipsychotic use is for unlicensed indications or at unlicensed doses.

Mixing medication into foodstuffs: identifying the issues for paediatric nurses.

Medication is often mixed into soft foods to aid swallowing in children. However, this can alter the physical/chemical properties of the active drug. This study reports on the prevalence of the modification procedure, the nature of foodstuffs routinely used and factors which influence how the procedure is performed by nurses working in the National Health Service in Scotland. Mixed methods were employed encompassing an online self-administered questionnaire and semi-structured interviews. One hundred and eleven nurses participated, of whom 87% had modified medication prior to administration. Fruit juice (diluted and concentrated) and yoghurts were most commonly used. The interviews (i) identified the limitations of the procedure; (ii) explored the decision-making process; and (iii) confirmed the procedure was a last resort. This study intends to address some of the uncertainty surrounding the medicine modification procedure within the paediatric population.

Paediatric nurses' knowledge and practice of mixing medication into foodstuff.

OBJECTIVE: To investigate paediatric nurses' knowledge and understanding of potential drug stability issues caused by mixing medication into foodstuff. METHODS: Self completion of semi-structured questionnaires and face-to-face interviews. KEY FINDINGS: Fourteen paediatric mental health and 16 paediatric general nurses (response rate, 71%) were investigated. With the exception of one nurse, all others reported they had modified oral dosage forms, or had mixed medication with food, prior to administration. The most common foodstuffs were fruit yoghurts, diluting juice and (concentrated) fruit juices. More than half of both cohorts felt sufficiently trained in carrying out the procedure, but 27% did not feel sufficiently knowledgeable about drug stability issues. The in-depth interviews highlighted a knowledge deficit as to the nature of clinical problems that could result from performing the procedures and the associated professional liabilities. Some interviewees expressed reservations about the effectiveness of the dose when administered in this way. Co-mixing was perceived as a time-consuming process and preference was expressed for mixing the powdered dosage form into juice or a liquid rather than into solid foods. Several training issues were identified from this study, including more information about drug/food compatibilities and the need for standardised documentation around the procedures which could be implemented at the ward level. CONCLUSIONS: Co-mixing of medication into foodstuff is a common practice. The majority of nurses are unaware of potential drug stability/degradation issues and/or the clinical impact of these practices.

Effective delivery of pharmaceutical palliative care: challenges in the community pharmacy setting.

BACKGROUND: Medication, particularly analgesia, is an important component of palliative care. However, timely access to medication, particularly opioids, can become problematic for patients receiving palliative care in the community setting. In Scotland in 2009, NHS Greater Glasgow & Clyde Health Board (NHS GG&C), in partnership with Macmillan Cancer Support, established a programme to improve the local provision of pharmaceutical palliative care services with the appointment of Macmillan Pharmacist Facilitators. Researchers at the University of Strathclyde were commissioned to support the development and evaluation of this new service. We report the findings of this initial investigation into the provision of current palliative care services and outline an evidence-based action plan to support service improvement. METHODS AND RESULTS: Qualitative data were gathered using focus group interviews. Three key themes were identified: medication supply, communication, and education and training. CONCLUSIONS: The study findings have been used to develop an evidence-based action plan for the Macmillan Pharmacist Facilitators. This program of work is due for completion by December 2012.