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What is the ‘political paradox of rationing’ and can it be avoided? – Richard Norris

Posted on May 30, 2018

In my last blog (Do we spend too much money on medicines in Scotland?19.11.2017) I looked at the issue of whether we get the right balance in spending on healthcare treatments (assuming there is one). I suggested that whilst it is in everyone’s interest to have a transparent, open and fair system for allocating healthcare resources, this was very difficult to achieve in practice. One problem I mentioned was the issue of what is known as ‘the political paradox of rationing’ and whether this can be resolved. The ‘political paradox of rationing’ is a phrase that was coined to describe the outcome of efforts made in the 1990s by the state of Oregon in the USA to make publicly transparent decisions about what treatments…

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The right words are crucial to empower patients and the public – Karen Graham

Posted on May 17, 2018

Karen Graham We know there are huge benefits to patients, the public and health and care services if people are at the heart of the care they receive.

To achieve this, one element that is crucial is the importance of finding and using the right words that help build a meaningful connection between people and their care givers.

SIGN, part of Healthcare Improvement Scotland, produces guidelines for health and care professionals in Scotland on the best treatments that are available for a range of conditions, including asthma, heart disease, various forms of cancer, ADHD and a number of mental health conditions.

“For some time we have understood to the need to ensure patients and the public understand the guidelines. And since 2007 we’ve placed increasing importance on producing accessible patient-friendly versions of our advice that help inform people about their own condition and the care options open to them.”

Recently, we produced information for people living with Coronary Heart Disease (CHD) or who are at risk of CHD. Our information sought to inform people about their condition and empower them to take responsibility for aspects of their health.

Here are a couple of quotes from people living with CHD about the information we provided:

“I’ve never seen this kind of thing and it helped me understand. I’m at high risk of a heart attack so I’m really clear about what I can do now to be a bit healthier. It’s quite hard to eat the right things and get your exercise but this is realistic and gives helpful tips. My GP makes me feel like I’m to blame, but this explains things well.”

“After reading this I felt I would be more in control of my health. It has everything you need to know. I think this is really good information so you can then chat to your GP about it all. The style it is written in helps people to feel in control and you’re not getting told what to do.”

Patient versions of guidelines can act as a discussion aid to promote shared decision-making. Whether a person has autism or is being treated for a heart condition, people want to know that they have all the necessary information to make decisions about their care. Without support from accessible and reliable health information, it’s almost impossible for people to understand and take part in shared decision-making.

In 2016 we produced an advice booklet for children and young people on assessment and treatments for autism, a lifelong condition causing difficulties with social and communication skills and behaviour.

We heard from young people with autism to make sure their views were reflected in the advice. We visited schools and spoke to young people about their experiences of living with autism. They also told us it was the first time they had ever been asked what they thought!

“We’ve now produced around 30 patient-friendly versions of our guidelines and we continue to learn how to communicate effectively using words that patients, service users and members of the public understand and relate to. It’s a two-way process: we learn from the people we involve in our work and they learn to take control of their condition. In essence, they empower us to help to empower them.”

The more patient versions of guidelines we produce the more it becomes apparent just how important it is that the advice is understood by everyone involved. Health and care professionals increasingly request copies of these booklets for their clinics and patient groups order them for their information packs.

I would like to say a big Thank You to all those who take the time to tell us exactly what they think, who let us know what it’s like to be them and help us to connect meaningfully. Together we’re shifting the focus of care from what is done to patients, to what happens in collaboration with them – with meaningful words at the heart of the bridges we build.

To read our patient-friendly advice on a range of conditions, visit our website www.sign.ac.uk.

Karen Graham is Public Involvement Advisor at the Scottish Intercollegiate Guidelines Network (SIGN), part of Healthcare Improvement Scotland.

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Safeguarding antibiotics to preserve their use for future generations – Dr Andrew Seaton

Posted on May 15, 2018

20180514 SAPG chair Andrew Seaton Antimicrobial resistance and drug resistant infections are major public health issues which are already complicating treatment for many patients and posing significant threats to the future of healthcare. To address this growing global problem we must ensure that we ‘take good care’ of our available antibiotics through good antimicrobial stewardship.

Healthcare Improvement Scotland has a key role to play in establishing strong antimicrobial stewardship through the Scottish Antimicrobial Prescribing Group (SAPG). Established in 2008, SAPG works in collaboration with regional board Antimicrobial Management Teams (AMTs) and clinicians from a range of specialties across hospital and community settings. Together, we have made great progress in improving use of antibiotics and promoting optimal safe care of patients with infection.

About 80% of antibiotics are used in the community and the commonest reason for an antibiotic prescription is for a suspected respiratory tract (throat, ear or chest) infection. Many such infections are caused by viruses or are otherwise self-limiting so do not require antibiotic therapy. We continue to work with and support primary care teams in the recognition and management of those situations where symptomatic measures should be promoted over an antibiotic prescription.

“This collaborative work has paid off, with a 3.1% reduction in total antibiotic use between 2012 and 2016 and an 11.1% reduction specifically in primary care, the lowest point since 2004.”

In 2016, 29.0% of the population received at least one antibiotic prescription in primary care which was the lowest proportion since data became available in 2010.

SAPG’s work isn’t just about reducing antibiotic prescribing, it’s about improving prescribing to ensure better outcomes for patients and to minimise harm to individuals and wider society. A key measure of quality prescribing is choice of antibiotic following recommendations in local guidelines. In 2016, first line recommended antibiotics – the initial recommended treatment – accounted for 81.5% of antibiotic use in primary care, suggesting GPs and other prescribers are following local guidelines. In hospitals, improved use of antibiotics has had a significant and sustained impact on reducing Clostridium difficile in our most vulnerable patients. We have also been successful in introducing good practice recommendations for some of our most challenging infections and establishing safety monitoring processes for our most complex antibiotics.

“Antibiotic stewardship is everyone’s business and we all have our part to play.”

It is important that patients and the public are supported in their understanding of the difference between when an antibiotic is needed and when and how they should practice self-care. We take part in European Antibiotic Awareness Day (EAAD) every November to raise professional and public awareness of the problem of antimicrobial resistance/drug resistant infections and what everyone can do to use antibiotics more wisely. We also support the Antibiotic Guardian campaign developed by Public Health England, which encourages everyone to make a pledge about how they can personally help to make better use of antibiotics. To date over 2600 people (mainly healthcare workers) across Scotland have become Antibiotic Guardians. We aim to increase public participation in this programme through posters and leaflets in community pharmacies during EAAD. We also promote community pharmacies as the ‘first port of call’ for anyone with symptoms of infection for advice on symptom relief and whether they need to consult their GP.

Our current and future work is closely aligned with the Chief Medical Officer’s vision of Realising Realistic Medicine, the aim being to reduce harm, waste and variation in antibiotic prescribing practice and to develop individualised treatment for patients wherever possible. This includes clinical decision support tools available at the point of care to inform individual patient treatment decisions, national antimicrobial Quality Indicators and metrics to drive improvement in prescribing practice and Penicillin allergy review to develop a simple, easy to use algorithm within hospitals to support de-labelling of patients without a true allergy. One success we have had in this area is with our Antimicrobial Companion app, which gives practitioners quick and easy access to clinical guidance and supports decision making on antibiotic prescribing. Registered as a medical device with the Medicines and Healthcare products Regulatory Agency (MHRA), the app was developed in partnership with NHS Education for Scotland (NES) and with the input of clinicians from hospital and primary care practices across Scotland.

Although we have made progress, there is still much work to do to protect our population from antimicrobial resistance and drug resistant infections and to preserve our precious antibiotics for future generations. Our collaborative way of working, which has yielded these results, will continue to be central to everything we do.

Dr Andrew Seaton is the chair of SAPG and Infectious Diseases Consultant/AMT Lead at NHS Greater Glasgow and Clyde.

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The Scottish Patient Safety Programme: Celebrating 10 years of reducing harm and improving care – Joanne Matthews

Posted on May 3, 2018

In this landmark year of the NHS turning 70 and 50 years since the Social Work (Scotland) Act was introduced, the Scottish Patient Safety Programme (SPSP) is marking its own milestone – 10 years of improving safety.

Since its launch in 2008 the programme has expanded to support improvements in safety across a wide range of care settings and themes including Acute and Primary Care, Mental Health, Medicines, Maternity, Neonatal and Paediatric services. All of which have been underpinned by the robust application of quality improvement methodology to bring about significant change in outcomes across Scotland.

Central to these improvements has been the relentless focus on the programmes overall aim to improve the safety and reliability of care, reducing harm whenever care is delivered.

From patients and families, front line teams, the SPSP Programme Managers and Board Executive Sponsors to our SPSP national team within Healthcare Improvement Scotland’s ihub, this truly is a nationwide safety movement which continues to improve the quality and safety of care each day.

A decade of dedicated effort and collaboration at all levels of the system to support a culture of safety and learning, is evident through the sustained improvements being reported across the country:

21% reduction in mortality from sepsis since 2012
31% reduction in the cardiac arrest rate in hospitals 2013
31% reduction in the most severe pressure ulcers (Grade 2-4) since 2015
SPSP has contributed to a 19.5% reduction in the rate of stillbirths since 2013
89% reduction in Paediatric Ventilator Associated Pneumonia to date
20% reduction in self harm in acute mental health settings

And yet this is only a small glimpse of the improvements that have been made and in truth, impressive as they are, tell only part of the story. In our experience improving safety has resulted in improvements in many more aspects of quality. For example the 31 per cent drop in pressure ulcers is the equivalent to 46 fewer pressure ulcers a month. In reality that means fewer patients in hospitals are experiencing the pain and discomfort caused by this key harm, their length of stay is not extended because of the requirement for additional treatment which results in the avoidance of associated costs of approximately £184,000 per month (if all were a Grade 2 pressure ulcer).

The continued adaption of the SPSP offer to meet the needs of people and services within the evolving health and now social care context reflects the continued commitment to safety both locally and nationally. In 2008 it was not envisaged that we would have safety improvement programmes in dental practices and in care homes, but we now do. SPSP is now embedded within Healthcare Improvement Scotland’s Improvement Hub (ihub) supporting improvements across NHS boards and the new integration authorities.

As we start to consider what next for SPSP, it is important to reflect on the achievements so far, use the learning to inform our future approaches but l believe the aim of improving the safety and reliability of care, reducing harm whenever care is delivered will remain true to all involved.

Joanne Matthews is Head of Improvement and Safety at Healthcare Improvement Scotland.

Related content

Visit the SPSP10 section of the ihub website

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Making sure we all benefit from medicines that are both clinically and cost effective – Dr Alan MacDonald, Chairman – Scottish Medicines Consortium

Posted on May 1, 2018

We have witnessed a revolution in therapeutics in recent years. With every year we are able to treat more conditions than ever before. However we are also conscious that resources for health and social care face unprecedented pressures as people are able to live longer than previous generations.

NHSScotland spends over £1.67 billion a year on prescription medicines (around 14 per cent of overall healthcare spending), with one in five adults in Scotland being prescribed five or more medicines. So when it comes to accepting new medicines for routine use we need to be confident that those medicines are both clinically and cost effective.

The Scottish Medicines Consortium (SMC) is key to this. We assess the benefits of all new medicines compared to existing treatments and decide whether the cost can be justified.

In 2017 alone, we issued 100 pieces of advice, with 68% of those medicines being accepted for use by NHSScotland. The conditions we consider medicines for vary enormously.

For example, just last month we accepted medicines for paediatric onset short bowel syndrome (an extremely rare condition in which nutrients and fluids are not properly absorbed by the gut) hepatitis C, rheumatoid arthritis and plaque psoriasis.

If we consider the volume and range of advice issued over a 16 year period, we know the impact of our recommendations will have been felt by a large percentage of the population.

The views of patients and their carers are increasingly heard in our decision making: only they will know the reality of living with a condition. We take great care in the committee to understand the impact a new medicine might have on them before drawing a conclusion. Last year, our Public Involvement team actively engaged with 186 patient groups, resulting in 87% of our medicine appraisals including a patient group submission, compared to 65% in 2014. Enabling patient interest groups and the public to contribute to a discussion on the likely impact of a new medicine has enriched our deliberations and consequently the decisions committee members are able to make.

However, the reality is that we can’t say “yes” to all medicines that are presented to us. I can fully understand reaction from patients who are looking for hope in a new medicine becoming available when we do not recommend it for routine use. However the only way to make decisions in a way that is fair and equitable to all patients is to base them on balanced evidence that is presented to us by the company, patient groups and clinicians. And we have to take into account all patients who might need treatment, not just the ones who stand to be treated by the medicine under review. If patients and society benefit in the way that the evidence suggests, we will be spending valuable NHS resources wisely. If decisions are not based on objective assessment of the evidence, we run a very high risk of disappointing patients and the public who believe a medicine will help them. We will also be wasting precious resources.

The benefits to both the public and NHSScotland in operating this way are many. Before SMC was established, 14 individual local Area Drug and Therapeutics Committees (ADTCs) advised their respective NHS boards which products should be accepted for use in their area. The introduction of SMC in 2002 provided a single point of advice, reducing duplication of work and differences in availability of medicines across NHSScotland.

I believe the impact of SMC across Scotland has been enormous – I am confident that, by having one national point of advice for boards to follow, SMC has supported a fairer access to medicines across the country and in addition has saved NHSScotland a large administrative burden.

However, no successful operation can stand still and we continue to evolve, listening closely to patient voices and adapting to deal with a complex new medicines pipeline. Following reviews in 2013 and 2016, we have worked with stakeholders from the pharmaceutical industry, NHS and patient groups to constantly develop and review our processes. After the 2013 review, we were given a clear steer to increase access to medicines specifically for those people at the end of their lives and those for people with rare conditions. Since then, having built greater flexibility into our committee’s decision making process, more medicines that fall into these categories have been approved, with acceptances increasing from 48 per cent between November 2011 and October 2013 to 75 per cent between May 2014 and March 2016.

SMC’s work will continue to evolve as the importance of medicines as part of someone’s well-being will remain important. The work is challenging, but critical to ensuring the best use of new medicines in Scotland for both patients and the NHS.

Dr Alan MacDonald is Chairman of Scottish Medicines Consortium.

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