How pharmacy teams are helping to reduce harm from high risk medicines – Mark Easton

Posted on November 12, 2018

Measton In Scotland, one in five adults are dispensed five or more medicines at any one time and there are 4 million prescribing errors occurring in primary care every year. With a pharmacy almost on every high street, the numbers involved are huge which is why improving safety in pharmacy, particularly around high risk medicines, is a vital piece of work.

As a community pharmacist and the National Pharmacist Clinical Lead for the Scottish Patient Safety Programme, I’m working with pharmacies to help improve safety.

A few years ago, I became involved in some pilot work within NHS Grampian as part of the Scottish Patient Safety Programme (SPSP) Pharmacy in Primary Care Collaborative, which was funded by The Health Foundation.

We tested a pharmacy Patient Safety Climate Survey, which produces a ‘snapshot’ of the safety culture in a pharmacy. It is designed to start a conversation about patient safety and provide a focus on where pharmacies can make improvements. We also tested care bundles for warfarin and for non-steroidal anti-inflammatory drugs (NSAIDs), which are a range of medicines that can relieve pain, reduce inflammation, and bring down a high temperature. These can include medicines such as aspirin and ibuprofen. NSAIDs are widely available on prescription and across the counter. However, this class of drugs is associated with more emergency hospital admissions due to adverse drug reactions than any other class of medicine. Some UK studies have shown that almost 30% of all adverse drug reaction related hospital admissions are linked to NSAIDs and Scottish data indicates that NSAIDs are implicated in over 50% of all bleed related hospital admissions and 60% of deaths due to bleeds. As both the bleed risk and the Acute Kidney Injury (AKI) risk are linked to NSAIDs, these outcomes are predictable, and therefor potentially preventable.

We discovered that pharmacies undertaking the Pharmacy Patient Safety Climate Survey led to conversations about patient safety and a focus on where pharmacies can make improvements. As a result, some pharmacies introduced a daily communication huddle or a communication record book. These in turn led to improvements in key safety and patient information being shared and disseminated more effectively, while other pharmacy teams improved their data collection around ‘near misses’. This led to a better focus on areas of potential harm and improved training.

The Pharmacy Patient Safety Climate Survey is now available to every community pharmacy team in Scotland through the national pharmacy contract, meaning that people all over Scotland are receiving safer care from their pharmacy.

“We discovered that pharmacies undertaking the Pharmacy Patient Safety Climate Survey led to conversations about patient safety and a focus on where pharmacies can make improvements. As a result, some pharmacies introduced a daily communication huddle or a communication record book. These in turn led to improvements in key safety and patient information being shared and disseminated more effectively.”

This improvement drive was further developed in a large piece of work that I have been involved in this year which has seen the roll out of an NSAIDs Pharmacy Pack.

We knew that there were clear ways to improve care. For example, informing people to take NSAIDs with or after food reduces the risk of gastrointestinal side effects .We knew that earlier recognition by patients of the side effects allows action to be taken before they develop into something more serious. We also knew that raising awareness among patients of the medicine sick day rules can reduce the risk of acute kidney injury, as a result of a dehydrating illness.

To help pharmacies prevent adverse drug reactions, the NSAIDs care bundles were developed into the NSAIDs Pharmacy Pack, which gives clear guidance and improvement resources to help reduce gastric bleeding and acute kidney injury.

Pharmacy staff who are using the pack have reported that they are having better quality conversations with patients, and are informing them of the ‘medicine sick day rules’ which is to stop taking certain medicines if they have a dehydrating illness and restart their medication when they are well again. Before many patients were unaware of this key information. An unintended result of the better quality conversations has been that patients are willing to share additional key information relevant to their health which the pharmacist was previously unaware of, this has the potential to significantly improve the safe delivery of pharmaceutical care.

“To help pharmacies prevent adverse drug reactions, the NSAIDs care bundles were developed into the NSAIDs Pharmacy Pack, which gives clear guidance and improvement resources to help reduce gastric bleeding and acute kidney injury.”

One patient who has been prescribed NSAIDs told us that he had previously had an episode of sickness and became acutely unwell spending several days in hospital due to the reaction of his sickness with his medication. He said: “I was picking up my prescription and the pharmacist gave me a little card, this told me what to do if I had another dehydrating illness. Sometime later, I had another episode of sickness, but I remembered the card. As a heart failure patient you have it drilled into you that you must take your medication, but I followed the instructions on the card and I stopped taking the NSAIDs medication. I then became better. So, that little card made a big difference, to me as I didn’t have to spend days in hospital again.”

The NSAIDs Pharmacy Pack has now been distributed to every community pharmacy in Scotland and is supporting pharmacy teams to provide key safety messages to patients and customers whenever NSAIDs are dispensed or purchased, which will make a real difference to people’s health outcomes.

I’m looking forward to continuing to build on safety work by supporting pharmacists and pharmacy technicians in their improvement journey, and through the development of new models of care in GP practices and through better use of prescribing data, leading to better integration of pharmaceutical care across the primary care sector.

Mark Easton is National Clinical Lead (Pharmacist) at the ihub Primary Care Improvement Portfolio.

More information about the Pharmacy Safety Climate Survey is available by visiting the ihub website

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Creating standards that give people a voice – Fiona Wardell

Posted on November 6, 2018

Fiona Blog Pic In my role as Standards and Indicators Lead for Healthcare Improvement Scotland, I’m sometimes asked, “What impact do standards have?”

On hearing this question, two key answers spring to mind: the quality of health and social care services that our standards work to improve, and also the people who use those services and the impact our standards can have on their lives.

But, first of all, let me explain what we mean by standards.

A set of standards is primarily a document setting out what people who use services should experience, and how organisations and services can demonstrate how they have met these standards. So they impact on the planning, design and delivery of services, and support both national consistency and improvement. And with our commitment to ensure they are focused on real outcomes, they have huge potential to impact on people’s experience of care and support. When we develop standards for health services (and more recently social care services), we work with experts (including those who are experts due to their experience of particular services) from across Scotland. Services and people, therefore, are closely connected.

“With our standards for people who have experienced rape, sexual assault and child sexual abuse, already we are seeing improvements in care and support with compassion and responsive care driving changes in the training of staff.”

Take the development of our neurological care standards as an example. A key driver for Sue Ryder championing for our organisation to develop standards for people living with neurological conditions was their belief that our standards positively impact on bringing about changes and improvements in the delivery of care and support. This expectation was founded in part through our work on HIV, where our standards have led to direct improvements in care and support for people living with HIV in Scotland, such as the development of integrated care pathways, which tell care providers, people using services and their carers, what should be expected at any point along a journey of care. NHS boards welcomed them as an opportunity to focus on the key quality issues relating to HIV care.

Similarly, with our standards for people who have experienced rape, sexual assault and child sexual abuse, already we are seeing improvements in care and support with compassion and responsive care driving changes in the training of staff. For example, work is being undertaken to recruit and train more female forensic examiners which would enable people’s request for a female examiner to be fulfilled. Another example is our work to develop the Health and Social Care standards, which included targeted engagement with young care experienced children. As a direct result of their feedback, the standards were revised and updated to include the importance of feeling ‘valued, loved and secure’.

A vital part of our standards development process is reaching out to ‘seldom heard’ groups to capture their feedback, and to use this feedback to further develop our standards. Every comment is heard. Every comment is responded to. This week I met with survivors of child sexual abuse to hear their views and ensure the things that we think are important and have identified as priorities in our indicators, matter to them. In the summer, when we were consulting on our pregnancy and newborn screening standards, we met with parents and carers of children born with fetal anomalies. Again, we wanted to hear from them, first hand, to make sure our standards are focusing on the things that are important. And we’re sharing all these comments with our development groups and ensuring that our standards are revised to reflect this feedback.

“When we were consulting on our pregnancy and newborn screening standards, we met with parents and carers of children born with fetal anomalies. Again, we wanted to hear from them, first hand, to make sure our standards are focusing on the things that are important.”

And for me, this is a really important area of ‘impact’. Our standards reflect and echo the voices and experiences of people who use services. They give people the opportunity to help shape what high quality care looks like. And that feedback sits alongside evidence, practice and professional judgement. Through this approach, we connect with people with lived experience (and their families), we build relationships, raise awareness of our work, the work of our organisation and the value of collaborative working. When we evaluate our processes there is a constant theme saying, “We felt heard”.

Moreover, following publication of our standards for people who have experienced rape, sexual assault and child sexual abuse, we received very positive feedback from individuals who could see their specific suggestions and comments had been incorporated throughout the document. For example, one young woman had noted during consultation the importance of being able to have a shower, a cup of tea and replacement clothing after her forensic examination. She contacted us to say how grateful and proud she was to see her words included in the standards. An unexpected impact, but imperative to delivering truly person-centred care.

But in thinking about the impact on standards, I’m also acutely aware of the impact that they have on me personally. Hearing someone say, “Thank you for listening. I hope my story makes something better for someone else” is a gift. It keeps me enthused, motivated, connected to my work and also connected to the impact we can have on real people and their lives.

Dr Fiona Wardell is Standards and Indicators Lead at Healthcare Improvement Scotland

Visit the Healthcare Improvement Scotland website for more information on the range of standards we produce.

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With every challenge comes opportunity – Ruth Glassborow

Posted on October 11, 2018

A fresh perspective on Scotland’s progress in improving and redesigning health and social care

Ruth-3711-Edit We know the challenges facing our health and social care system are, and will continue to be, significant. They are well understood; increasing demand, ongoing difficulties recruiting to a range of posts, and an ever more challenging financial context.

When helping providers improve care it can be easy to feel daunted by the challenges as they can seem so difficult to address. So recently I was fascinated to see our context through others’ eyes.

Over the last year, through the support of the Health Foundation, I’ve been privileged to participate in Sciana, a new European network of Healthcare Leaders.

To say I was surprised when some colleagues from another European country described their main challenge as too much money in their system is an understatement. And the reason why they described it as a challenge: they have no incentive to change and they know that the current system is not fit for purpose for today’s health and care needs.

It gave me a new perspective on our financial challenges as they are enabling a much needed redesign of our health and social care system. It reminded me of a quote from an Integration Joint Board (IJB) Chief Officer (CO) “Crises and challenges have created the sense of urgency and the willingness to think the unthinkable that allows us to tackle the wicked issues”.

“We have proved that we can do change at scale in Scotland”

This rings very true to me as, in the midst of our challenges, we also have so much to celebrate. The improvement and redesign work happening across Scotland every single day is really impressive. Healthcare Improvement Scotland’s ihub has just published our latest Impact Report which details just some of the fantastic success stories taking place across health and social care in Scotland.

Through the Scottish Patient Safety Programme (SPSP), we have proved that we can do change at scale in Scotland. This year we are celebrating 10 successful years of SPSP and the data around safety work speaks for itself.

But it is worth pointing out what we have learned about how that success has been created:

Relentless focus on skilling up those who deliver care in quality improvement techniques
The development of national learning systems which bring those working on common improvement challenges together to share learning and problem solve
Person-centred, evidence and data informed improvement work.
The political support for an approach which takes time initially, but delivers sustainable results at scale in the longer term.

Yet, when we set up the ihub at Healthcare Improvement Scotland, we were clear that the nature of the challenges meant that we needed to go even further. In addition to our continuous improvement approach we needed to also focus on system and service redesign. We believe that both are vital if we are to deliver the transformation of health and social care that we all aspire to and so desperately need.

Relationships are the glue that holds our system together. So all our work is co-designed, co-owned and co-delivered with partners – with the aim of building local improvement capacity to meet local need. A recent count of organisations we actively worked in partnership with during 2017-18 highlighted an incredible 117 separate organisations. And thanks to the work of programmes such as the Children and Young People Improvement Collaborative and NHS Education for Scotland’s Quality Improvement training programmes we now have quality improvement expertise that has been built up not just in health but also in the wider social care and educational environments.

“We actively worked in partnership with an incredible 117 separate organisations during 2017-18”

Our collective response in challenging conditions is aided by the fact that we all share the same simple goal – better health and wellbeing outcomes for people in Scotland.

One look at the stories in the Impact Report and we can see what is possible. There are amazing people in every service in Scotland working tirelessly every day to deliver and improve our health and social care services; sometimes in very challenging circumstances. I often hear comments highlighting that we are delivering improvement in Scotland despite the challenging context; hearing from colleagues in other countries has got me wondering if maybe we are delivering such exciting innovations precisely because of the challenging context.

What for me is unquestionable is that we wouldn’t be achieving any of this without the dedication and commitment of those involved in supporting and delivering health and social care across Scotland. It leaves me confident that whether it is because of, or despite of, our circumstances, by working together we will continue to find solutions that deliver better outcomes for people in Scotland.

Ruth Glassborow is Director of Improvement with Healthcare Improvement Scotland.

Click here to access the The ihub Impact Report.

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Our Death Certification Review Service is helping drive improvement in how doctors record information on deaths – George Fernie

Posted on October 3, 2018

George Fernie Blog We recently published the third Death Certification Review Service annual report. The report highlights that, since the Death Certification Review Service was established as part of Healthcare Improvement Scotland in 2015, there has been a significant reduction in errors made by doctors in the information they complete when someone dies.

In fact, accuracy errors by certifying doctors have reduced by more than a third – 37% to be precise – since the service was introduced to help improve the quality and accuracy of Medical Certificates of Cause of Death (MCCD).

An MCCD is the form that must be completed by a certifying doctor when someone dies in Scotland. The MCCD provides a permanent legal record of the death, records information about the death (including the cause of death) and allows the death to be registered.

The Death Certification Review Service checks the quality and accuracy of MCCDS in order to improve the way that information about deaths is recorded.

We review approximately 10% of all deaths, with MCCDs randomly selected for review by an algorithm developed by National Records of Scotland. Some deaths require to be reported to the Procurator Fiscal and are therefore not reviewed by the service.

“In fact, accuracy errors by certifying doctors have reduced by more than a third – 37% to be precise – since the service was introduced to help improve the quality and accuracy of Medical Certificates of Cause of Death.”

Reviews of MCCDs are carried out by medical reviewers, all of whom are trained and experienced doctors both from a general practice and secondary care background.

The review process enables the medical reviewer to speak to the certifying doctor about the certificate and case history. The purpose of the review is to determine if the MCCD completion is in order rather than look at the quality of care provided to the deceased prior to their death.

In 2017-2018, the Death Certification Review Service found that 27.6% of MCCDs reviewed were ‘not in order’. This compares to figures for 2015-2016 when 43.9% of MCCDs reviewed were found to be ‘not in order’. The overall improvement between 2015 and 2018 represents a 37% reduction in ‘not in order’ cases.

Of those MCCDs found to be ‘not in order’ in 2017-2018, 93% had minor errors such as a spelling mistake, lack of specific detail or missing contributory information in the second part of the certificate.

Only 7% of MCCDs had major errors such as omission of hazards, e.g. pacemakers, or an incorrect cause of death and required a replacement MCCD to be produced.

It’s very pleasing to see that the Death Certification Review Service is having such a positive impact on improving the accuracy of MCCDs in Scotland.

While the vast majority of errors that we see in MCCDs are minor, it is nevertheless important that we continue to drive improvements as bereaved families want to be assured that all of the information relating to the death of their loved one is as accurate as possible.

Improving the quality and accuracy of MCCDs will also lead to better public health information and contribute to safer clinical practice.

We saw a good example of this last winter we used our data to identify an upsurge in winter deaths and requested a temporary suspension of the requirement to automatically report deaths from influenza to the Procurator Fiscal. This removed a layer of administration and helped to alleviate pressure on medical staff during the peak winter period. This was the focus of my previous blog, from March 2018.

“While the vast majority of errors that we see in MCCDs are minor, it is nevertheless important that we continue to drive improvements as bereaved families want to be assured that all of the information relating to the death of their loved one is as accurate as possible.”

In addition to carrying out reviews, the Death Certification Review Service has also developed a number of educational tools to support improvement including producing guidance for certifying doctors and developing eLearning modules in collaboration with NHS Education for Scotland.

The service continues to work successfully in collaboration with our partner organisations: National Records of Scotland, NHS24, National Services Scotland and NHS Education for Scotland, in addition to wider stakeholders, and public partners.

Together we have helped improve the quality and accuracy of MCCDs across Scotland and our focus continues to be to ensure that these quality improvements have minimal adverse impact on the families of those bereaved.

George Fernie is Senior Medical Reviewer with the Death Certification Review Service.

Click here to access Healthcare Improvement Scotland’s Death Certification Review Service Annual Report 2017-2018.

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How sharing intelligence can help keep people safe – Donald Morrison

Posted on September 28, 2018

Donald Morrison Blog A number of years ago I was watching the news on TV and there was a tragic report about a child who had died as result of domestic abuse. Scrolling on the TV screen was a list of the numerous occasions when this child had come into contact with health or social care services. The pressure these services were working under was acknowledged, but the question remained: why did these services not communicate better with each other to see what was happening to this child and to step in? How did they miss the signs?

As well as feeling sad and frustrated, it got me thinking about my own work at Healthcare Improvement Scotland. Was there anything more I could do to help avoid issues arising in our healthcare system by helping people to communicate more openly and effectively? This was also one of the points made by Robert Francis QC in 2013 when he reported the findings from the public inquiry into Mid Staffordshire Foundation NHS Trust. He talked about the need for better sharing – within and among national agencies – of potentially serious concerns about healthcare systems. This would help ensure that concerns about quality of care are better understood and acted upon as early as possible.

It’s good to talk

That’s why we established the Sharing Intelligence for Health & Care Group, a partnership between seven national agencies that enables them to share and consider intelligence about care systems across Scotland. Our main objective is to ensure that, when any of the seven agencies have a potentially serious concern about a care system, this is shared and acted upon appropriately. Sharing concerns at the right time can help identify emerging problems which can then be acted upon.

“Sharing intelligence must start at home. Our own organisation has grown over the last few years and we now host a broad spectrum of knowledge, expertise and experience. “

In August we issued our third annual summary report. Over the last year, on the basis of intelligence shared within the group, some of the organisations responded to concerns raised about mental health services in Tayside, as well as concerns about the training environment for doctors in general (internal) medicine at University Hospital Ayr. Both these concerns resulted in reviews by Healthcare Improvement Scotland and recommendations for improvements. We also heard many positive things, despite pressures on the care system, these include examples of high quality services, and also areas where improvement has been made. In addition, we heard repeatedly of instances where NHS boards had responded well to the findings from external reviews, even when these sometimes drew attention to challenging issues.

Sharing intelligence within our own organisation

Sharing intelligence must start at home. Our own organisation has grown over the last few years and we now host a broad spectrum of knowledge, expertise and experience. Our many parts, one purpose ethos certainly rings true for me and I chair a meeting every two months at which colleagues from Healthcare Improvement Scotland’s different teams get together to discuss and share what we’ve learned about the quality of care.

“It’s really important that we nurture a culture and environment where colleagues feel safe sharing information, including about potentially serious concerns. We also need to make sure that we’re looking at the most relevant pieces of data and information that we hold.”

We focus on two or three NHS boards at each meeting, and the focus is very much on learning together. It feels right to me that we’ve now got this forum to bring together colleagues from our different teams to talk about our fundamental purpose to improve the quality of care.

These conversations feed into the meetings of the wider Sharing Intelligence for Health & Care Group.

How will this work make a difference?

If this intelligence sharing work is really going to add value then I think there are different aspects that need to work well. It’s really important that we nurture a culture and environment where colleagues feel safe sharing information, including about potentially serious concerns.

We also need to make sure that we’re looking at the most relevant pieces of data and information that we hold.

I think we’ve made a solid start to our intelligence sharing work, and we now need to build on this. I was pleased to see that a recent independent evaluation that we commissioned of our Sharing Intelligence for Health & Care Group work reached a similar conclusion.

How did they miss that? A thing of the past

A recent Guardian photograph captures the essence of the need for intelligence sharing work. In the centre of the picture is a photographer sitting on an African plain and looking through the viewfinder of a long lens camera, waiting patiently to snap some wildlife action. Unbeknown to the photographer, not far behind him are two enormous rhinoceros getting amorous with each other. The caption: how did you miss that?!

Hopefully, through the work that we’re doing with other agencies, and the work within our own organisation, we can look back on this photograph as a historical curio, a memory of the problems that we used to face. It will take time to get there, but when keeping people safe within the care system is the prize, it’s vital that we all keep talking and sharing, openly and honestly.

Donald Morrison is Head of Data, Measurement & Business Intelligence with Healthcare Improvement Scotland

Click here to read the latest Sharing Intelligence for Health & Care Group Annual Report.

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Developing a community driven health and social care system on the Orkney Islands – Zaid Tariq

Posted on September 20, 2018

Zaid Border The Orkney Islands are unique in Scotland’s health and social care system. Home to around 21,000 people, and spread over 70 isles, these are mostly rural communities, diverse in size and setting, with fewer than 20 residents on some of the smaller islands.

And while this can complicate the delivery of joined up care, what struck me on my first visit to the islands was the passion and keenness everyone I spoke to had for improving health and wellbeing for the people there. Whether working in statutory services or the third and independent sector, they were all saying and wanting the same things.

The challenge for the Health and Social Care Partnership (HSCP) is how to develop a more singular, flexible and community-driven approach that matches their health and social care resources with community needs and priorities.

With that in mind, the HSCP asked for support as they considered different approaches to commissioning care.

“The challenge for the Health and Social Care Partnership is how to develop a more singular, flexible and community-driven approach that matches their health and social care resources with community needs and priorities.”

We initially facilitated a learning session with strategic managers on best practice and community priorities. There was clearly already very good tacit understanding of the lay of the land, which is a great place to start from.

From these discussions it became clear that a shared visual understanding of the current structure of health and social care services could enable local conversations around optimising how resources, assets and ultimately people connect on the Orkney Islands.

As a bespoke way to respond to this, our team used a technique called Integrated Systems Mapping (ISM). Working with the Health and Care Partnership team, the local authority, and third sector organisations, we spent several months building a picture of the various connections between the Orkney Islands’ current health and social care services.

We asked ourselves the question: how do we work together and build relationships to make better use of our resources?

Co-production with the partnership is key to this process and important for our future aims and ambitions to improve health and social care and wellbeing for the people of Orkney. By identifying local solutions to local needs, community is placed at the heart of the integrated health and social care system.

The map helps present something which is complex in a clear and accessible way, which is something which hadn’t been done before – this includes cross-sector adult and children’s health and care resources and Orkney’s community assets. This whole system view enables Orkney HSCP to facilitate local conversations around how the totality of Orkney Island’s health and care resources and community assets could be optimised to meet its populations needs in the future.

The map is ultimately a strategic tool that can be used to encourage conversations with all the relevant people, to think about how resources are used and distributed. By capturing and visualising clearly on one page the totality of the health and care system, it should help build a consensus locally on what needs to change, what can be refined, and what should be invested in further.

John Trainor, Head of Health and Community Care with Orkney Islands HSCP, was pleased with the technique and its results, commenting: “ISM has pulled the intelligence together in a way we haven’t done before, and it is a really useful way to present and share with others.”

In parallel to this, we’ve been working with the Care Inspectorate, Scottish Social Services Council, and others, to share learning around the Neighbourhood Care model.

“We are continuing to work with the HSCP to design working practices that are community supported, test new models of care and build on the learning from the Integrated Systems Map work.”

Based on Buurtzorg, a Dutch approach to holistic neighbourhood care, this model offers more flexible ways of working, presents opportunities for more non-formal care providers, greater self-management for workers, and the use of funds to better meet individual and service outcomes in line with self-directed support and person-centred care.

We hope this will help shape a new health and social care system for the Orkney Islands.

As I mentioned, the Orkney Islands are unique, relying on few people to have or share multiple roles in the community. Flexibility is a welcome foundation for them. For a small island community, inward investment is vital to support a thriving local economy, to support the development of integrated services, and to retain a flexible workforce.

We are continuing to work with the HSCP to design working practices that are community supported, test new models of care and build on the learning from the Integrated Systems Map work.

These approaches are a more sustainable, long-term way to address the challenges and opportunities around health and social care, in Orkney and potentially across Scotland.

For the partners and Orkney, the next step is to embrace these challenges, to build on what makes them unique. This is the spirit and the strength I saw in their communities.

Zaid Tariq is Strategic Planning Portfolio Lead with Healthcare Improvement Scotland

More information

Video – Zaid Tariq on developing a community driven health and social care system on the Orkney Islands

For more information visit the ihub website.

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The Rule of Rescue – Richard Norris

Posted on September 17, 2018

What does the story of 12 boys and their football coach rescued from an underground cave in Thailand and decisions made in Scotland about allocating healthcare resources have in common?

Many people will be aware of the recent story in the media about the rescue of 12 boys and their football coach who were trapped in an underground cave in Thailand. Huge resources were devoted to rescuing them, although there is no reliable estimate of how much the concerted rescue efforts cost. Nobody (to my knowledge) raised the issue of cost or questioned whether the amount of resource being expended could be used in better ways.

And yet, more commonly, when we are examining how we spend healthcare resource, a very major consideration is whether we are spending money effectively, i.e. getting the most benefit for the money we spend.

The term ‘Rule of Rescue’ was coined by Albert Jonsen, (a biomedical ethicist and author) in 1986. By this he was referring to the sense of duty we feel, as human beings, to aid or rescue others who are clearly in peril. There are many examples of this ‘rule’ in operation – rescuing people lost on mountains, from burning buildings, in shipwrecks. But this principle also extends to healthcare, as Jonsen himself says:

“Our moral response to the imminence of death demands that we rescue the doomed. We throw a rope to the drowning, rush into burning buildings to snatch the entrapped, dispatch teams to search for the snowbound. This rescue morality spills over into medical care, where our ropes are artificial hearts, our rush is the mobile critical care unit, our teams the transplant services.”

“And yet, more commonly, when we are examining how we spend healthcare resource, a very major consideration is whether we are spending money effectively, i.e. getting the most benefit for the money we spend.”

But what happens if there is a limit to the amount of resource we can expend? Unlike in emergency situations where an instant and energetic, and sometimes ad hoc, response is required (as in the Thai cave rescue) medical rescues tend to take place within a much more structured and managed environment, where interventions are calculated, within a matrix of other possible interventions, opportunity costs, and limitations to knowledge and resource.

If the Rule of Rescue is our intuitive sense of duty to save those in peril, modern health care services, medical knowledge and technology, with its constant discovery and innovation, have created a situation in which our instincts, unfettered, could mean our entire economic output (GDP) is used in facilitating rescue. This is because the situation of peril, or avoidable death, in a medical setting, is far less a rare emergency event, and much more an ever present reality, a drama being played out in hospitals and non-medical settings all around us every day. And new technological developments, including medicines, are creating new Rule of Rescue situations, where, a few years ago, no rescue would have been possible.

So how do we decide what amount of resources to devote to rescue? Health economists have devised an approach called the QALY (quality of life year) to compare the benefits of diverse treatments, including medicines, with their costs. However, this formal calculation, based on comparing different treatments to identify the most cost-effective, can become controversial when used to make assessments on treatments for conditions that appear to evoke our ‘rule of rescue’ moral instinct, for example, expensive new drug treatments for those severely ill, but which have limited effectiveness.

One ethical issue raised by the ‘Rule of Rescue’ is visibility, in the sense that we have to be aware that someone is in danger and there is a clear opportunity to try and save their life. If we prioritise interventions based on rescuing people who are clearly present and in visible peril, there is a risk that we neglect those who are in just as much peril, but for whatever reason, are not as present or visible to us.

In the professional health care world, based on costs and benefits and calculations about the efficacy of different treatments, it seems only natural to prioritise those approaches and treatments that seem to offer the most value. However, when decisions affect real lives, to some people this calculation can seem ‘out of sync’ with the moral intuition to rescue people in peril. There is a strong pull towards rescuing in a way that precludes the calculation of cost.

Although prioritising those healthcare treatments that offer the most benefit seems a statement of the obvious, the view that we should do our utmost to alleviate avoidable deaths or suffering also seems a statement of the obvious. In practice, these two ‘statements of the obvious’ can come into conflict when allocating healthcare resources to different areas and priorities. And this is before we get into other ethical issues regarding health care allocation, e.g. the strongly held view that there should be equity of access for all.

“only by continuing to be open, and questioning, and sensitive to the conflicting viewpoints and interests, can we be certain – not that we are making the right decisions – but that we are trying our best to make the fairest decisions. And that process involves being fully aware of the opportunity costs of decisions, i.e. not just having more transparency about a priority setting decision, but also about the alternative benefits we could have realised with the funding.”

One answer that can be given is that we engage with the public to understand how they would manage the trade-off that is necessary between our natural desire to rescue, and the limitation of resources we have to carry that out. Such studies that have been done suggest that although the public, just like the professionals, holds a variety of views, a reasonable proportion of the public would be prepared to spend more resource on ‘rescue’ than is justified under strict cost benefit calculations.

For example in 2006 the NICE (National Institute for Health and Care Excellence) Citizen Council looked at the Rule of Rescue and the majority (21 out of 27 members) decided that there are occasions where extra resources, over and above the level required under cost benefit calculations, should be provided, and developed a list of examples, including where there was the chance to avoid immediate loss of life. Importantly the Citizens Council felt that society’s worth could be diminished if ignoring the Rule of Rescue appeared as inhumane, and that there was a greater societal good provided by the Rule of Rescue, that went beyond the immediate benefits to particular people.

And in practice NICE does tolerate higher costs for end of life cases and in examples of rare or severe diseases. In Scotland, similarly, the Scottish Medicines Consortium applies additional flexibility in its decision making to medicines for rare conditions or for end of life conditions, where quite usually costs of medicines can be higher. Is this fair?

It could be argued that this is unfair to patients who miss out on treatments that they would have otherwise received, if we hadn’t spent the money on ‘rule of rescue’ cases. Quite often these patients are difficult to identify, and they may not know that they have missed out, or they may be statistical, hypothetical patients in the future rather than actual patients now. This may be ethically hard to justify, but when the public have been asked for their views on this, they tend to think that we have a greater duty to help those in need now rather than those potentially in need in the future. However, just like ethical experts, the public, when consulted, don’t give us easy answers or precise formulas for resolving these issues in practice. And the ‘future hypothetical patients’ point doesn’t answer the question of whether it is fair to patients who are also in need now, but for some reason miss out. One reason they may miss out is because they do not have strong advocates in the medical world or the media to argue their case.

There is probably no perfect formula or criteria for making these decisions. It feels uncomfortable precisely because there is no right or wrong answer. However only by continuing to be open, and questioning, and sensitive to the conflicting viewpoints and interests, can we be certain – not that we are making the right decisions – but that we are trying our best to make the fairest decisions. And that process involves being fully aware of the opportunity costs of decisions, i.e. not just having more transparency about a priority setting decision, but also about the alternative benefits we could have realised with the funding.

Richard Norris works for Healthcare Improvement Scotland and is a Honorary Fellow at the University of Edinburgh.

Categories: Uncategorized

How pharmacy teams are helping to reduce harm from high risk medicines – Mark Easton

Posted on November 12, 2018

“To help pharmacies prevent adverse drug reactions, the NSAIDs care bundles were developed into the NSAIDs Pharmacy Pack, which gives clear guidance and improvement resources to help reduce gastric bleeding and acute kidney injury.”

Creating standards that give people a voice – Fiona Wardell

Posted on November 6, 2018

“With our standards for people who have experienced rape, sexual assault and child sexual abuse, already we are seeing improvements in care and support with compassion and responsive care driving changes in the training of staff.”

“When we were consulting on our pregnancy and newborn screening standards, we met with parents and carers of children born with fetal anomalies. Again, we wanted to hear from them, first hand, to make sure our standards are focusing on the things that are important.”

With every challenge comes opportunity – Ruth Glassborow

Posted on October 11, 2018

A fresh perspective on Scotland’s progress in improving and redesigning health and social care

“We have proved that we can do change at scale in Scotland”

“We actively worked in partnership with an incredible 117 separate organisations during 2017-18”

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Posted on October 3, 2018

“In fact, accuracy errors by certifying doctors have reduced by more than a third ­– 37% to be precise – since the service was introduced to help improve the quality and accuracy of Medical Certificates of Cause of Death.”

“While the vast majority of errors that we see in MCCDs are minor, it is nevertheless important that we continue to drive improvements as bereaved families want to be assured that all of the information relating to the death of their loved one is as accurate as possible.”

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Posted on September 28, 2018

It’s good to talk

“Sharing intelligence must start at home. Our own organisation has grown over the last few years and we now host a broad spectrum of knowledge, expertise and experience. “

Sharing intelligence within our own organisation

“It’s really important that we nurture a culture and environment where colleagues feel safe sharing information, including about potentially serious concerns. We also need to make sure that we’re looking at the most relevant pieces of data and information that we hold.”

How will this work make a difference?

How did they miss that? A thing of the past

Developing a community driven health and social care system on the Orkney Islands – Zaid Tariq

Posted on September 20, 2018

“The challenge for the Health and Social Care Partnership is how to develop a more singular, flexible and community-driven approach that matches their health and social care resources with community needs and priorities.”

“We are continuing to work with the HSCP to design working practices that are community supported, test new models of care and build on the learning from the Integrated Systems Map work.”

More information

Video – Zaid Tariq on developing a community driven health and social care system on the Orkney Islands

The Rule of Rescue – Richard Norris

Posted on September 17, 2018

“And yet, more commonly, when we are examining how we spend healthcare resource, a very major consideration is whether we are spending money effectively, i.e. getting the most benefit for the money we spend.”

“In fact, accuracy errors by certifying doctors have reduced by more than a third – 37% to be precise – since the service was introduced to help improve the quality and accuracy of Medical Certificates of Cause of Death.”