Feature
Just keep taking the tablets...
Shamsul Alam and Myra Garrett explain how correcting patient misunderstanding can improve care, reduce the risk of harm—and save money into the bargain
Research has suggested that 150 tonnes of medicine are thrown away in England every year. It is difficult to calculate what percentage of this is a result of lack of patient information, but most agree the figure would be significant. This is, in principle, a preventable drain on NHS resources and deserves serious attention from commissioners and practitioners alike to achieve cost-effectiveness in prescribing.
East London and City health authority, using London Implementation Zone funds to develop co-working between community pharmacists (CPs) and Tower Hamlets health strategy group, a voluntary sector provider, is piloting ways to tackle patients’ misunderstanding and lack of knowledge of their prescribed treatments.
The project identified CPs as key members of the primary healthcare team and the pharmacy as a significant setting for informing and empowering users, especially when, as is increasingly the case, a consultation area is available. At the time of dispensing, CPs have the opportunity to clarify, reinforce and remind patients of the instructions of the prescriber.
The project targeted patients whose first language is not English, in the knowledge that a language barrier would cause them greater problems. Bilingual advocates were employed to work with CPs and users, and several approaches were used including domiciliary visits at the request of GPs, producing bilingual labels and translated materials, and organising information stalls and educational sessions with community groups.
The most specific and accurate information about patient misuse and misunderstanding of medications comes from the detailed recording of home visits carried out by the project. One CP and bilingual advocate visited 50 individual Bengali patients registered with GPs at an East London health centre. The role of the advocate in these visits was crucial to the two way communication needed to explore confusions over medications, explain the relationship between various illnesses and the relevant prescriptions, and ensure that advice was culturally appropriate and understood.
Despite widespread recognition that patients often do not know how to use their prescriptions or what they are for, these findings are shocking because of the extent and seriousness of the misunderstandings revealed. The documentation shows costly waste of prescribed medications, as well as a failure to provide relief and prevent even more costly episodes of illness, leading ultimately to the need for acute intervention.
“Accurate, accessible information is not only what patients need and ask for—it is also a powerful tool in the fight against waste in the prescribing budget”
The information also shows a worrying potential for poisoning and overdose. There are many factors at work in these situations which are exacerbated, but not satisfactorily explained, by a language difference between professionals and users. The case studies on this page give a snapshot of the sorts of problems regularly encountered by the community pharmacist.
The possibilities for commissioners to tackle the problems identified here may be limited, but are certainly worth exploring. Contract specifications may not be relevant since CPs’ and GPs’ status as independent contractors largely determines their relationships with the health authority. Although a number of incentives for changing practice are available for prescribers, there are few if any for community pharmacists.
But there are numerous ways of building on the professional good practice demonstrated in this and other projects. Among these are training, advice, support, networking and information sharing across the primary healthcare team, particularly enhancing the valuable role of the practice nurse. Preparing bilingual medication labels (which could be developed as integral to computerised labelling systems), as well as promoting CPs’ roles in information giving and trouble shooting has been shown through the project to be successful.
Posters displayed in surgeries and pharmacies in various community languages have been successful in encouraging patients to inquire about specific issues, such as effective use of asthma medications. Translated materials, both written and on audio tape, on commonly used preparations and appliances are also providing important information to non-English speakers targeted by this project.
Developing the role of the advocate and the empowerment of patients opens up another range of opportunities for exploration by commissioners. Such an approach lends itself to extending collaboration with voluntary sector groups which have direct access to large numbers of primary care service users. The advocate can alert users to the sort of information they need and then help put that information in their hands.
For example, developing a list of questions for patients to ask regarding every prescription, would encourage them to take more responsibility and can be supported by an advocate or community group when appropriate. (A sort of ‘pharmacy users’ charter’ perhaps?) GPs and CPs can encourage the distribution of such a list and other information on prescriptions as an additional tool in their efforts to ensure users play their full role in effective use of prescriptions.
Accurate, accessible information is not only what patients need and ask for — it is also a powerful tool in the fight against waste in the prescribing budget. While the initial responsibility for providing such information clearly lies with prescribers and practice staff, there is a significant role to be played by CPs, advocates and ultimately patients themselves l
x
Shamsul Alam and Myra Garrett work for Tower Hamlets health strategy groupThe community pharmacist’s casebook
Mr A and family
Mr A had a number of prescribed medications, including Zantac (antacid tablets), eye drops, Diamicron (diabetic medication) and preventive and reliever inhalers. He had misplaced his urine testing strips sometime ago. His wife had several prescriptions for stomach complaints and pain relief. The baby had an unfinished antibiotic prescription.
Mr A was taking Zantac early morning and not at night as prescribed. He was using his inhalers incorrectly and did not know the difference between the various types. He used them three to four times a day but still seemed to get breathless after the smallest physical effort, such as going to the toilet. The eye drops were not in the box so I could not check the date and Mr A did not know that they should be discarded four weeks after opening. He had two boxes of diabetic tablets — one from the GP labelled Diamicron and the same drug from the hospital labelled Gliclazide, the generic name. He was taking both thinking they were different.
Mrs A was taking Zantac and Cimetidine (both for ulcers) as she did not realise that they were prescribed at different times for the same condition. The antibiotic prescription for her baby was not kept in the refrigerator.
With the help of the Bengali advocate, I explained the purpose of the various medications and corrected Mr A’s inhalation technique. I advised Mr A to get more urine testing strips, explaining their importance in managing his diabetes, and to dispose of the eye drops.
Mr B and family
I found three courses of antibiotics — one unfinished, and two prescribed seven days earlier but still unopened — on the table. The names on the labels did not correspond to the family names, but we soon sorted out the right prescriptions for the right patient. Mr B had preventer and reliever inhalers and the children were also on asthma medications. Several prescriptions for ‘colds’ for children and adults were sorted by patient.
The antibiotics were used by all family members when they thought it necessary, but not in a regular way, and were stopped when the person felt better. Mr B used the asthma preventer often, but had no understanding of its purpose, and his technique showed that little, if any, medication reached the lungs.
We talked about the purpose, proper use and storage of antibiotics, and the importance of taking them regularly until finished. Since the liquid antibiotics had been kept in a warm room for some time, I recommended their disposal. I explained the difference between the various inhalers and demonstrated their proper use, and gave advice on physical activity and indoor environment in relation to asthma. I also suggested a volumetric inhalation aid for the children.
