The Winterbourne Medicines Programme Zoe Lord, Improvement Manager, Patient Safety Team, NHS Improving Quality Presentation from the Annual Residential Higher Trainee Intellectual Disability Conference 6 & 7 November 2014, Thistle Hotel, Manchester @NHSIQ #winterbourne_meds @ZoeLord1

1. Winterbourne
Medicines Programme
@NHSIQ #winterbourne_meds @ZoeLord1
Improving health outcomes across England by providing improvement and change expertise

2. • Who we are and where we’ve come from!
• Who we’re working with and what we’re up to!
• Findings

3. A national response to Winterbourne View Hospital
“7.31 We have heard deep concerns about over-use of
antipsychotic and antidepressant medicines.
Health professionals caring for people with learning
disabilities should assess and keep under review the
medicines requirements for each individual patient to
determine the best course of action for that patient, taking
into account the views of the person if possible and their
family and/or carer. Services should have systems and
policies in place to ensure that this is done safely and in a
timely manner and should carry out regular audits of
medication prescribing and management, involving
pharmacists, doctors and nurses.”

4. Programme Board and Reference Group
• Chaired by Dr Keith Ridge
• Family / Carers
• Department of Health
• NHS England
• NHS Improving Quality
• Royal Colleges across professions
• Care Quality Commission
• Independent sector
• Charities

5. Aim of the Winterbourne Medicines
Programme
Safe, appropriate and optimised use of medication
for people with learning disabilities whose behaviour
can challenge

7. Programme Objectives:
1. Ensure the service user is central to the work.
2. To review and develop a deep understanding of issues
around current medication processes.
3. To identify and share notable practice.
4. To identify a method of measuring change and
improvement.
5. Test new ways of working to improve process where
appropriate.
6. To improve awareness of the issues around medication.

8. Working in partnership with:
• Northumberland Tyne and Wear NHS Foundation Trust
• Cheshire and Wirral Partnership NHS Foundation Trust
• South West London and St Georges Mental Health Trust
• Sussex Partnership NHS Foundation Trust
• Hertfordshire Partnership Foundation Trust
• Devon Partnership NHS Trust

9. Community of Practice…
• 6C’s Website - www.6cs.england.nhs.uk
• Blogs
• Research Papers
• Documents & Publications
• News Articles
• Links and websites
• Forums
• Hot topics via webex!
• Quality Improvement Training

11. Ministerial Support
“I am very pleased to support the NHS Improving Quality
launch of the Winterbourne View Medicines Programme.
We know that inappropriate medication is a significant
problem across the country.
This programme through its project sites and
community of practice will help drive
improvement in safe and appropriate medication.
I look forward to seeing progress in this area.”
Norman Lamb MP, Minister of State for Care and Support

12. Message from Dominic Slowie,
National Clinical Director for Learning Disability, NHS England
“Far too many people have their behavioural problems
managed with anti-psychotics. The Learning Disability
Census highlighted that there are huge numbers of
people on anti-psychotic medication who haven’t got a
psychiatric diagnosis.
I see this as an infringement, or abuse of people’s human
rights. I am really looking forward to the findings of the
pilot in order to improve the care, and experiences of
care for people with learning disabilities.”

13. Early findings…
• Reasons for Prescribing
• Information
• Pathway
• Skills and Culture

14. Reasons for prescribing
• There appears to be complex reasons for prescribing –
requested by a variety of people including parents, carers, care
homes, schools etc
• Lack of alternative therapies that would mitigate the need for
some medication use.
• Medication sometimes seen as ‘the answer’
• “Reactive” service
• Current resource constraints and their impact on safe and
appropriate prescribing

15. Information
• Lack of data and awareness of the current case load and prescribing data
for challenging behaviour
• The diagnosis of challenging behaviour is not always clear.
• Lack of information about the medication including risks, evidence base,
benefits and side effects - the individual, families and care staff.
• Need to acknowledge what is going on around the prescription of
medication – i.e. no other services, families wanting meds...
• Lack of information re: medication history to inform clinical decisions.
• Lack of individualised information for clients
• Lack of detailed analysis of recording of use of PRN medication pre, during
and post admission

16. Pathway
• Lack of clear pathway for initiation and monitoring of
medication
• Lack of timely structured review
• Repeat prescriptions without face to face review
• Monitoring of side effects.
• No standardised guidance for the integration of
pharmacological and non pharmacological approaches
• Not enough joint working on medication issues between
community and inpatient services
• Ensuring flow through the service - discharging back to the
GP

17. Skills & Culture
• There appears to be a culture not to challenge
prescribing decisions.
• Off licence use and multiple prescribing of same drug
category is common.
• Lack of improvement knowledge and expertise to
provide the continuous improvement of services.
• Minimal clinical pharmacy expertise and input to support
prescribing and review

18. Partnership Sites

19. Northumberland Tyne and Wear NHS
Foundation Trust
• Adult Community Services
• Gathering a baseline data on number of adults with CB on anti-psychotics,
mood stabilisers anti-depressants and
benzodiazepines
• Development of standardised pathway for prescribing
• Integration with and development of non pharmacological
pathways (e.g. Positive Behaviour Support pathway for CB)
• Develop way of measuring clinical outcomes and audit pathway

20. Cheshire and Wirral Partnership NHS
Foundation Trust
• Adult Community Services
• Benchmark current practice
• Implement CB pathway
• Meet quality standards specified in CB pathway
• To prevent inappropriate use of medication to manage people with
challenging behaviour.

21. South West London and St. Georges
Mental Health Trust
• Children and Young People Community services
• Clear auditable care pathway for initiation and monitoring of
medication as part of an overall management plan
• Development of structures/ systems to support timely reviews of
medication use
• Promote wider understanding of appropriate use of medication
amongst parents , carers and other agencies
• Develop literature and monitoring tools to support self-management
when appropriate

22. Devon Partnership NHS Trust
• Adult community Team
• Specialist Pharmacists
• Ensure medicines optimisation
• Increase understanding about medication
• Creation of a Pharmacy risk tool (‘traffic light’ system for triage)
• Medication reviews by specialist Pharmacists

23. Sussex Partnership NHS Foundation
Trust
• 10 bedded assessment and intervention service for adults
• Increased understanding of prescribing and use of
medication
• Detailed analysis and monitoring of PRN usage
• Listen and act on stories from carers and clients about
experiences regarding medication
• Knowledge and awareness of how they can improve

24. Hertfordshire Partnership University NHS
Foundation Trust
• Adult Community Services
• Develop a standard template for functional analysis and
motivational assessment
• Develop a pathway to manage challenging behaviour
• Work with primary care to improve referral into the service

25. To conclude…
• Overview of Winterbourne Medicines
Programme
• Community of practice
And to leave you with…