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Workshop1
When What Who
14.00-14.10 Welcome and scene setting Stephen Rogers
Amalin Dutt, Sandy Keen
14.10-14.30 Systems/design thinking Thomas Jun
14.30-15.30 Whole system
understanding and issue
identification
Group discussion
15.30-15.40 Risk thinking James Wards
15.40-16.10 Issue prioritisation Group discussion
16.10-16.30 Group feedback All
16.30-16.45 Issue prioritisation All
16.45-17.00 Summary and plans Amalin Dutt, Thomas Jun
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Project - Team
Project team
– Amalin Dutt: Head of Medicine management, Islington CCG
– Priyal Shah: Research pharmacist, Islington CCG
– Dr Stephen Rogers (Clinical lead): GP, Islington CCG
– Thomas Jun: Systems/design thinking, Loughborough University
– James Ward: Risk thinking, University of Cambridge
– Ran Bhamra: Lean thinking, Loughborough University
– Graham Martin: Implementation research, Leicester University
Leadership support (Sponsor)
– Avni Shah: Head of commissioning development, Islington CCG
– Jo Sauvage & Katie Coleman: Joint vice chair, Islington CCG
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Context - problems
• 80% of those aged ≥ 75 take medicines
• More than 1/3 of them take four or more medicines
• Medication-related hospital admission: 57 amongst
409 older people (around 14%)
• Islington has one of the highest emergency hospital
admission
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Context – Integrated Care Programme
1. Frail and Older people
Multi-disciplinary, GP and consultant leadership, and dementia and medication.
2. Self Care
Review of scale of training for professionals and support for patients and act on the patient
experience.
3. Long Term Condition Pathways: Diabetes, COPD and Heart failure
Primary care management with specialist support and pathway redesign for more responsive
care
4. Mental Health
Joining up mental and physical health services for better outcomes and using communities as an
asset
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Workshop - Purposes
• To develop ideas which you would never have
had if you are alone
• To challenge ourselves
• To learn new thinking and methods
• To have fun
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Three Workshops
1. To develop the whole system understanding
Top priority issues to be addressed
2. To develop solutions for improvement
Specific ideas to address the issues
3. To develop implementation plans
Detailed plans for idea implementation
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Methods to be used
• Systems thinking: Looking at big pictures
• Design thinking: Users, Doing Not just Talking
• Proactive risk thinking: Structured what-if
• Lean thinking: Flow thinking
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15. Criteria for the winning idea
• Short-term ideas (3 months) • Long-term ideas (5 years)
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√ Focused on Users’ Needs
√ Supporting Integrated Care
√ Cost-Effective
√ Sustainable
√ Ready-to-be–implemented √ Wide impact
26. Jeff Abbensetts
• Age: 77
• Ethnic Background: Afro Caribbean
• Residence: Live alone between Upper
Holloway and Crouch Hill (North Islington) on
the 2nd floor of a tower block (no lift)
• Family & Support Network: Grown-up children
who live Manchester visit once or twice a year;
he has limited interaction with other people
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• Hobbies & Leisure: quitted smoking a few years ago, reduced mobility
(scooter) and mostly TV watching
• Value: reduced motivation to continue with healthy lifestyle or
medication
27. Jeff Abbensetts
• Medical History
– COPE (Chronic Obstructive
Pulmonary disease)
– Type 2 Diabetes mellitus
– Hypertension
– Mild depression
• Current medication:
Delivered to patient’s home
each month by the local
pharmacist
29. Medication in a blister pack
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Medication Dosage
Atorvastatin 20 mg tablets (cholesterol) One tablet at night
Amlodipine 5 mg tablets (blood pressure) One tablet each morning
Clopidogrel 75 mg tablets (blood thinning)
One tablet each morning (with or after
food)
Sertraline 50 mg tablets (depression) One tablet each morning
Gliclazide 80 mg tablets (diabetes)
TWO tablets Twice daily (just before or
with food)
Metformin 500 mg tablets (diabetes)
TWO tablets THREE times a day (with or
after food)
Sitagliptin 100 mg tablets (diabetes) One tablet each morning
Folic acid 5mg tablets (supplement) One tablet each morning
30. Outside the blister pack
Medication Dosage
Calcium and vitamin D tablets Two tablets daily
Paracetamol 500 mg tablets (relief of
pain)
1-2 tablets four times a day when required
for pain
Tramadol 50 mg capsules (relief of pain)
One capsule four times a day when required
for pain
Tiotropium inhaler 18 microgram
inhalation capsule (shortness of breath)
One capsule inhaled each day via
handihaler
Budesonide / Formoterol 200/6
microgram inhaler (shortness of breath)
Inhale Two puffs twice daily
Salbutamol inhaler
(relief of breathlessness)
Two puffs when required for relief of
breathlessness
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31. Service
Interaction
- Jeff
Partnership
Primary Care Centre
(COPD clinic)
Hanley Primary Care Centre
(GP)
Social Worker
Ambulance Service
Community
Pharmacy
Service
user
Expert Patient
Programme
- Four weekly repeat
prescription
-Six monthly review
- Transportation to
the COPD clinic
- Prescription collection service
- Medicine delivery service
- Support for
Independent life
- Training support
for self-
management
of long term health
condition
- Monthly pulmonary
rehab
- once a day visit,
but not anymore
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Issues - Jeff
1. He feels that he has too many tablets to swallow in
the morning.
2. He finds it difficult to take his diabetic medication in
relation to meals because he does not eat regular
meals.
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Issues - Jeff
3. He was coping better when he had his carer to prompt
him to take his medication at regular times. Care
agency workers, however, are inconsistent in their
ways of prompting patient to take medication.
4. What is worse, he is no longer qualified for free
domiciliary care.
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Issues - Jeff
5. Some medicines start to stack up and are often wasted.
He usually ticks every medicine when he requests repeat
prescription. Pharmacy also delivers all the medicine
without checking how much medicines are left.
6. He once ran short of some medicines owing to his late
repeat prescription request (confusing 28 day supply)
and GP’s delay in issuing a repeat prescription.
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38. 38
- Patient takes medicine
Patient with low on medicine
When patient/carer does it him/herself
- Patient/carer fills in the repeat prescription slip
- Patient/carer drops the repeat prescription slip at GP (visit/call?)
- Patient/carer collects repeat prescription (within 48 hrs?)
- Patient/carer drops repeat prescription to pharmacy
When pharmacy has agreed to act on behalf of patient
(prescription collection service)
- Pharmacy contacts patient (every patient?)
- Pharmacy fills in the repeat prescription slip
- Pharmacy drops the repeat prescription slip to GP
- Pharmacy collects a repeat prescription from GP
Patient at home with sufficient medicine
New (repeat) prescription at pharmacy
Patient admitted
to hospital
When patient needs hospital care
- Patient goes to hospital
- Patient takes own medicine to hospital (?)
When patient ready to go home
- Hospital discharges patient
- Hospital provides medicine for 0/2/4 weeks?
- Hospital informs GP and pharmacy?
- Pharmacy checks prescription
- Pharmacy contacts GP for enquiry (if required)
- Pharmacy dispenses medicine
Patient seen
by GP or nurse
When patient has appointment at GP
- Patient visits GP
When no change in medicine
- Patient goes home
When need for medicine change
- GP issues prescription
- GP calls pharmacy (?)
- Patient drops it to pharmacy
When pharmacy offers delivery and patient chooses to get it
- Pharmacy delivers medicine to patient's home
Otherwise
- Patient/carer collects medicine
Patient at home with sufficient medicine
(over 4 medicines)
Medicine dispensed (ready to be collected)
39. - Patient takes medicine
Patient with low on medicine
Patient admitted
to hospital
When patient needs hospital care
- Patient goes to hospital
- Patient takes own medicine to hospital (?)
When patient ready to go home
- Hospital discharges patient
- Hospital provides medicine for 0/2/4 weeks?
- Hospital informs GP and pharmacy?
Patient seen
by GP or nurse
When patient has appointment at GP
- Patient visits GP
When no change in medicine
- Patient goes home
Patient at home with sufficient medicine
(over 4 medicines)
When need for medicine change
- GP issues prescription
- GP calls pharmacy (?)
- Patient drops it to pharmacy
40. Patient with low on medicine
When patient/carer does it him/herself
- Patient/carer fills in the repeat prescription slip
- Patient/carer drops the repeat prescription slip at GP (visit/post)
- Patient/carer collects repeat prescription (within 48hrs?)
- Patient/carer drops repeat prescription to pharmacy
When pharmacy has agreed to act on behalf of patient
(prescription collection service)
- Pharmacy contacts patient (every patient?)
- Pharmacy fills in the repeat prescription slip
- Pharmacy drops the repeat prescription slip to GP
- Pharmacy collects a repeat prescription from GP
New (repeat) prescription at pharmacy
- Pharmacy checks prescription
- Pharmacy contacts GP for enquiry (if required)
- Pharmacy dispenses medicine
Medicine dispensed (ready to be collected)
41. 41
Patient at home with sufficient medicine
When pharmacy offers delivery and patient chooses to get it
- Pharmacy delivers medicine to patient's home
Otherwise
- Patient/carer collects medicine
Medicine dispensed (ready to be collected)
42. 42
- Patient takes medicine
Patient with low on medicine
When patient/carer does it him/herself
- Patient/carer fills in the repeat prescription slip
- Patient/carer drops the repeat prescription slip at GP (visit/call?)
- Patient/carer collects repeat prescription (within 48 hrs?)
- Patient/carer drops repeat prescription to pharmacy
When pharmacy has agreed to act on behalf of patient
(prescription collection service)
- Pharmacy contacts patient (every patient?)
- Pharmacy fills in the repeat prescription slip
- Pharmacy drops the repeat prescription slip to GP
- Pharmacy collects a repeat prescription from GP
Patient at home with sufficient medicine
New (repeat) prescription at pharmacy
Patient admitted
to hospital
When patient needs hospital care
- Patient goes to hospital
- Patient takes own medicine to hospital (?)
When patient ready to go home
- Hospital discharges patient
- Hospital provides medicine for 0/2/4 weeks?
- Hospital informs GP and pharmacy?
- Pharmacy checks prescription
- Pharmacy contacts GP for enquiry (if required)
- Pharmacy dispenses medicine
Patient seen
by GP or nurse
When patient has appointment at GP
- Patient visits GP
When no change in medicine
- Patient goes home
When need for medicine change
- GP issues prescription
- GP calls pharmacy (?)
- Patient drops it to pharmacy
When pharmacy offers delivery and patient chooses to get it
- Pharmacy delivers medicine to patient's home
Otherwise
- Patient/carer collects medicine
Patient at home with sufficient medicine
(over 4 medicines)
Medicine dispensed (ready to be collected)
44. Blister Packs
Pro
• Very convenient to patients/carers
• Home carers can prompt
medications only when they are in
blister pack
Con
• Very tricky to manage when
additional medicines need to be
prescribed (GPs and hospital).
e.g. Whittington hospital does not
prescribe medicine to blister-pack
patients. Instead, they fax GPs and
community pharmacy to respond just
before patient discharge.
• Patients become less in
control/charge of their medication
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Blister Packs - No one-size-fits-all
• What type of patients can benefit most from blister packs?
– Patients with memory loss, e.g. dementia
– Patients without arthritis
– Patients in residential care
– Patients with less likely to have prescription changes
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Communication
• No feedback to GPs/pharmacists on how patients are
really taking medication
• Some pharmacists found it challenging to contact GPs
• No easy communication mechanism for home carers to
inform GPs or pharmacists when potential medication
issues are noticed
• Disintegration of NHS emails and emis web
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Potential Challenges
• Different practices and individuals have slightly different
ways of operation.
• Some relationships, e.g. GP and pharmacist, are good,
but some are not good.
• Lack of continuity, e.g. locum pharmacists, locum GPs
and high turnover of care workers
• Liability and distrust between professionals
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Workshop1
When What Who
14.00-14.10 Welcome and scene setting Stephen Rogers
Amalin Dutt, Sandy Keen
14.10-14.30 Systems/design thinking Thomas Jun
14.30-15.30 Whole system
understanding and issue
identification
Group discussion
15.30-15.40 Risk thinking James Wards
15.40-16.10 Issue prioritisation Group discussion
16.10-16.30 Group feedback All
16.30-16.45 Issue prioritisation All
16.45-17.00 Summary and plans Amalin Dutt/Thomas Jun
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When What Who
14.00-14.10 Summary of the last
workshop
Stephen Rogers
Amalin Dutt
14.10-14.20 Risk treatment principles Thomas Jun
14.20-14.30 Lean thinking Ran Bhamra
14.30-15.00 Solution development Group discussion
15.00-15.10 Benchmarking solution
showcase
Priyal Shah
15.10-15.20 Prototyping Thomas Jun
15.20-16.20 Solution development Group discussion
16.30-16.45 Solution presentation All
16.45-17.00 Summary and plans Stephen Rogers
Amalin Dutt
Workshop2
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Workshop3
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When What Who
14.00-14.10 Summary of the last
workshop
Stephen Rogers
Amalin Dutt
14.10-14.20 NHS change model Thomas Jun
14.20-14.50 Barriers and drivers Group discussion
14.50-15.00 Business case example ?
15.00-15.30 Business case development Group discussion
15.30-15.40 Gantt chart example ?
15.40-16.00 Gantt chart development Group discussion
16.00-16.30 Final presentation All
16.20-16.40 Workshop evaluation All
16.45-17.00 Award and conclusion Amalin Dutt
