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The National Service Framework for Older People

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Medicines and Older People
Extract of evidence presented by the Welsh Food Alliance January 2006

In our view this aspect of the NSF for Older People has a food dimension and this could be made explicit in sections 4. - 7. For example:
Section 4. An extra bullet point should (a) capture the need for medical doctors to be advised to check patients' diets/eating arrangements before prescribing powerful drugs, and

(b) For doctors, nurses, patients and carers to be alert to the relationship between food and medicine consumption. The before and after regime which patients follow at home should be, but does not appear to be followed by at least one NHS Trust in Wales. In this Trust, the arrival of the medicines trolley rules the timing at which nurses request patients to take the all drugs supplied. In another Trust patients are given greater ownership of this process.
Background - Food
Doctors should be asked to check their patients' diets more closely to ensure that mixing their medication and the food they eat does not result in life-threatening cocktails. Are ëtool kitsí available to help with this task? Our understanding is that Government safety advisers are concerned that powerful drugs, already toxic by their very nature, may be made even more dangerous by interacting with ingredients in foods, drinks and supplements. Alternatively, patients may unwittingly undermine the effectiveness of their medical treatments by eating the wrong foods.
4. Rationale, 5. Risk Assessment, 6. Effective Interventions, 7. Service Models ‚ and food products
In addition to context section to this paper, the following observations may assist with brief textual changes required under these different headings.

Section 4:Many patients may be taking up to 10 medicines at a time, meaning that the "potential for interaction in some individuals is great". But there is unlikely to be any formal public education campaign or compulsory warnings on food products, despite some of the drugs concerned being prescribed to millions of patients.
Section 5:Food dimension to the risk assessment process
Given the increasing synergies between medication and food it would be helpful if this could be acknowledged. For example, less is known about interactions, including how milk and dairy products might reduce the effectiveness of antibiotics taken for respiratory and genital infections.
New foods such as probiotic yoghurts and dairy drinks, designed to improve people's health by changing the microflora in their guts, might lead to more food-drug interactions. Government-backed efforts to reduce the amount of sodium salt in the diet might also cause a problem. Although this may reduce the risk of high blood pressure, heart attacks and strokes in the population as a whole, people cooking at home and food manufacturers may turn to potassium salts instead. But this could cause a problem for people taking diuretics, or who are on some anti-arthritis drugs or on drugs that manage high blood pressure.

Not all combinations will be dangerous. Indeed, sometimes patients who are responding well to drugs may be better off staying with their existing diets. However there have been at least two deaths linked to the intake of cranberry juice with medication. There is also little data on which groups are most vulnerable to food-drug interactions, although they are likely to include frail, older people.
6. Effective Interventions ‚ all six types of intervention. The official UK position appears to be that most people will not be affected; therefore there should not be more public information. Instead better awareness among doctors and other prescribers is advised. Exceptions to this rule appears to be where in some cases practitioners have built up knowledge about interactions in specific groups of patients taking particular drugs, such as the interaction between St John's wort and anti-HIV drugs. We would take some persuading that this is a correct position for government to take. It would be useful for the Assembly government to check with MHRA if such advice is complete and the much wider availability of advice and information regarding avoiding interactions (See Note One). With increasing use of the internet we see an important potential role and responsibility for patients and carers (see 6.5.1). Have we fully explored the contribution of expert patient programmes?
5. Risk Assessment / Effective Interventions: 6.1 Advice and Support and 6.5 Education and Training issues
We understand that there may be as many as 200 drugs whose action or toxicity is affected by food, according to advice being drawn up by advisers to the Food Standards Agency and the Medicines and Healthcare products Regulatory Agency (MHRA). This aspect needs to be acknowledged as part of the risk assessment process. Can the Assembly arrange for this official advice to be put into the public domain?

Some safety advice has previously been issued to doctors and other prescribers such as pharmacists and nurses. This has included the potentially lethal combinations of the anti-coagulant warfarin and cranberry juice, anti-cholesterol drugs known as statins and grapefruit juice, and antidepressants and anti-HIV drugs and the popular herb St John's wort. If service users and carers are to be co-producers of good health, effective communication with a wider public is essential, especially since some already have access to such information via the internet. It is for these reasons that we recommend:
(a) The need for changes in the (nutrition) knowledge and communication skills required by medical and non-medical healthcare professionals through education and continuing professional development (see later comments about the Foster and the CMO Review of Medical Regulation); and
(b) that where ever possible, patients / carers have access to safety advice previously been issued to doctors and other prescribers such as pharmacists and nurses.
Section 7: Service Models
Local Health Boards. Does this section require a public health dimension at 7.1, 7.2, 7.5, 7.6 and 7.7? To help drive the review process could specific reference be made to Public Health Directors and medication reviews for frail older people as part of the current review of the needs assessment process and the revision of future local Health, Social Care and Well Being strategies and local authority Community Plans?
Should the Assembly identify a role for local authorities? Could future local authority ëCommunity Plansí provide an opportunity to raise the need for large food retailers to have a role and responsibility to provide consumers information and helpline services on the interaction of food and medicines, or should this be captured in the other strands of the NSF for Older People? How might Trading Standards assist consumers?
Public engagement is a missing dimension to the service models presented. Our older peoples national food surveys (2001, 2003) provided a rich source of anecdotal information about the needs and concerns of older people. We would like to see a further similar annual independent survey covering medication issues that could feed into a regular monitoring and review process. We are sure that this could provide useful information about how medication can be made to work more effectively for the patient. For example, in some recent research we learnt that:
(a) Some patients and carers have the time to thoroughly read medicine instructions and to point out contra-indications that may have been overlooked by the healthcare professional and thereby monitor medication errors and side effects, such as loss appetite and hair. (See section 6.6)
(b) In hospital, drugs are dispensed at predetermined times, from the medicines trolley, and therefore at a time which could be inappropriate. For example, patients being instructed to take medication when this needs to be taken by the patient before or after food consumption.
(c) There needs to be a clearer understanding on the part of both patients and healthcare professionals where the avoidance of certain types of food is recommended. For example, when warfarin is being taken (see Note One).
(d) Some patients are not advised by doctors, especially ëout of hoursí doctors, about the importance of taking certain powerful drugs, such as steroids, with food, even if taken late at night. This not only has serious long-term consequences for the patient, but also adds considerably to NHS costs, through the admission of patients. It also underlines the importance of good common communication skills across all healthcare professions when listening and responding to patient concerns.
Changes proposed in this paper could help make a reality of patient centred care principles set out in the Assembly policy ëDesigned for Lifeí (2005).
Note One Avoiding interaction: what not to mix
Warfarin to prevent blood clotting
Reacts with cranberry juice and green vegetables. Efficacy may be reduced by ice cream, soya beans and avocados, although clinical significance and prevalence of this problem is unclear
Cholesterol-lowering or immunosuppressant drugs - Patients should not drink grapefruit juice
Sedatives; other drugs including paracetamol should not be mixed with alcohol
Lithium to treat bipolar disorder - Patients must not vary intake of salt once they have been stabilised on the drug
Anti-HIV drugs - Do not mix with St John's wort, even though there is evidence that it can help treat depression too
Antibiotics in the tetracycline and quinolone classes - Milk and dairy products can reduce their effectiveness

Appendix One
We were impressed by a Progress Report of the Scottish Parliament Audit Committee, 3rd Report, 2004 (Session 2). ëSummary of Findings and Recommendationsí Supporting Prescribing in General Practice. The Committee sought to examine:
… maximising the benefits of computerisation
… repeat prescribing and reducing waste
… The new General Medical Services Contract
… The patient experience
Unless evidence can be presented to the contrary their recommendations, suitably refined, appear to be an excellent basis for future action. Extracts can be found at Appendix One


Audit Committee

3rd Report, 2004 (Session 2)
Supporting Prescribing in General Practice - A Progress Report

The Committee reports to the Parliament as follows-
1. In considering the report of the Auditor General for Scotland (AGS) entitled "Supporting prescribing in general practice - a progress report" (AGS 2003/5) the Committee took evidence on 30 September 2003 from Mr Trevor Jones, Head of Scottish Executive Health Department and Chief Executive, NHS Scotland; Mr Bill Scott, Chief Pharmaceutical Officer and Dr Hamish Wilson, Head of Primary Care Division, Scottish Executive Health Department.
2. In taking evidence, the Committee sought to examine:
… maximising the benefits of computerisation
… repeat prescribing and reducing waste
… The new General Medical Services Contract
… The patient experience
3. Our main findings and recommendations are as follows:
Summary of Findings and Recommendations
… The Committee notes the progress which has been made by NHSScotland since the 1999 baseline report both in improving the quality of prescribing and achieving savings. (Para 7)
… The Committee believes that the development and application of modern Information Management and Technology (IMT) systems to support effective and efficient prescribing practice within NHSScotland has been too slow and, at times, piecemeal. The Committee acknowledges that there are many local examples of good practice but is concerned that these have not been adopted more widely across the country. The Committee recognises also that the Scottish Executive Health Department (SEHD) has supported a number of innovative pilot projects but is concerned that many such projects remain in pilot phase for many years. It recognises that the process for national roll-out of technological change is complex and involves considerable investment as well as significant changes to clinical practice. Nonetheless the Committee believes that greater priority and impetus must be given to accelerating the process of evaluation and roll-out both to achieve best value and to provide a modern and effective service to patients. (Para 12)
… The Committee believes that the pace of technological change must be significantly advanced and recommends that SEHD sets out an explicit action plan, including timescales and targets, on how this will be achieved. (Para 13)
… The Committee is firmly of the view that a failure to embrace modern technology in areas such as repeat prescribing and the transfer of prescribing data will result in an inefficient use of NHS resources and a less than optimal service to patients. (Para 14)
… The Committee is concerned about the risk involved in moving from many local IT systems to national systems, given the substantial financial resources involved as well as the need to maintain continuity of service and to protect patient safety. (Para 15)
… The Committee therefore recommends that the risks involved in moving over to new national IT systems are properly evaluated through a formal risk assessment procedure which should be examined by the Executive's auditors. (Para 16)
… The Committee recommends that work to roll out successful pilots which have been shown to combat waste in repeat prescribing is given a much higher priority to ensure that improvements for patients and savings are generated at the earliest opportunity. (Para 21)
… The Committee requests that in responding to this report, the Executive sets out the progress being made in resolving a) the issue of electronic signatures on prescriptions and b) difficulties relating to current remuneration and reimbursement models. (Para 22)
… The Committee believes that the delay in delivering the benefits of pilot projects to patients throughout Scotland is unacceptable. The Committee considers that a clear structure for agreeing and adopting successful practices identified by pilot projects is urgently required and that this should be accompanied by definite timescales. (Para 25)
… While the Committee recognises the benefits of minimising the bureaucracy involved in the operation of the quality framework associated with the new General Medical Services (GMS) contract, it is essential that proper systems controls are in place in order that the Accountable Officer can ensure that public money is used with due regularity and propriety. (Para 30)
… The Committee has received no evidence of the risk assessment procedures which may have been carried out in relation to the operation of payments under the quality framework. The Committee therefore recommends that a comprehensive risk assessment is drawn up and applied. (Para 31)
… The Committee appreciates the complexities involved in estimating the financial impact of the new General Medical Services contract. However, it remains concerned that the Executive was not able to provide a more detailed assessment of the possible cost pressures which may arise. Despite the difficulties involved, the Committee believes that an evaluation of the impact of the contract on prescribing costs, including a margin for error as appropriate, is a fundamental of sound financial planning. (Para 34)
… The Committee would like an assurance that SEHD has measures in place to ensure that other services would not be adversely affected should the introduction of the new GMS contracts result in an unforeseen rise in prescribing costs. (Para 35)
… The Committee welcomes the developments in information management and technology across the Primary Care sector, which aim to improve the efficiency of prescribing, but feels there is a lack of focus on treating patients more effectively. SEHD is unable to say when systems will be capable of allowing a comparison to be made between diagnosis and prescription on a large scale. This is needed to facilitate improved clinical audit and allow the development of robust performance indicators. (Para 37)
… The Committee is concerned that many of the delays and repeat visits experienced currently by patients could be avoided through improvements to prescribing practice and more effective use of IMT. The Committee believes that patient safety and the overall quality of care depends upon effective sharing of prescribing data, particularly in the interface between primary and secondary care, and requests that SEHD review and report upon current progress in this area. (Para 38)
… The Committee welcomes the Executive's plans to launch more public awareness campaigns to equip patients with more information on the use and cost of medicines. It further welcomes the dump campaign which the Executive Health Department intends to run early in 2004 to encourage the return of unused medicines. (Para 40)
… The Committee is disappointed by the ad hoc manner in which patients gain access to alternative treatments and the lack of evidence gathering to evaluate the effectiveness of lifestyle prescriptions and herbal or homeopathic remedies against established treatments. (Para 44)
… The Committee considers that SEHD, in its consideration of best value, should ensure that the full range of possible approaches is considered alongside conventional treatments. (Para 45)
… The Committee recommends that SEHD support more studies to evaluate both the effectiveness and cost-effectiveness of alternative therapies, including lifestyle prescriptions and herbal and homeopathic remedies, compared with established therapies. (Para 46)
December 2005
South East Sheffield  PCT, Clinical Effectiveness and Audit
Strategy , 5

7.0 Public and Patient involvement
The PCT will actively encourage patients to participate in measuring the
effectiveness of services.  Patient views will be sought in respect of their
views of services and their care and outcomes of interventions.
 4.0 Links with other strategies
The clinical effectiveness and audit strategy impacts on, and must link with,
the following strategies and Plans:
ï Information Management strategy
ï Training and Development strategy
ï Research and Governance Plan
ï Patient and Public Involvement strategy
ï Risk Management strategy
ï Performance management plan
6. 2 Education and Training of staff
There are specific aspects of clinical effectiveness and audit that require
specialist skills.  The PCT will ensure that appropriate staff are equipped with
knowledge and skills in the following:
ï Clinical audit skills, including electronic audit (the recording and
retrieval of electronic data for audit purposes)
ï Use of information and clinical data management (library, searching
and appraisal skills, disseminating guidance)
ï Research Appreciation Skills
ï Critical appraisal of evidence and research
The Sheffield Evidence Based Networking Group (SHEBANG) has been
created to provide a mechanism for all staff throughout the city to develop
their capacity for interpretation and implementation of evidence from research
literature in a way that is sensitive to the needs of the local health community.
The PCT will support and encourage access to this.

Improving prescribing practice through pharmacy audit
Authors: Griffith D.; Diggory P.; Jones V.; Mehta A.
Source: International Journal of Health Care Quality Assurance <http://www.ingentaconnect.com/content/mcb/062;jsessionid=rujin7yookh4.victoria> , Volume 15, Number 2, April 2002, pp. 74-79(6)
Publisher: Emerald Group Publishing Limited <http://www.ingentaconnect.com/content/mcb;jsessionid=rujin7yookh4.victoria>
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The classic audit cycle has been applied to the prescribing practice to improve aspects of the quality of prescribing in the setting of a department of health care for older people in a district general hospital. Details the methods used both to increase the appropriate prescribing of drugs of proven benefit, and also to restrict the use of drugs which may prove hazardous. The latter provides an example of risk management. Also discusses the dilemmas posed in treating older people with multiple pathologies, on the one hand, trying to avoid an ageist approach, on the other, attempting to minimise the pitfalls of polypharmacy.