Catherine Holmes

1. The Right PrescriptionA Call to Action on the use of antipsychotic drugs for people with dementia. Catherine Holmes

2. Our goal By 31st March 2012: • all of the estimated 180,000 people with dementia who are receiving antipsychotic drugs will have undergone a clinical review , to ensure that their care fits with current best practice and guidelines and that alternatives to their prescription have been considered • People with dementia are not prescribed antipsychotics in future unless their situation fits the guidelines

3. The challenge • There is a lot of activity and energy for change....... • Unless that energy is translated into appropriate prescribing and appropriate review of medications, it counts for nothing • We want to provide a focus and direction that moves everyone in the same direction

4. What did we need to agree? • Who we are calling to action • What actions we want them to take • The sources of supportand resources that will be made available to help them in their actions

5. Eight groups to call to action • People with dementia and their carers • Leaders of care homes • GPs and primary care teams • Psychiatrists and mental health teams • Pharmacists • Hospital doctors and their teams • Commissioners of health and social care • Medical Directors and Nurse Directors of acute and mental health trusts/providers

6. COMMITTMENT FOR GENERAL PRACTICTIONERS AND PRIMARY CARE TEAMS Specific commitment? Main themes for action? Resources/sources of help? Undertake audit of accuracy of practice registers. And review of prescribing decisions National standards & recommendations for review and withdrawal of antipsychotic drugs and non-pharmaceutical alternatives. GPs commit to identify and review their patients who have dementia and are on antipsychotics with the purpose of understanding why antipsychotics have been prescribed. Working in partnership with the person with dementia, their family and carers and their medical colleagues in psychiatry to establish whether or not the use of antipsychotics is inappropriate and whether or not it is safe to begin the process of discontinuing their use and to establish that access to alternative interventions can be secured Identify who is on repeat prescriptions and review timescales in place. Guidelines for Care Homes and Nursing Homes (example from Medway) & Skills for Care guidance. Develop an understanding of the alternatives, the evidence base for these and their availability locally .Put referral processes in place- e.g. memory clinics Awards for good practice including Cornwall STAR (challenging antipsychotics and commissioning in dementia, via Martin Freeman) martin.freeman@glos.nhs.uk ) . Work in partnership with other colleagues (psychiatrists, pharmacists, care home leaders) to develop a mutual understanding of the existing issues and develop a planned review for people with dementia who are on antipsychotics –to include specific support around the withdrawal of antipsychotics. Prescription guidelines authored and owned by all partners (example available from Medway achild@nhs.net Link with the Coroner’s office- avoidable deaths. Script switch messages for use in practices-prescribing software and AP alerts Discuss patients/families/carers’ expectations around prescribing – what people think they want. Using practice based communications- leaflets, RCGP good practice with carers

7. COMMITTMENT FOR GENERAL PRACTICTIONERS AND PRIMARY CARE TEAMS continued… Main themes for action? Resources/sources of help? • Audit who is on Aps- • Diagnosis • Under review Pharmacy/non pharmacy interventions. Holistic assessment carers/families Predictive modelling GPs commit to identify and review their patients who have dementia and are on antipsychotics with the purpose of understanding why antipsychotics have been prescribed. Working in partnership with the person with dementia, their family and carers and their medical colleagues in psychiatry to establish whether or not the use of antipsychotics is inappropriate and whether or not it is safe to begin the process of discontinuing their use and to establish that access to alternative interventions can be secured At risk- Care plan for. people at risk Appropriate use of medicines and alternatives. Focus on admission prevention Appraisal revalidation, QoF, Qipp, CQuin Communication Secondary care at discharge-identifying post discharge support. Improved information in community regarding relevant life history to know the pt. Primary to secondary care passport. Carers/families questionnaire Hospital Passport Reminiscence. Community Matrons Medicines Management Team Admission prevention teams Third sector Social services ) . Environment/co-working. Resources and mapping of non-pharmacy alternatives. Use of personal budgets Business case development for investment in alternatives for commissioners Holistic assessment -Interia project . Map of medicine

8. COMMITTMENT FOR COMMISSIONERS IN HEATH, SOCIAL CARE AND GP COMMISSIONING Specific commitment Main Themes for action Resources/sources of help? Needs Assessment Joint Strategy Needs Assessment and Health & Wellbeing Strategy (and wider strategic plans) demonstrate the needs of people with dementia and carers by including residential care standards, workforce capacity & capability, health promotion and prevention and safeguarding protocols. Commissioning pack to include SCIE recommendations Recommended reading / information prescriptions (see appendix 1) Audit results and statistics with examples and key questions to ask of the audit data e.g. % prescriptions generated in secondary care, no of pts on anti-psychotics with no diagnosis, what % people in care homes have had no review in last 6 months, what are prescribing stats in primary care, what is the incidence of falls reported from people with dementia on anti-psychotics. • I (we) commit to: • Improving the quality and experience of care for people with dementia ( and their carers) ,by commissioning a whole systems approach to dementia • . Ensure through effective evidence-based commissioning, we support providers to minimise the need for antipsychotic drugs , and in addition to ensure prescribing is in line with NICE guidelines across the health and social care system Needs Assessment/Priority setting All localities to take local audits (using available / shared audit tools) of current practice for antipsychotic prescribing medication for people with dementia which covers the whole health and social care system by 31st March 2012 Commit to change local commissioning plans as appropriate and contracts with all partners to reflect this and to reduce antipsychotic prescribing. measured by: - the lens of people with dementia and their carers - professional behaviours/practice - actions at an organisational/system level Commissioning specifications and contracts which reflect interventions and functions which deliver outcomes which minimize the need for anti-psychotics. Examples of good practice include: SE Collaborative – audit and quality indicators Surrey – whole systems model inc Telecare Local and national publications (see appendix 1). Dementia portal / NHS Networks – dementia section “This is me” Alzheimer's society “Misspent opportunities” audit commission Service review/Priority setting Ensure local plans are in place by 31/3/12 to deliver the national dementia strategy specifically anti psychotic prescribing. Publicize and promote this plan and ensure is accessible and understandable by the public Commissioners to make dementia business as usual across all areas of commissioning. Commissioners to develop and enhance leadership and governance for prescribing. Compendium of good practice and success stories/case studies , including those alternative approaches Set up a steering group to share good practice Create a central place to collate information – National Field or dementia portal. Reference and link to websites which contain to partnerships, protocols for good practice. Service redesign and supplier side reshaping Enabling providers with MDT to use appropriate alternatives to prescribing by strong evidence based commissioning in all areas ( this is the primary responsibility of the doctors but a part of the commissioning ethos). Ensure ‘in reach ‘ services appropriate to your locality is a priority within commissioning intentions. Incorporate within primary, acute, mental health and care home contracts governance mechanisms for regular audit of anti-psychotic prescribing. Implement NICE compliant protocols between primary and secondary care for the review of anti-psychotic medication on patient transfers. Local QOF data with up to date information Link to QIPP and QOF data / LES CQuINs. CQC. Clinical Decision making Monitor and implement an MDT and multi-agency process for serious untoward incidents associated with people with dementia and their carers Link to specific web pages and key documents which support commissioning decisions Workforce development Education commissioned for the public, workforce and managers enabling each to gain key skills to improve outcomes. Setting key educational stds for people in the health & social care , independent sector workforce , working with people with dementia . Enabling provision of training for lay carers

9. COMMITTMENT FOR LEADERS OF CARE HOMES: Specific commitment Main themes for action Resources/sources of help National Dementia Strategy Guidelines from Alzheimer’s Society Guidelines from Dementia Alliance NICE and SCIE Guidelines Review processes and infrastructure which may lead to inappropriate prescription of antipsychotics and put in place other systems to support best practice (See slide 2: Sub-themes for action arising from this). Multi-disciplinary care pathway: management of challenging behaviour Department of Health: compendium of best practice (Examples of non-drug alternatives) BUPA Mental Capacity Act ‘postcard’ for staff Develop/put in place a proactive, systematic register for maintaining and monitoring all antipsychotic prescriptions, reviews and outcome decisions. I (we) commit to: Identifying all people prescribed antipsychotic medication and to documenting and delivering an evidence-based, personalised care-plan developed in partnership with the individual, their family & the multi-disciplinary clinical team Undertake a home-wide review of prescriptions initially & then establish a system of proactive review for all new residents, upon taking up residence, and thereafter in line with current clinical /best practice guidelines. SCIE Dementia Gateway Social Care TV Charities Websites Social Media (e.g. Facebook): BUPA, Dementia UK, possibly others Establish clear relationships with, and links in to, emerging collaborative partnerships between GPs and Pharmacists - establishing as part of the wider call to action. Develop clear, systematic protocols to ensure support to care home staff in actively challenging antipsychotic prescribing. Care UK: Experiential Learning Course (Surry Pilot) BUPA: How to work with challenging individuals BUPA: Understanding behaviour (partnered with Bradford University) Alzheimer’s Society: Focused Intervention Training for Staff (FITS 10-day programme) Boots: Dementia Medication Training ElBox, SKIP, MABO, Studio 3 & Edge Develop clear, systematic information resources & support for use by the individual, their family and care home staff Provide access to dementia-specific training & development opportunities for all care home staff.

10. COMMITTMENT FOR LEADERS OF CARE HOMES: (Continued) Key Theme for Action Sub-themes for action Resources/sources of help Tools to help in the care environment e.g. Dependency scoring template Flowchart for recognising problems which could change behaviours Observational tools SCIE website, gateway &social care TV Identify a named ‘Dementia Champion’ in each care home, supported through appropriate specialist education and training, with sufficient authority to effect change. Training resources e.g. Training DVDs Resident experience training Motivational mapping tools Voluntary sector - Alzheimer’s Society training and resources E-learning resources Medicines management training Identify and utilise personal information resources for use by the individual, their family and care home staff. Review processes and infrastructure which may lead to inappropriate prescription of antipsychotics and put in place other systems to support best practice Provide the times and resources for recognised accredited training on good dementia care. Sources of support/service other than antipsychotics e.g. Alternative therapies and activities Local memory clinics Environmental resources - e.g. Eden Journal of dementia care Build relationship with the community to put in place interventions in the care home in line with best practice. Health and social care professional support Provide ongoing training and support to staff. Care plan The individual, their family and carers e.g. This is me document/Dementia passport Establish and maintain a clear relationship with multidisciplinary team members (e.g. GPs and pharmacists). Examples of good practice e.g. Nothing ventured, nothing gained DH doc DH Compendium of best practice

11. COMMITTMENT FOR PHARMACISTS Specific commitment? Main themes for action? Resources/sources of help? Establish a clear dialogue and agree joint working practices for reviews with all prescribing partners Guidance in Bannerjee report Source of specific guidance from RCGP Become better informed about best practice guidelines for the prescribing of antipsychotic medication, and alternative interventions, for people with dementia. Provide support and sign-posting to alternative resources for people with dementia and their carers http://www.rcpsych.ac.uk/files/pdfversion/CR138.pdf http://www.rcpsych.ac.uk/files/pdfversion/cr119.pdf (see section 8 and appendix) I (we) commit to: Reviewing the people under my care to identify those who are prescribed antipsychotic medication and to work in partnership with my prescribing and other health care colleagues to review each individual by 31st March 2012 Community pharmacists: Query every prescription for an antipsychotic for people aged 65 years or over and/or those known to have dementia and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months Guidelines from Alzheimer’s Society Guidelines from Dementia Alliance Talking with people with dementia and their families NICE and SCIE guideline Hospital pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines) All antipsychotic are flagged on transfer documentation with a clearly identifiable review date PCT and commissioning pharmacists: Include antipsychotic within QOF action plan and QIPP target. Review/challenge high prescribers Multi-disciplinary care pathway – management of challenging behaviour in dementia Department of Health – compendium of best practice (Examples of non-drug alternatives) Report back on my progress in these activities

12. COMMITTMENT FOR PSYCHIATRISTS AND MENTAL HEALTH TEAMS Specific commitment? Main themes for action? Resources/sources of help? To challenge routine practice and update knowledge base using current evidence and best practice NICE guides for dementia Royal College Psychiatrists resource pack Utilise clinical governance esp. clinical audit, to provide information on local practice to inform required local action ‘Getting to Know You’ charts – to help identify causes of disturbed behaviour I (we) commit to: Review the causes(s) of disturbed behaviour before initiating or continuing antipsychotic treatment Offer local education opportunities to all psychiatrists and to all hospital doctors Review the causes(s) of disturbed behaviour before initiating or continuing antipsychotic treatment Annual mtg of Faculty of Old Age Psychiatrists / Royal College (March mtg– but could utilise newsletters) Increase links and offer educational support to Care Homes e.g. 1 day conference with input from psychiatrists and care homes staff Increase links with local GPs esp. identifying and working with GP 'dementia leads’ to review local practice Flowchart for identifying causes of BPSD – Anne Child. a.child@nhs.net RAGE for monitoring Joint visits (psychiatrist and GP) to ‘struggling’ care homes (possibly monthly) Admission process pathway – North Staffs (audit data to demonstrate benefits) Patients discharged on antipsychotic treatment to have a clear management plan and support from the Care Home liaison team v090511

13. COMMITTMENT FOR PEOPLE WITH DEMENTIA, THEIR CARERS AND FAMILIES Specific commitment Main themes for action Resources/sources of help Care plan and ‘who I am‘ document (e.g. This is me, Dementia Passport) Seek information and support from the voluntary sector and other resources on treatment and care options and seek guidance on how to establish a dialogue with health and social care professionals. Information from the voluntary sector (e.g. Alzheimer’s Society’s antipsychotics booklet, Alzheimer’s Society website, Age UK website). I/We commit to Proactively seeking a conversation with my (our) GP to review care and agree a personalised care plan (in line with best practice) Local services and peer support networks (e.g. Memory clinic, dementia adviser, support group). Take responsibility for sharing insights into who I am and what I want (who the person I care for is and what they want) to support the development and implementation of an effective, valuable and realistic care plan. Information from membership organisations such as UKHCA and ECCA Take responsibility for working in partnership with care team to ensure initial and ongoing appropriate review of the care plan. Non-web information sources (e.g. Alzheimer’s Society help lines, libraries) Local and national media Health and social care professionals (e.g. GP, CPN, consultant)

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