Compliance Support DDA

1. Compliance Support & DDA A number of Anecdotes!

2. DDA applies to People with a mental, sensory or physical impairment that has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities (no longer necessary for the mental impairment to be clinically recognised) The DDA is part of the continuing process to improve the rights of disabled people and all pharmacists providing services in the UK have a legal obligation to comply with it. Who and what is covered by the DDA? The requirements that apply to community pharmacy services are that disabled people should not be treated less favourably than others, for reasons related to their disabioity, reasonable adjustments to services to help disabled people should be made, and reasonable adjustments to the physical features of pharmacy premises to over come barriers to access should be made. The DDA is part of the continuing process to improve the rights of disabled people and all pharmacists providing services in the UK have a legal obligation to comply with it. Who and what is covered by the DDA? The requirements that apply to community pharmacy services are that disabled people should not be treated less favourably than others, for reasons related to their disabioity, reasonable adjustments to services to help disabled people should be made, and reasonable adjustments to the physical features of pharmacy premises to over come barriers to access should be made.

3. What does this mean? Substantial – has an impact on day to day tasks Long-term – lasts at least a year or for the rest of the person’s life

4. Substantial A person would be considered as having a disability only if the impairment has a substantial effect on the person’s ability to carry out normal day to day activities The DDA applies only where the patient’s ability to carry out day to day functions is compromised, it is not intended to support carers, or nursing or residential home staff. For example, we may consider it reasonable for a carer to be trained to support the safe supply of medicines as an integral part of a care package, but this would need to be funded separately.The DDA applies only where the patient’s ability to carry out day to day functions is compromised, it is not intended to support carers, or nursing or residential home staff. For example, we may consider it reasonable for a carer to be trained to support the safe supply of medicines as an integral part of a care package, but this would need to be funded separately.

5. Impairment Must impact on at least one of: Mobility Manual dexterity Physical co-ordination Speech, hearing, eyesight Memory Ability to concentrate, learn or understand Continence Ability to lift, carry or move everyday objects Understand the risk of physical danger BUT – there is no definitive list ……….. Recent amendments have been made to the DDA to cover conditions that cause an intermittent disability or a progressive disability that affects or will affect day to day activities. These conditions include for example cancer, HIV and multiple sclerosis from the time of diagnosis. So a person likely to need a wing capped or oversized container when their condition deteriorates can expect pharmacists to make such adjustments to their current services. The amendment also removed the criteria for a mental impairment to be clinically well recognized.Recent amendments have been made to the DDA to cover conditions that cause an intermittent disability or a progressive disability that affects or will affect day to day activities. These conditions include for example cancer, HIV and multiple sclerosis from the time of diagnosis. So a person likely to need a wing capped or oversized container when their condition deteriorates can expect pharmacists to make such adjustments to their current services. The amendment also removed the criteria for a mental impairment to be clinically well recognized.

6. Support for people with disabilities All service providers have to make “reasonable adjustments” No service provider can be directed to make a specific adjustment Does not include supporting carers who are not insured to ‘give’ medicines So to recap, reasonable adjustments have to be made by all service providers, importantly no one can direct another service provider to make a specific adjustment, it does not include supporting carers directly employed by other providers, and there is a need to develop links into the SAP.So to recap, reasonable adjustments have to be made by all service providers, importantly no one can direct another service provider to make a specific adjustment, it does not include supporting carers directly employed by other providers, and there is a need to develop links into the SAP.

7. Where to start…. It’s a minefield! The Collaborative’s work has been involved predominantly with one pharmacist and his Monitored Dosage System (MDS) domiciliary patients – and a PCT led initiative to asses the size of the problem The LPC has also been involved in large project in this area

8. The Mid Devon Experience! Pharmacy Forum held in December to discuss an LES in compliance support All pharmacists re-assessed their base line number of patients on MDS Over a considerable period of time the assessments forms were submitted for further work

9. The Neil Ansell Experience! Large number of patient on MDS Prior to the forum, consulted the GPs and told them he was inundated with MDS and could not cope. Surgery agreed to think before recommending patients for MDS Forum made position very clear for Neil – visited and assessed his pre existing 42 patients, with both an MUR and the Devon Concordance Tool. Neil and Collaborative worked together on a measuring sheet to see if the reassessment improved the patient experience (included in your packs)

10. The Results!!! * Some with diagnosed conditions, but since Dec 2005 very difficult to ascertain this criteria.

11. Some more facts! The 11 patients not DDA all had carers (family/paid carers) - majority of which did not understand the medication of their relatives / clients Assessment took 45 minutes per person, mostly after work, or if a locum cover available 3 per day. Of the entire 42 original patients, only 5 regularly came into the shop

12. The Next Steps The agreement is now when GP’s phone the pharmacy and request an MDS, Neil makes it clear he will carry out the assessment and make the decision himself.

13. Some Problems! Customer demand their medicines be put in a tray, as OT said this could be done for free in chemist. Work with and re-educate other healthcare providers e.g. district nurses and Occupational Therapists about this situation. Find out from your local PCT who the leads are.

14. Current Situation Since the re-assessment 6 new requests for MDS – from patients / carers / surgery requests. Carried out an assessment – started them all with medicine reminder chart with a review after 1 month. Only 1 had a blister pack after this initial period but deteriorated very quickly and went into a nursing home. This proves that pharmacy judgement and worth in the community. If they still insist on having a tray Neil gave them an over the counter simple medicines tray if this is better for the carers confidence in administering medicines.

15. Torbay Assessments 2004 Survey to establish baseline usage of community based patients Devon LPC Torbay tPCT Joint Project Concordance survey Assessment tools tested The Limited research that is available about the use of MDS does not indicate that wholesale provision of MDS is of benefit to patients, and that they can cause harm in some cases; there is a strong link between the provision of MDS and direct remuneration via seven day prescriptions. In response to local concerns about the growing number of requests for the provision of MDS in the community and the capacity of the local pharmacy network to provide these, the LPC and Torbay PCT agreed to survey local pharmacies and practices to establish some baseline data about the demands for MDS, point of referall and funding implications. The survey was undertaken in 2004 and we had a 100% response rate from pharmacies which we felt indicated just how important the subject is. At the time of the survey there were 432 MDS patients within the community. Torbay then agreed to fund a detailed concordance survey of 80 patients identified as being in receipt of MDS as a measure of how appropriate these were and to test assessment tools. With the emerging findings that MDS was only indicated in about a third of the patients, and the noise from local GPs about the continuing demand for seven day prescriptions it was agreed to work jointly with the LMC, LPC and Care Trust to start to address the problems. What is important to remember is that in the same way pharmacists cannot be directed to supply MDS as a “reasonable adjustment” likewise GPs cannot be directed to write a seven day prescription as their “reasonable adjustment”! The Limited research that is available about the use of MDS does not indicate that wholesale provision of MDS is of benefit to patients, and that they can cause harm in some cases; there is a strong link between the provision of MDS and direct remuneration via seven day prescriptions. In response to local concerns about the growing number of requests for the provision of MDS in the community and the capacity of the local pharmacy network to provide these, the LPC and Torbay PCT agreed to survey local pharmacies and practices to establish some baseline data about the demands for MDS, point of referall and funding implications. The survey was undertaken in 2004 and we had a 100% response rate from pharmacies which we felt indicated just how important the subject is. At the time of the survey there were 432 MDS patients within the community. Torbay then agreed to fund a detailed concordance survey of 80 patients identified as being in receipt of MDS as a measure of how appropriate these were and to test assessment tools. With the emerging findings that MDS was only indicated in about a third of the patients, and the noise from local GPs about the continuing demand for seven day prescriptions it was agreed to work jointly with the LMC, LPC and Care Trust to start to address the problems. What is important to remember is that in the same way pharmacists cannot be directed to supply MDS as a “reasonable adjustment” likewise GPs cannot be directed to write a seven day prescription as their “reasonable adjustment”!

16. LPC Project - Main findings 432 patients in the community 57 assessments – 20% fell outside DDA MDS appropriate in less than one third of all patients assessed Eight MDS initiated in secondary care, one patient appropriate Identification of patient group outside DDA who would benefit from support At the time of the survey there were 432 MDS patients within the community. Torbay then agreed to fund a detailed concordance survey of 80 patients identified as being in receipt of MDS as a measure of how appropriate these were and to test assessment tools. Assessments took place in a domiciliary setting, 57 patients were assessed. At the time of the survey there were 432 MDS patients within the community. Torbay then agreed to fund a detailed concordance survey of 80 patients identified as being in receipt of MDS as a measure of how appropriate these were and to test assessment tools. Assessments took place in a domiciliary setting, 57 patients were assessed.

17. How do you know? The assessment process – 3 steps Identify factors that affect the patients ability to take their medicines Identify what adjustment would enable the person to take their medicines Identify whether ‘DDA’ applies Patient assessment could involve an informal discussion or a more formal approach using assessment forms. Pharmacists should make a professional decision regarding the conditions they are effectively able to assess. A pharmacist for example may feel unable to assess a patient’s mental or cognitive impairment in which case you may feel you want to refer that patient for a full cognitive assessment. This is a good example of where in Torbay integration of pharmacy within the zones will be so important. Can you think of where any of the resources you have for the essential services component of the new contract may help you? In cases where as a pharmacist you are unable to support a patient you could signpost them to local support groups, or refer them through the SAP for an assessment according to local protocols.Patient assessment could involve an informal discussion or a more formal approach using assessment forms. Pharmacists should make a professional decision regarding the conditions they are effectively able to assess. A pharmacist for example may feel unable to assess a patient’s mental or cognitive impairment in which case you may feel you want to refer that patient for a full cognitive assessment. This is a good example of where in Torbay integration of pharmacy within the zones will be so important. Can you think of where any of the resources you have for the essential services component of the new contract may help you? In cases where as a pharmacist you are unable to support a patient you could signpost them to local support groups, or refer them through the SAP for an assessment according to local protocols.

18. Outcomes Sight – can you read the instructions on the label? A reasonable adjustment might be A pictogram Large font RNIB bump ons An unreasonable adjustment might be Making an adjustment if the patient does not have corrective spectacles As you know it is a common appproach to provide medicines in a MDS compliance aid. You may not think this is a reasonable adjustment to your service and there may be more appropriate aids or support you can give. Go through the trigger questions here - As you know it is a common appproach to provide medicines in a MDS compliance aid. You may not think this is a reasonable adjustment to your service and there may be more appropriate aids or support you can give. Go through the trigger questions here -

19. Outcomes Manual Dexterity – Do you have problems getting medicines out of their bottles or popping medicines out of blister packaging? A reasonable adjustment might be Supply of larger than needed bottles or easy to open caps, winged lids De-blistering of medicines or the free provision of a de-blister device An unreasonable adjustment might be The provision of medicine in a compliance aid that the person is unable to self manage

20. Outcomes Mobility – Do you have problems getting a regular supply of your medicines? A reasonable adjustment might be Free collection and delivery service even if the service is offered to other patients at a small charge An unreasonable adjustment might be The introduction of a collection and delivery service if one is not in place, or extending the collection and delivery area to an unreasonable distance

21. Lessons learnt so far Link to Medicines Use Review Approach the assessment like a structured consultation Develop communication skills and TIME management Engage other members of the health and social care team - TALK Investigate opportunities under practice based commissioning MDS is not always the answer! Sum up with the lessons learnt to date. Link into the Torbay Zones, integrated health and social care teams and communication with local practices.Sum up with the lessons learnt to date. Link into the Torbay Zones, integrated health and social care teams and communication with local practices.

22. Useful websites www.psnc.org.uk www.primarycarecontracting.nhs.uk www.pjonline.com www.drc-gb.org (Disability Rights Commission) www.npa.co.uk www.opsi.gov.uk/acts/acts1995/Ukpga_1995050_en_1.htm (Disability Discrimination Act)