For many years the NHS has struggled to fulfil the NHS Out of Hours (OOH) standards that stated ‘patients should be able to access the medicines they need at the time and place of the OOH consultation’. The Drug Tariff, which determines the list of products which can be prescribed on FP10 and their re-imbursement costs, still includes a rather dated ‘Out of Hours national formulary’ which categorises a wide range of medications for emergencies which include palliative care.
When this formulary was introduced, in about 2008, various solutions were proposed and many OOH medical services started to investigate whether they could be the place to keep a stock of the medicines required. Palliative care pharmacists worked with some of these services to help with logistics of ordering, storing and transporting Controlled Drugs in a service – made additionally challenging in a service which was not staffed 24 hours each day. Unfortunately, regulatory changes meant that in order to do this, OOH services would require a Controlled Drugs licence so most decided against holding stocks in a comprehensive way.
Many areas have OOH systems where a select few community pharmacies hold an agreed stock of end of life care medicines. In most of these areas, there is an arrangement for the pharmacist to be available to attend at any time in the OOH period to meet the healthcare professional or family member and dispense the medicines required. This is a valuable service which has prevented many hospital admissions but there are occasions where it is still not sufficiently responsive to meet the needs of the patient. In a few cases, the medicines could be delivered but not all and it is never right to take a family member away from the patient to obtain medicines – they should be able to stay with them.
‘Just in case medicines’ started as a project nearly 20 years ago in Bedfordshire and Hertfordshire. It was set up by two palliative care pharmacists with support from other healthcare professionals including Ros Taylor, now medical director for Michael Sobell House. In an article (1) they were able to show that provision of a selection of the essential end of life care injections in prepared packs over a 6 month period made it possible for 16 patients in the area to stay at home to die rather than be transferred to hospital. The Gold Standards Framework encourages pre-emptive prescribing of ‘just in case’ medicines and people discharged from hospital or hospice will usually be supplied with injectable medicines for use when they can no longer take their oral medicines. This practice has become widespread and has reduced the requirement for emergency medicines so the schemes in place have not been on everyone’s radar. It is a very positive practice with one downside, which is that these injections are not always needed so at times they are wasted but on balance, it is preferable to have the assurance they are in place.
People dying with or from COVID-19 have been reported as experiencing rapid deterioration, so prompt access to injectable medicines has never been more urgent.
Although we seem to be in a quieter period now, we need to be prepared for winter and a possible second surge. The pharmacy systems have not worked as well in practice when the need for medicines is less easy to anticipate yet more urgent. One of the hospices we work with has come up with a potential solution, based on practice in at least one other hospice.
We have been working with colleagues in Hillingdon CCG and Central and West London NHS Trusts to build a procedure which allows Michael Sobell Hospice to act as a hub for the supply of medicines when other systems are not appropriate due to rapid deterioration. We have commissioned one of the licenced pre-packing units to prepare some small packs of injectables and a couple of oral medicines. With the support of the CCG, Michael Sobell House will keep a small stock and in extreme circumstances, the nurse or on call GP will be able to call the hospice doctor on call and arrange a prescription and pick-up of the medicines required in as timely a way as possible.
We know some other hospices are interested in this possibility and we look forward to seeing how it goes in the Hillingdon area. Once it’s been tried and tested, we would love to support other hospices in sharing this good practice. Although this scheme has been created during the COVID period, like other initiatives, we hope to be able to continue this afterwards. Please feel free to contact me for more information.