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Children should have access to safe medicines in appropriate formulations
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The long-awaited National Service Framework for Children, Young People
and Maternity Services, published last week by the Department of Health
(PJ, 18 September, p369), sets out 11 standards to be met over the next
decade. The NSF is aimed at everyone involved in providing healthcare,
social care and education services to children, and focuses on delivering
these services around the needs of children and their families.
Part 1 of the NSF sets out the five core standards, part 2 sets out standards
6 to 10, which address children and young people with particular needs,
and part 3 covers maternity services. There is also a document outlining
the key issues for primary care. Several versions of the NSF are available,
including a children’s version, young people’s version and
a parent’s version.
The 10th standard of the NSF focuses on medicines. It states: “Children,
young people, their parents or carers, and health care professionals
in all settings make decisions about medicines based on sound information
about risk and benefit. They have access to safe and effective medicines
that are prescribed on the basis of the best available evidence.”
Markers of good practice in the medicines standard
· The use of medicines is based on the best available
evidence of clinical and cost effectiveness
· Children have equal access to safe, clinically and cost effective
medicines in age-appropriate formulations
· Information support is available for those who prescribe, dispense
and administer medicines for children and young people
· Children and their carers receive consistent, up-to-date information
on the safe use of their medicines
· Parents, young people and children, if appropriate, should
be active partners in the decision about their medicines
· The use of medicines in children is incorporated in the clinical
governance and audit arrangements of PCTs, NHS trusts and other
organisations
· The contribution of pharmacists in the effective and safe use
of medicines in children is maximised |
One
of the markers for good practice for this standard (see panel) is to
ensure that the contribution of pharmacists in the effective and safe
use of medicines in children is maximised, and there is also a section
dedicated to the specific role of the pharmacist. However, the medicines
standard is designed to be used in conjunction with the other standards,
all of which have aspects dealing with medicines.
Tony Nunn, clinical director of pharmacy, Royal Liverpool Children’s
NHS Trust, and chairman of the external working group on medicines, says: “If
pharmacists read the NSF carefully they will find lots of opportunities
relating to medicines that don’t specifically mention pharmacists,
so I would recommend that they read the other parts as well as the medicines
section. If they don’t have time to read it all, they should read
the primary care section and the executive summary.”
David Pruce, director of practice and quality improvement at the Royal
Pharmaceutical Society, points out that the NSF for Children, Young People
and Maternity Services is the only NSF to have a specific standard for
medicines, although the NSF for Older People did have a document devoted
to medicines. “The fact that medicines management is one of the
11 standards as well as there being a separate document on the subject
helps ensure that what is in the NSF about medicines will be implemented,” he
says.
Throughout the medicines standard, team working and communication are
key themes, as is the promotion of healthy lifestyle messages in relation
to nutrition, physical activity, reducing alcohol intake and substance
misuse, especially in areas of deprivation.The NSF says that community
pharmacists should be encouraged to focus on the most hard-to-reach and
vulnerable families in their community. Mr Pruce explains: “Inequality
in childhood is a key indicator of future health. If you target services
towards the more disadvantaged, you are more likely to narrow health
inequalities.”
The NSF calls for greater use to be made of community pharmacies as a
health resource, noting that 20 per cent of calls to a primary out-of-hours
centre and at least 8 per cent of accident and emergency department consultations
could be handled by a community pharmacist. Pharmacists also have a role
in providing smoking cessation advice to young people or referring customers
to other NHS smoking cessation centres.
The document suggests that confidentiality requirements set out in the
Royal Pharmaceutical Society’s code of ethics should be promoted
in an attempt to increase young people’s confidence in approaching
pharmacists for advice. It acknowledges that 80 per cent of teenagers
using community pharmacies to access emergency hormonal contraception
generally find the level of privacy acceptable, although the fact that
20 per cent of young women using this service have concerns about confidentiality
shows that there is room for improvement through premises design and
consultation areas.
Mr Nunn says: “The first five sections of the NSF, the core standards,
talk about health promotion and acknowledge the community pharmacist
as a source of healthy lifestyle information, as well as providing information
and advice on medicines and management of minor illness.” He points
out that comments in the section covering “children and young people
who are ill” (standard 6) say that community pharmacists are a
point of entry to the NHS and an important part of primary care provision.
Hospital pharmacists also have an important role in the provision of
children’s services, which may include arrangements for the child’s
treatment after discharge and liaising with community services. The NSF
states: “Hospital pharmacists should communicate directly with
colleagues in other hospitals and in the community when a child or young
person is transferred or discharged, when medicines are unusual, require
special preparation or consideration, or are difficult to obtain.” It
says that in the future, the development of robotic dispensing and electronic
prescribing will enhance the contribution that hospital pharmacists can
make to the team. Hospital pharmacists can also provide advice on the
clinical and cost effectiveness of medicines.
Steve Tomlin, principal paediatric pharmacist at Guy’s and St Thomas’ NHS
Trust and chairman of the Faculty of Neonatal and Paediatric Pharmacy
(FNPP), was also a member of the external working group on medicines.
He says: “While the document may not be rocket science, it must
be remembered that the NSF is a document from Department of Health ministers
to encourage best practice across England, and not
produced to discuss every issue of paediatric medication management or
every cutting edge piece of practice. The document does, however, invite
some forward thinking and set base line standards. It looks forward to
integrating technology into medicines support and finding ways of providing
appropriate information to children and carers. It also asks about competence
to practise in the paediatric setting, an issue that the FNPP has been
trying to address for the past year or so.”
Other issues covered in the medicines standard include:
Unlicensed and off-label medicines Customised formulations for children
should only be used when there is no licensed medicine that would meet
the clinical need and proper guidelines and supervision procedures should
be followed.
Support and information All health professionals treating children should
have access to support and information. (Mr Pruce says: “Health
care professionals don’t always have access to good information
regarding medicines in children. Although there are some excellent sources
around, these tend not to be used outside paediatric departments of hospitals.
We are now developing the BNF for children to provide an authoritative
publication that we hope will be widely available.”) PCTs and NHS
trusts should ensure that clear and prompt written communication takes
place between hospital specialists, GPs and, where appropriate, community
pharmacists about medicines prescribed for a child.
Medicines at school Schools should have access to appropriate advice,
training and support from local health professionals, including pharmacists,
so they can make decisions and support children taking medicines during
the school day.
Improving access to medicines Pharmacists should provide compliance
aids where appropriate and agreed locally, carry out regular medication
reviews for children and young people on complex long-term treatments
and advise on appropriate formulations. (Mr Pruce says: “We recognise
that pharmacists are doing a lot of this anyway, whether as specialist
paediatric pharmacists or as ordinary hospital or community pharmacists.
There is a lot of good practice out there already, and this NSF is about
bringing it all together and encouraging all pharmacists to adopt good
practice.”)
According to Mr Nunn a key point about the NSF is that it is realistic.
He says: “The Government has to make a judgement on what is affordable
and what impact practitioners will have on improvements in child health.
It has to put out a balanced, achievable document. All of the medicines
aspects of the NSF are achievable, although a lot of work is needed in
some areas. It is important to remember that this is a 10-year journey.
This is the direction of travel that we need to follow and we don’t
expect it all to be implemented tomorrow.”
He adds: “The Royal Pharmaceutical Society is an important agent
for change in pharmacy and should be one of the champions for children.
We need local champions as well, so any pharmacist who picks up a copy
of the NSF should see opportunity for change and consider how to contribute.”
Mr Pruce says: “We will be looking closely at how the NSF for Children
is implemented and at what our role might be in supporting the implementation,
especially of the medicines management standard.”
Mr Nunn also says that he would advise pharmacists to find out who their
local children’s lead or commissioner is. This is a named individual
with responsibility for planning and delivering services for children
who should be in place in all trusts including PCTs and the Strategic
Health Authority, as outlined by Al Aynsley-Green, national clinical
director for children, in “Getting the right start: NSF for Children — emerging
findings” (PJ, 19 April 2003, p539). “Pharmacists
should aim to get together with their children’s commissioner or
medicines management pharmacist in their primary care trust to discuss
what the
NSF means
and how changes can be implemented locally,” says Mr Nunn.
Mr Nunn notes that although there was no new money specifically provided
for the NSF, the Government has promised to fund the BNF for children
and provide funding for the paediatric
medicines strategy announced in
August (PJ, 21 August, p246).
The NSF can be accessed here
Broad spectrum, p416
FIP congress report, p434
What is happening with services for children and young people in
Wales and Scotland
Wales
In 2001 Jane Hutt, health and social services minister for Wales,
announced that Wales would have its own separate National Service
Framework for Children, Young People and Maternity Services. The
consultation document for this is due to be launched on 15 October.
Huw Jenkins, director of health care services for children and
young people in Wales, has been directing work on the document
since it
began in 2002. He explains that the different structures of the NHS
in England and in Wales mean that separate NSFs are likely to produce
better results. He says that the aim is to make the Welsh NSF more
inclusive across all the agencies that have an impact on children’s
health and wellbeing and that, whereas the English NSF is a partnership
between health and social services, the Welsh NSF also includes standards
for housing, leisure, transport and education. He says: “To
limit standards to health and social services would not really impinge
upon children’s lives. To make a difference to children’s
and families’ lives you need to make sure that all the potential
areas and agencies that may affect children’s heath and wellbeing
are involved.”
The aim of the Welsh NSF, also a 10-year programme, is that “all
children and young people achieve optimum health and wellbeing and
are supported in achieving their potential”.
It will consist of the following seven modules incorporated into
one document:
· Improving health and wellbeing of all children and young people
· Mental health and psychological wellbeing of children and young
people
· Disabled children and young people
· Maternity
· Children and young people in special circumstances
· Children and young people suffering from acute and chronic illness
or injury
· Medicines
Dr Jenkins says that the standards within each
module will be followed by key actions that are specific, achievable
and measurable. He stresses
that these will be written in the present tense so that they can
be specifically audited with a “yes” or “no” answer.
He acknowledges that there are similarities between the English and
Welsh NSFs, although he says there may be differences in the interpretation
and delivery of the key actions.
“ We are conscious in Wales that having a glossy document of standards
and key interventions is all very well but that is the easy part.
The difficult part is the implementation and monitoring, which is
absolutely key.”
He explains that Wales is developing a unique self-assessment audit
tool that has not been used with any other NSF.
The Welsh NSF will be produced as a full version (200 pages) containing
the rationale and references, a shorter version containing the specific
standards and key actions, and a young person’s version.
Although no money has been promised specifically for the implementation
of the NSF, Dr Jenkins explains that he hopes it will provide a platform
from which to bid for funding from the Welsh Assembly Government.
A three-month consultation period will follow the launch of the consultation
document, during which three regional workshops will take place,
attended by all relevant stakeholders. Following the collation of
responses, the final document is expected to be launched next summer.
Further details are available at www.wales.nhs.uk/nsf.
Scotland
In October 2001 the Scottish Executive published a report entitled “For
Scotland’s children” which outlined how all agencies
should work together to integrate children’s services. An action
plan detailed ways in which local authorities, the NHS and the voluntary
sector can work together to create a single children’s services
system. |
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The
Pharmaceutical Journal