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Letters to the Editor
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Monitored dosage systems (MDSs)
Requests are often inappropriate and ill-considered
From Ms S. Higgins, RegPharmTech
I am entirely in agreement with Bob Gartside (PJ, 13 August, p192).
In my experience of working on elderly care wards in Portsmouth, requests
coming from wards for patients to be discharged from hospital with a
monitored dosage system are often inappropriate and ill-considered. That
social services carers are “not allowed to give medicines unless
they are in an MDS” is the frequent reason given for this request.
Who, then, administers the medicines that are physically unsuitable for
inclusion in an MDS, such as soluble tablets, liquids, eye preparations
etc? This identifies the need for training for home carers who care for
patients who are unable to manage their own medicines. MDSs are not the
answer here. My own grandmother was frequently not given her medicines
by her home carers, despite the fact that they were in a blister system.
I have often found that other options to assist patients in understanding
and managing their own medicines have not been considered by nurses or
by staff from social services. Many patients have their own individual
methods of coping with their medicines and, since taking medicines is
part of their daily lives, it is our place to help them to manage in
the way that best suits their needs. Sometimes assessing a patient’s
medication management needs while they are still in hospital is difficult
because they do not have their familiar containers and storage places
and cannot always explain their coping strategies. I have had more that
one interaction with a patient who was upset that we wanted her to change
the way that she managed her medicines at home by putting them in an
MDS. I have found that compliance cards are often all that the patient
wishes us to provide because they have helpful neighbours, friends or
relatives who already have a system set up to assist the patient with
all aspects of daily living.
MDS trays are mistakenly seen as the solution for patients who cannot
remember to take their medicines. Having medicines in an MDS does enable
a person to see whether they have taken their medicines or not, but it
does not remind them to take them in the first place.
Some patients in my experience have had complex prescriptions and it
is understood that an MDS device can be of some help. However, taking
into account when medicines should be taken in relation to food and other
medicines and, indeed, whether they are actually suitable to be included
in an MDS at all, is a minefield.
In the end, it is the patient’s choice whether or not they take
their medicines, and which medicines they choose to take. I have seen
a few returned MDS trays with contents that have been selectively taken,
which defeats the object of them being put in the MDS in the first place.
We cannot stop patients and their carers from putting their medicines
into the various organiser devices that are freely available to buy.
We can, and should, ensure that we only initiate dispensing into an MDS
when it is appropriate, and we are certain that the patient will be followed
up and any problems they have will be addressed.
Sue Higgins
Senior Pharmacy Technician
Queen Alexandra Hospital,
Portsmouth
I believe demand is likely to be high
From Mr G. Ratcliffe, MRPharmS
I have read and researched our liability with regard to the Disability
Discrimination Act (DDA) and the new contract framework.
My belief is that the qualification and subsequent demand for level 2
of the service, ie, monitored dose systems (MDSs), is likely to be high
and beyond the current level of funding via the additional practice payments.
I see this as an opportunity for the profession to negotiate centrally — and
locally — for funding to provide MDS services to all patients who
could benefit from them. Recent discussions with other pharmacists have
shown that some have the opposite view, believing that demand is likely
to be low and that this is an opportunity to withdraw MDSs from patients
that do not qualify for them via disability assessments. I would be interested
in the opinions of other readers.
Glyn Ratcliffe
Birmingham
Contract confusion over MDSs clarified
From Mr S. J. Lutener, FRPharmS
In his article on monitored dosage systems (PJ, 13 August, p192), Bob
Gartside begins by stating that the Pharmaceutical Services Negotiating
Committee and the Department of Health have decided that MDSs should
be covered by the new pharmacy contract. This is misleading and adds
to the confusion that surrounds the use of MDSs in community pharmacy.
The new contract service “support for people with disabilities” does
not mean “supply of MDSs” in all cases.
The PSNC and DoH agreed that the new contract funding would include a
contribution to the costs of compliance with the Disability Discrimination
Act 1995. Within the meaning of the DDA, a disabled patient is one with
a physical or mental impairment that has a substantial adverse effect
on their normal day-to-day life.
When providing dispensed medicines to this group of patients, the pharmacy
contractor is obliged to make reasonable adjustments if the patient would
otherwise find it impossible or unreasonably difficult to take their
medicines. The pharmacist must assess the individual needs of the patient
and how to address them. An assessment
toolkit has been produced.
MDSs are just one of the adjustments that might be required and, as Mr
Gartside points out, there will be only a narrow band of patients for
whom MDSs are suitable. Other support for people with disabilities include
large print labels, easy open containers and reminder charts.
Many pharmacists, patients, carers, prescribers and primary care organisations
have assumed that, because the new contract funding includes a contribution
towards compliance with the DDA, this provides funding for MDSs for all
patients who might benefit.
This is not correct, because many patients who would benefit from MDSs
do not fall within the definition of disabled, and so are not entitled
to additional support under the DDA. Formerly, these patients were supported
by local arrangements but, due to the misunderstanding of the extent
to which the national funding applies, many local arrangements have been
withdrawn.
I hope this letter removes some of the confusion, so that local arrangements
can be reintroduced to support patients who are not disabled but who
would benefit from MDSs or other additional support.
Stephen Lutener
Head of Regulation
Pharmaceutical Services Negotiating Committee
Important role in safe administration of medicines
From Dr B. B. Shetewi, MRPharmS
I worked for Boots The Chemists for many years promoting and training on the
use of its monitored dosage system service. Although I agree with many of
the issues raised by Bob Gartside (PJ, 13 August, p192), I would like to submit
the following observations:
Any system that mixes different medicines in the same compartment is unsuitable
because it takes the elimination choice out of the equation. This cannot be
acceptable, especially when we have so many formulations that are identical
in size, colour and shape.
I disagree with Mr Gartside when he asks whether, if there is no acceptable
evidence that MDSs do any good, it is possible that they are harmful. Why
can we not think of them as compliance aids and see the positive side that
they offer: the right dose and the right strength of the right medicine taken
at the right time and in the right way by the right patient. Where is the
harm in that?
Since we have no other criterion to go on so far, I believe that common sense
is a good yardstick. Opening bottles, reading labels and counting tablets
cannot be compared to the convenience and accuracy — yes, accuracy — that
the MDS provides, especially for the elderly and patients with impairments.
Mr Gartside cites the manual dexterity needed to extract tablets and capsules
from MDS trays. Are they different from those required to open bottles or
patient packs?
Regarding stability, what is the difference between a tablet sitting in the
pharmacy for umpteen weeks and one in the same blister for four weeks in the
MDS, or a tablet in a bottle? Let us be clear: if a medicine is used within
the time it is meant to be used then the stability question does not come
into the equation.
I agree that there is a lack of research into this area. I would have assumed
that the interested parties would have initiated a thorough independent study
into the above by now. It would have cleared the air and proved, beyond doubt,
the important role the MDS plays, and will continue to play, in the safe administration
of medicines, both to individuals in the community and in care establishments.
B. Shetewi
Fetcham, Surrey |
The
Pharmaceutical Journal