|
Martin Howard, MA, is service
improvement manager for long-term
conditions
Joel Hirst, MPhil, MRPharmS, is
quality improvement facilitator for
medicines and pharmacy
Alaster Rutherford, BPharm, MRPharmS,
is head of medicines management
All are at Bristol Primary Care Trust |
• How the service works
• Feedback and support
• Evaluation
• Next steps
Umda Dawa — case studies
|
Martin Howard
Cultural differences, such as diet, can affect patients’ management
and understanding of their diseases and medicines |
Umda Dawa is a local NHS service offering medicines advice to Bristol’s
south Asian population. The words can be translated from Urdu as “good
medicines”. The idea for the service arose from research and anecdotal
evidence that cultural differences, and not just language difficulties,
mean that people from a South Asian background can be disadvantaged in
understanding their medication and how it fits alongside diet and other
areas of life. The outcome can be poor or incorrect use of medicines,
leading to diminished or adverse effects.
Bristol Primary Care Trust
is seeking a new approach to the prescribing and taking of medicines,
based on partnership. An article in The Pharmaceutical Journal (14
May, 2005, p585), describing
similar issues in Glasgow and showing that
these
issues could be tackled, inspired us to pilot our Umda Dawa service,
which started in November 2005.
How the service works
We wanted to provide culturally sensitive advice to people on:
• How their medicines work
• Diet
• Practical aids to medicine taking
• Sources of information and help (eg, patient groups)
The service is run by two community pharmacists, Saeed Kamal and Uzma
Iqbal, who are employed by Bristol PCT for one day a week. Both come
from South Asian backgrounds. The choice of a male and female pharmacist
was deliberate, in order to reduce gender barriers in the service. The
pharmacists offer one-to-one pharmaceutical advice and medication reviews
to any South Asian adult from the community who might benefit. Because
of their cultural backgrounds, both pharmacists offer in their consultations
a way of bringing together western approaches to medicine, diet and health
with the client’s cultural approach to medicines. They encourage
a dialogue that supports clients to use and understand both their medicines
and their medical consultations to best effect. Umda Dawa is not a language
interpretation service, which the PCT already has, but more of a cultural
interpretation service.
Three methods of selecting clients were tried. The initial vision was
that the service would be offered outside the usual health care settings,
in order to find people in their own community, similar to the service
in Glasgow which offers medication reviews in a mosque (ibid). Early
weeks of the pilot were occupied by speaking slots at social and religious
gatherings. There was interest from the audiences, but the follow-up
by potential clients was poor and a drop-in session offered at a community
centre was unsuccessful. It was soon realised that although this community
health development approach was valuable, it was a slow way of starting
so, alongside this method, a more traditional way of finding suitable
clients, such as raising awareness at meetings of health care workers,
was used.
The third strategy, which is now our main one, was “case-finding”.
Although ethnic origin is not reliably recorded in practices, our two
pharmacists were able to use practice systems to find patients who were
over 40 years old, were taking three or more medicines and had coronary
heart disease, blood pressure, asthma or diabetes. From this group, patients
who were likely to be of south Asian origin (ie, had a South Asian name)
were selected, giving a list of possible clients. The best results came
from combining this with information from practice nurses. Potential
clients were then telephoned by the pharmacist, who explained the service
and offered an appointment at the clients’ own GP practice.
Both pharmacists spent time building relationships in the practices they
visited, and these relationships generate referrals to the service from
doctors and nurses. However, potential clients may be missed using this
method and case finding still presents the most thorough approach.
Readers may wonder how this service has been possible over an urban area
(formerly Bristol North PCT) that covers half of Bristol, with 220,000
patients and 31 practices. From census data and local knowledge it is
known that most of the population with a South Asian background live
in one area: Easton. This area has three times the average proportion
of black and ethnic minority people in Bristol, with large Pakistani,
Indian and Bangladeshi communities. The area is also within the worst
10 per cent of areas in England for deprivation. Once the co-operation
of the eight or so local GP practices in and around Easton had been obtained
it was relatively easy to find people who were likely to benefit from
the service.
Initially, the scope of the project was broad: testing for which medicines,
which acute or long-term conditions and which people the service would
best work. But our targeted case-finding approach has meant that most
of the clients have long-term conditions, diabetes being the most common.
The Panel (below) illustrates two consultations with patients with diabetes
that our pharmacists described.
Umda Dawa — case studies
Case 1 Mrs X is a 35-year-old woman who was diagnosed with type
2 diabetes a fortnight before the consultation. Since then she
had
been avoiding food because she thought that it would increase
her blood glucose levels and, as a result, she lost 3kg. Mrs
X was
stressed about the diagnosis because she is the only member
of her family to have diabetes. During the consultation, I explained
the importance of healthy eating, exercise and regular blood
glucose monitoring in order to control and prevent deterioration
of her
condition. Because her diet consisted of mainly Asian foods
I
told her what to avoid and what she could eat. After the consultation,
Mrs X felt more relaxed and had a better understanding of the
need
to control her disease and the lifestyle changes to make.
Case 2 Mr Y was a patient whose diabetes had
not been in control for a few years. His GP and the practice
nurse could not find
the core of the problem and I, too, was puzzled because the patient’s
medication compliance was 100 per cent. During a medication review,
I asked Mr Y what he ate each day. For breakfast he drank five
glasses of lassi, an Asian drink made with yogurt, with 10 spoons
of sugar. I asked him whether he had told his GP about this drink.
His answer was interesting: his GP or nurse would not understand
this drink because “it is not available in this country” so
he had never told them about it. He had told me because I spoke
with him in Punjabi. I asked Mr Y to stop drinking lassi. Apart
from this, his diet was healthy and I think this was the main
factor in his uncontrolled diabetes. |
In addition to a consultation and medication review, the pharmacists
occasionally acted as advocates in clients’ appointments with their
GP or nurse.
Feedback and support
We wanted the service specifically to respond to the local community
so governance of the pilot included the input of a community reference
group, comprising eight representatives from local groups, such as
the Asian Women’s Group and the Bristol Muslim Cultural Society.
The group gave feedback and also some opportunities for promoting the
service. It was chaired by a PCT non-executive director who is also
chairman of the Bristol Care Forum, an organisation that supports and
promotes partnership working with
the
voluntary sector. The project steering group is chaired by a PCT director.
We were also clear that the service, if it proved successful, needed
a high profile to have the greatest chance of sustainability. The service
is part of the NHS Live programme, which brings together diverse projects
that have a common thread of improving patient services with a high degree
of user involvement. Having our Umda Dawa service within NHS Live opened
the door to a partnership with AstraZeneca. The partnership does not
involve exchanges of cash or resources but is an opportunity to exchange
skills. Our immediate need was for marketing advice and the everyday
skills of this large pharmaceutical company were helpful to our keen
but less commercially aware NHS project team. Other benefits for the
PCT and AstraZeneca included learning to improve client consultation
skills and the chance for AstraZeneca to better understand the changing
landscape of primary care.
Evaluation
In the first 12 months of the project, the pharmacists saw 154 new
clients. A further 76 were invited but did not attend, and 64 people
turned
down an appointment after discussing it on the telephone.
Qualitative measures included collecting stories from clients to
illustrate the service, and their views on the value, convenience
and experience
of the consultation. These were collected by telephone two to three
months after the appointment. In addition, after each appointment,
the pharmacist
completed an evaluation form to score clinical outcomes and his or
her perception of the quality of the intervention.
The quantitative evaluation included an estimate of hospital admissions
avoided and possible savings in medicines costs. It is this information
that will enable the PCT to consider the real costs and savings if
the service is to be made permanent.
The evaluation is ongoing, but early results showed that in a sample
of 69 clients, main outcomes included:
• Fewer visits to the GP (3)
• A reduction in falls risk (1)
• Improved concordance (18)
• Better patient knowledge (61)
On average, each consultation lasted 46 minutes.
Next steps
If the service is made permanent, with the benefit of more people being
aware of it, we will try again to run consultations in non-medical
settings, such as community centres. However we have learnt that
running umda dawa alongside mainstream NHS health centre services appears
to
lend it credibility. In addition, people feel more comfortable in
places they are familiar with, such as their GP surgery.
We have also started to experiment with extending the service to
see if a case management role would be useful. Currently, clients
are offered
one appointment, with a possible follow-up. Case management would allow
for a selected group to benefit from a series of consultations.
Early indications are that this service is valuable to clients, and
we await other data by the end of the financial year that will indicate
whether or not it is cost-effective. If the service expands, it could
be offered to other ethnic groups, although this would rely on finding
equally enthusiastic pharmacists from the required cultural backgrounds. |
The
Pharmaceutical Journal