Pharmacy services for vulnerable patients

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Pharmacy services for vulnerable patients




Study Points



image Definition of vulnerable patients


image UK policies relating to vulnerable patients


image Pharmacy services for disabled patients, children and young people, the elderly and those unable to care for themselves


image How pharmacists can help protect children and vulnerable adults



Introduction


Vulnerable patients can be described as those: ‘who are or may be in need of care services by reason of mental or other disability, age, or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation’ (Taken from the 1997 consultation paper ‘Who decides’, issued by the Lord Chancellors Department). Pharmacists are often in a position to help and support vulnerable patients via the services that they provide, and they have a duty to help ensure the safety of children and vulnerable adults.


To identify how pharmacists can support vulnerable patients, the reasons why they may be vulnerable should be considered. Some patients with mental disabilities may have problems understanding disease and its treatment, or they may find it difficult to describe their symptoms or problems to healthcare professionals. These patients may require support to make decisions regarding their health. When dealing with patients with mental disabilities, there can sometimes be complications around consent to treatment. Usually patients should be fully informed about disease and treatment options, and be able to consent to any treatments provided; however in certain cases, if a patient has a reduced mental capacity, then parents, carers and healthcare professionals are involved in the treatment decisions of that patient. In most cases where decisions are made without the involvement of the patient, the actions are in their best interests; however on the very rare occasions that patients do not receive the care that they require, they may not be in a position to recognize a lack or care, raise their concerns or object, leaving them vulnerable to harm.


Some people with physical disabilities may be considered vulnerable as they may be relying on others for their basic daily needs such as bathing, dressing and eating. Some physical disabilities may lead to communication problems which can render a patient vulnerable if they are unable to communicate their needs or raise concerns about harm or exploitation.


Babies and children are considered vulnerable for a number of reasons. Primarily children rely on adults to feed, clothe, wash, care for them and protect them from harm. When adults fail to do this, children are often unable to verbalize their needs or recognize the lack of care. When considering health care, younger children have reduced mental capacity to understand disease and treatment, and rely on parents and guardians to make decisions based on their best interests. When considering UK law, parents and guardians usually consent to the treatments given to children; however as children develop into young adults they acquire more legal rights with regard to consent, and decisions around treatment can become complex. They tend to involve the young person, parents, guardians, local heath authorities and occasionally courts of law.


As people age, some issues around vulnerability can start to emerge, particularly the frail elderly who may find that they are no longer able to take care of themselves. When a person is no longer able to care for themselves either due to frailty or serious illness, they can be considered vulnerable, as they may rely on others for their basic needs and support with undertaking treatments for illness. These patients may require the services of carers or may live in a residential care home. Due to frailty or illness they may not be in a position to report lack of care or abuse from their care providers.


Pharmacists may find themselves providing services to patients who are unable to protect themselves from harm or exploitation; these patients could include children, drug misusers or those in abusive and exploitative relationships. These groups may feel afraid or unable to discuss concerns with health professionals or care agencies.



UK policies relating to vulnerable patients


In recent years, there have been a number of documents published that health professionals should be aware of relating to vulnerable patients. Some of these documents have sadly been published in response to high profile cases such as the Victoria Climbié Enquiry Report (2003), The Bristol Royal Infirmary Enquiry (1998) and the Peter Connelly Serious Case Review (‘Baby P’) (2010), where vulnerable people have been let down by social and healthcare services. These documents aim to prevent harm from occurring with other vulnerable patients. Pharmacists need to be aware of the content and implications for their practice.


No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse was published in 2000 for local authorities, social services, the police, health services, service users and carers. It gives guidance on how to work together and develop local protocols to deal with suspected abuse in vulnerable adults.


Subsequent to the Safeguarding Vulnerable Groups Act in 2006, the ‘vetting and barring scheme’ was developed to help prevent unsuitable people from working with children and vulnerable adults. The scheme is currently under review by the government. The scheme is run by the Independent Safeguarding Authority and is essentially a list to prevent individuals who pose a risk to vulnerable people, from working with them. This list is checked when pharmacy staff are required to undertake enhanced Disclosure and Barring Service (DBS) checks. Currently, pharmacists delivering some enhanced services such as emergency hormonal contraception are required to undertake a DBS check prior to accreditation for the service; however, it is likely in the future that pharmacists will have to undertake DBS checks when joining a new employer.


In 2011, Safeguarding adults: the role of health service practitioners was published. This is particularly relevant to pharmacists as it provides specific principles for all health practitioners to adhere to. The guidance reminds practitioners of their duties to safeguard adults, whilst providing assistance in how to prevent and respond to harm and abuse in patients.


Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children was updated in 2010. This document sets out how organizations and individuals should work together to safeguard and promote the welfare of children and young people. The guidance directs that the Local Safeguarding Children Boards should be working with pharmacists as they are involved in the delivery of services to children.


In addition to these documents that state a pharmacist’s duties in relation to the protection of vulnerable patients, there are also a number of guidance documents that identify where pharmacists can contribute to and enhance the lives of vulnerable patients. These include the National Service Frameworks for children and young people, older people and mental health. National Service Frameworks aim to increase the quality of care that these groups receive and within them many pharmacist roles are identified.



Pharmacy services for disabled patients


Pharmacists have a duty to comply with the Disability Discrimination Act 1995. The Act requires pharmacy premises to accommodate those with physical disabilities, e.g. ensuring wheelchair access. The Disability Discrimination Act also requires pharmacies to make ‘reasonable adjustments’ to support those with disabilities. What amendments are made to ensure that pharmacies comply with the Disability Discrimination Act affects the services that are provided. It can be difficult for a pharmacist to establish exactly what adjustments are needed; therefore decisions are usually best made in partnership with the patient or carer and dependent on their needs. Many services that pharmacies already offer comply with the Disability Discriminations Act. For example, those with dexterity issues could benefit from the use of oversize packaging or the supply of screw caps or wing caps for tablet bottles. Some physically disabled patients may benefit from collection and delivery services. Patients with vision impairments may benefit from the provision of large font labels or talking labels. The medicine use review service is an ideal opportunity to support those with disabilities. For example, if a patient is having difficulty swallowing, then medication could be rationalized to aid adherence or alternative dosage forms could be suggested. If a patient has a mental disability that results in decreased adherence due to cognitive issues, then provision of a multi-dosage system or a simple tick chart can be provided to support medicine taking. Pharmacists should ensure that their services are available to those with mental disabilities; this most often requires pharmacists to take time to ensure that their explanations are appropriate, and pharmacists may need to provide additional support such as providing leaflets or carrying out demonstrations. Involving carers and family members in decision-making and explanations can be helpful when appropriate.



Pharmacy services for children and young people


Pharmacists are often involved in the provision of prescribed medication for babies, children and young people. Particular care is often required when clinically checking prescriptions or carrying out full medication reviews for this group of patients due to the differences in drug handling from adults. As children mature, their total body water decreases, therefore neonates and infants may need larger doses of water-soluble drugs. Neonates, infants and children have a higher metabolic rate than adults, sometimes resulting in the need for more frequent dosing or higher doses of drugs on a mg/kg basis.


Ideally, the drugs used in children will have undergone clinical trials in young age groups for the condition that is being treated. However, most drugs are only tested on adults for safety and efficacy, and are therefore unlicensed for use in children. When prescribing decisions are made, pharmacists can provide their expertise by evaluating current clinical evidence. Pharmacists should recommend using a licensed product where possible, or evaluate the safest and most effective unlicensed products available. Parents and carers may be alarmed at the use of unlicensed products, especially if they read an inappropriate patient information leaflet. Explaining the use of the unlicensed medicines to the parent or carer and involving the whole family in any treatment decisions can help overcome this. If a drug has not been tested in children, then calculating the dosage can be difficult and the age and weight of the child should be considered. If a high-risk medicine is being used, such as those with a narrow therapeutic range, then the weight of the child and the dose in mg/kg should be stated on all prescriptions to ensure safety.


Pharmacists are often the first health professionals that a parent or guardian will encounter if a child is suffering from a minor ailment. When providing over-the-counter (OTC) treatments for children, only OTC products designed and licensed for use in children should be supplied, as they will have been tested for safety and efficacy in this age group. These products are often pleasant tasting, colourful liquids, or melt in the mouth sweets, and are more palatable to children. Parents sometimes have concerns about sugar content, and artificial flavourings and colours; information can be given to help them make informed choices when treating their children. When advising on OTC treatments, this is an ideal opportunity to advise parents about the safe storage of medicines in the home, as these medicines may appear appealing to children.


Pharmacists are able to carry out medicine use reviews and medication reviews with children; this will usually be with the consent of the parent or guardian. These are ideal opportunities to involve the child or young person in decisions around their medication with the intention of increasing adherence. It has been recognized that some teenagers may be embarrassed to take medicines to school, or they may decide that they do not need to follow advice as they assert their own independence. To overcome these problems, pharmacists can support by communicating disease and treatment options to the young person in a way that they will understand, and providing practical support such as suggesting modified-release preparations to avoid school-time dosing or supplying discrete appliances such as insulin pens.


Pharmacies have a role in informing parents and children of local health promotion initiatives. This can include advice on healthy eating, immunization programmes and sexual health. Pharmacists are in an ideal position to promote breast-feeding, give advice on the use of formula milk and help parents to wean their babies correctly and at an appropriate time. Children have different dietary needs to adults; although children do not require the same volume of food as adults, they may need more energy-releasing foods to support their higher metabolic rate. As children develop into young adults, pharmacists can advise on what constitutes a healthy diet, promoting the intake of at least five portions of fruit and vegetables a day, with the hope that good eating habits are taken forward into adulthood.


Babies and children receive a number of different immunizations and parents often have concerns about their use. Pharmacists have a role in educating parents about the safety and importance of immunizations, and they can ensure that they are received at the correct age. It can be difficult for pharmacists to keep up-to-date with what the current recommendations are. The best resource to use in the UK is The Green Book, which is regularly published and updated by the department of health.


Pharmacists are often the first healthcare professionals that a young person may encounter for advice on contraception and sexual health. Pharmacists sell condoms, provide emergency contraception, signpost to family planning clinics, provide Chlamydia screening and treatment programmes, and provide health promotion about sexually transmitted infections. Emergency hormonal contraception (EHC) can be sold to young people over the age of 16 where appropriate, and some pharmacists supply EHC to under-16-year-olds using a patient group direction (see Ch. 48 for further details).


When pharmacists are delivering sexual health services to young people, it is prudent to be aware of child protection and the local safeguarding children procedures. Pharmacists should be aware of repeated requests for EHC, and signs of sexual abuse. Pharmacists need to know what to do if it is suspected that a young person needs help. Usually this involves contacting the local child protection officer and sharing your concerns. The Sexual Health Act 2003 states that children under the age of 13 are unable to consent to sexual activity, therefore if a young person under this age requests advice on sexual matters particularly EHC, then this should be taken seriously, and reported to social services, unless there are exceptional circumstances backed by documented reasons for not sharing the information.

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Jun 24, 2016 | Posted by in PHARMACY | Comments Off on Pharmacy services for vulnerable patients

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