Disruptive innovation works!

February 16, 2018March 10, 2020 Steve Turner

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Being a disruptive innovator is hard to start with and may not fit into the standard tendering process, and you may appear to conflict with existing hierarchies.

Although I try to avoid jargon and avoid buzz words and fads, I think ‘disruptive innovation’ is probably a good description of work my Associates and I have been involved in.

You may find that the final product isn’t what you originally thought it was going to be, and it may take a long time for the beneficial changes to become accepted and spread.

In the end the benefits to patients and the public speak for themselves and it’s a hugely rewarding undertaking.

Some examples:

Childrens’ medicines safety

A successful interdisciplinary, multi-organisational prescribing project and the development of a parent held medicines record for children in the community with complex conditions.

This work was published as a NICE shared learning example, was highly commended at the NICE Conference in 2005. It has had a lasting legacy.

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Helping patients lead on their own care

My Associates and I have also developed, and successfully piloted, ‘patient led clinical medicines reviews’.

This novel approach involves medicines education session for patients, followed by the opportunity for people to review their medicines in a 3/4 hour session with two health professionals. It is published as a NICE shared learning example .

It’s listed on the NICE Shared Learning pages here: https://www.nice.org.uk/sharedlearning/patient-led-clinical-medicines-reviews

I spoke on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference.

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Implementing safer prescribing in substance misuse

A successful inter-disciplinary project to implement non-medical prescribing across a substance misuse service. This project included developing and implementing an interdisciplinary / cross organisational medicine governance process.

This project was presented at the national NHS Change Day event in 2012 and published in the Nurse Prescribing Journal.

Ref: Introducing nurse prescribing in a substance misuse treatment service (Nov 4, 2012) Nurse Prescribing 2012 Vol1 10 No 11

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Turning Up The Volume! for patient safety

In 2014 set up the Turn Up The Volume! patient safety movement, the aim of which is to promote best practice in patient safety through listening openly to concerns of patients, staff, carers and relatives, and taking actions together.

Dr Steve Bolsin talking at Turn Up The Volume! 2 London 2017

We have held two successfully open events and been influential in shaping NHS initiatives on ending the need for whistleblowing in relation to patient safety. I have presented on this at a number of national and local events, including a Health Education England ‘Future of Medical Education’ Conference in 2016 and at Barking Havering and Redbridge University Hospitals NHS Trust, as part of their dignity at work month.

Author: Steve Turner steve@carerightnow.co.uk 07931 919 330 @MedicineGovSte

Join in with #MedLearn – and follow @MedicineGov

#EDUCATION

Version 2 : 09/07/2019

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Medicines Optimisation – what does this mean to patients?? (5 minute read)

February 12, 2018February 2, 2022 Steve Turner

Medicines Optimisation and shared decision making are frequently used buzzwords – what do these terms mean in practice?? – here’s some patient stories to reflect on:

These stories are fictitious but based on real events:

Ben’s holiday – (finding out what a medicine does by accident) :

Ben is a 16 year old boy who has been prescribed a drug for a behavioural condition, it’s a powerful drug (called an antipsychotic) which he has taken for over a year. His parents think it helps. Ben hasn’t said what he really thinks, but accepts the tablet.

A few years ago the family went on holiday to Poland. During the holiday there was an air traffic controller’s strike. The family were stuck overseas waiting for the strike to end. They ran out of Ben’s medicine and were unable to obtain any or anything similar. As a result, out of desperation, they gave Ben a saccharin tablet instead, and hoped for the best. He was fine. Over the next few weeks they even noticed an improvement in his mood and behaviour. He seemed to be enjoying life more. When the family returned to the UK they stopped giving him the ‘placebo’ tablets, and he has not needed to take medicines since.

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Ian’s secret: (in jargon this is ‘intentional non-adherence’)

Ian is a 35 year old man diagnosed with bipolar disorder. When Ian moved to another part of the country he was allocated a new community psychiatric nurse [CPN] and, as he was unwell at the time, was re-started on medication. Over the next 18 months Ian’s condition improved so his CPN reported a ‘good response to the medication’. It was only after 2 years of knowing him that Ian confided in his CPN that he didn’t take the medication consistently, and never had.

The medicine was lithium, which requires regular blood tests. This is because too much of it is toxic and too little has no effect. Ian revealed that he had only taken it before his blood test days, then always stopped taking it in between.

Ian’s medical notes had stated that he always ‘responded well to lithium’!

As a result of Ian being able to trust his CPN, and let on that he wasn’t taking it, his medical records were corrected to say that he did not want to be prescribed lithium, confirming that other options worked much better. These options include some medicines which he had previously ‘borrowed’ from someone else, or bought on the internet. Of course he didn’t tell medical staff about this at the time.

So his choice is now clearly written up, should he become unwell again.

…and now the ‘science bit’. If you want them I can provide references for medicines geeks like me! steve@carerightnow.co.uk

Medicines Optimisation is a powerful term because it brings in the:

Patient’s views and their decision

Clinical people may think they ‘know best’, but in the end it is the patients (you and I) who will decide whether or not we take the medicine, and we will not always tell the doctor or nurse if we don’t feel we can trust them. Statistically around 50% of people, (all ages all types of people), don’t take their medicines as prescribed.

The ‘human factors’ and health beliefs related to having to take medicines

Medicines aren’t always the answer. We may have strong beliefs in favour or against them; these beliefs are hard to change and need to be respected. Basically we usually know what’s right for us.

The ‘evidence base’, which means is it known to work?

People who prescribe medicines (usually doctors, pharmacists or nurses who have the qualification) need to offer the medicines which are proven to be most effective. And there is often a choice.

Repeatedly studies have shown that clinicians have a list of medicines they prescribe for various illnesses in their minds, and this list may bear little or no relation to the evidence available on what works best.

Medicines optimisation is not simply another term for ‘medicines management’, which is generally used to refer to the mechanics of the medicines process. This leads us to consider not just the process of selecting, prescribing; ordering; supplying; administering and monitoring, but also whether the person has the capacity and enough knowledge to decide to take a medicine; if they actually take the medicine and indeed whether the medicine is needed in the first place.

Sometimes people need multiple medicines (referred to as polypharmacy) because of the complexity of their illnesses. This can be inappropriate if, for example, a medicine is simply added to counteract the side-effects of another medicine.

I will be speaking on Managing care for patients with multimorbidities – case studies of implementing NICE guidance at the 2018 NICE Annual Conference

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Steve is a nurse prescriber, Head of Medicines and Prescribing for @MedicineGov , Associate Lecturer at Plymouth University and former NICE Medicines and Prescribing Programme Associate.

You can follow Steve’s tweets @MedicineGovSte

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Version 1 Added 12/02/2018 Amended 15/11/2019 & 02/02/2022

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Nurse & former patient teaching together as equals

January 30, 2018July 9, 2025 Steve Turner

Shared decision making in mental health.

‘Such a great lecture one of the best since I’ve started Uni’

A workshop session delivered jointly by a facilitator and a user of mental health services

Comments from our students:

‘Thank you. It is always much more real and interesting when taught by someone with real experience, as opposed to theories. Really useful’.

‘It was great to hear Sam’s personal experiences and hear how Steve related them to practice.’

In these sessions you can ask us both anything.

Join us on YouTube.

Aim of the session:

To discuss adherence to medicines and treatments; relate this to practice through group work and discuss this with a user of mental health services

Example learning outcomes (can be tailored to individual needs):

• To be able to relate theory to practice and give examples of techniques to achieve adherence

• To be able to describe the key issues around adherence and shared decision making

• To be able to define compliance; concordance and adherence and why these are helpful terms

• To have the opportunity to ask questions directly to a user of services and a front line clinician

Comments from attendees include:

• Real life experience better learning environment

• Fascinating and very brave to explain one’s highs and lows to strangers. Thank you x

• Great hearing first-hand experience

• Good balance of theory and practice

• Sam’s talk was brilliant and really helpful

• Brilliant having opportunity to speak to someone who has been through it

• Found the opportunity to question a service user very beneficial. To hear first-hand what he found good and bad during his experience in the mental health system

• The user of services sharing their views on meds, treatment and compliance, concordance and adherence

• Shared info. from a person with own experience & what he identified are characteristics that made a good nurse & the honesty of his own concordance with meds.

• (appreciated) Your honesty

• Providing insight into personal experiences and services

• Nice to hear someone speak honestly about concordance from a service user’s perspective, especially from not taking meds.

• Learning in-depth about adherence, concordance and compliance

• The way our guest was talking about his experience was great, very interesting; honest …just real

Steve Turner and his company Care Right Now CIC were involved in innovative healthcare projects, several of which have achieved national recognition in the UK.

Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed

Author: Steve Turner

Updated: 09.07.2025

Accountability, clinical education, Clinical Governance, Community Care, Ethics, health, healthcare, Law, medicines, nhs, prescribing

Psychotropic medicines for people with learning disability / autism

January 25, 2018January 3, 2025 Steve Turner

Prescribing psychotropic medicines for people with learning disabilities / autism who show symptoms of distress*

( #jargonbuster – psychotropic medicines = The phrase “psychotropic drugs” is a technical term for psychiatric medicines that alter chemical levels in the brain which impact mood and behaviour. Often referred to as anti-psychotic medicines).

Summary:

People with learning disabilities and / or autism can be prescribed antipsychotic medicines for reasons other than to treat psychosis. This is a complex area that involves detailed knowledge off the patient and inclusion of everybody concerned with their care. This includes parents relatives and carers and must involve anyone with power of attorney [LPA] or a Court of Protection Deputyship. This piece sets are some of the key areas to consider when prescribing in the form of an aide memoire. It is important to note that the art and science of prescribing is not simply about writing a prescription. It is also prescribing decision if a medicine is stopped, changed or the dose altered, or if a non-medical option is chosen. Avoiding unnecessary prescribing should be an absolute priority and all guidelines refer to this. On the other hand, some patients require unusual medicines regimes. If this is the case, then the reasons for this must be fully documented as part of a multidisciplinary process including best interest decision-making. This must then be regularly monitored and reviewed.

Key points:

Facts:

Most of the prescribing in this area is ‘off label’ ( #jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine, or is over/under the recommended dose).
This prescribing can include multiple anti-psychotic medicines, often medicines in the same class. There is a limited evidence base for this type of prescribing. Concurrent prescribing of this nature renders the medicines off-label.
Psychotropic medicines in people with learning disabilities / autism who show symptoms of distress* should be initiated by an appropriate specialist, after which they are not always prescribed by a specialist in this area.
Diagnostic overshadowing may lead to inappropriate prescribing.

Diagnostic overshadowing is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition.

Actions to take for each person:

A Holistic assessment including taking all measures possible to understand why the person may be distressed, and taking actions to alleviate this, based around the person.*
Ensure that the prescribing takes into account the tests and monitoring required for safe prescribing, and takes into account the latest national and local guidelines.
Before prescribing it’s important to understand all triggers and environmental factors. Plus the reasons for behaviour now and what has happened in the past, including what works well and what acts as triggers*.

There are ongoing concerns that psychotropic
drugs are used inappropriately in people with
intellectual disability. [2]

After exploring ALL options, if medicine is thought to be the answer:

Ask about allergies, sensitivities and adverse reactions to medication. Check the documentation on this and ensure it’s recorded accurately (e.g. if the person has reacted to a drug is the nature of the reaction recorded in full, and has it been shared with all involved in the person’s care).
Take into account views of family and carers.
Take into account any advance decisions and support plans.
Take care to avoid diagnostic overshadowing.
Ensure there is specialist initiation and review of the prescribing.
Ensure Multi-Disciplinary team involvement & inter-organisational involvement.
If the prescribing deviates from guidelines (for example around tests and monitoring required and dosage) this must be documented, with a reason.
Act in accordance with the Mental Capacity Act [MCA] , where capacity to make a specific decision is lacking. (NB: Mental Capacity assessments must be time and decision specific).
Best interests decisions must involve all parties, be fully documented & regularly reviewed. This includes involving people who have Lasting Power of Attorney [LPA] or are Court of Protection Deputies.
Where appropriate, use a tiered approach to prescribing – ‘start low, go slow’.
Ensure involvement of Second Opinion Appointed Doctors (SOADs#) to provide a statutory safeguard where consent is an issue.

Follow up and monitoring:

Confirm the monitoring required and ensure a process is in place for this.
Set a review date.

Link to above page (section 4 of the MCA on best interests)

#‘SOADs visit the person and explore the current and proposed treatment, certifying what is considered to be appropriate and reasonable in circumstances where the person cannot or does not consent to it, discussing it with team members and the person before reaching their conclusions.’

Clear documentation is vital:
- Of the holistic assessment
- Of the condition that’s being treated by the medicine(s)
- Of the indication for each medicine (i.e. what it is being prescribed for) is explicitly documented, and this information is available to everyone involved in their care.
- Of possible precipitating factors and measures that help the person*
- Of patient involvement
- Of carer and family involvement
- Of multi-disciplinary team involvement
- Of the decision making process and rationale for any best interests decision(s).
- Of the rationale for prescribing / not prescribing
- Including review dates and evidence of reviews
- Real time monitoring of the effect of the medicine(s), including any as required ‘prn’ medicines.
- Documenting evidence of changes in response to the medicine(s) not being as expected, including if the medicines has no effect, and the actions taken on this.

Information sources and links:

Royal Pharmaceutical Society [RPS] (2021) A Competency Framework for All Prescribers https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/competency-framework 
Royal College of Psychiatrists – Faculty of Psychiatry of Intellectual Disability (2016) Psychotropic drug prescribing for people with intellectual disability, mental health problems and/or behaviours that challenge: practice guidelines. Document Ref: FR/IXD/09 http://www.rcpsych.ac.uk/docs/default-source/members/faculties/intellectual-disability/id-faculty-report-id-09.pdf?sfvrsn=55b66f2c_6

Personal views of Steve Turner RGN; RMN; Ba (Hons); P.G. Dip Ed Feedback and views welcome, send them to carerightnow@gmail.com

Steve is a retired nurse prescriber, former Head of Medicines and Prescribing for @MedicineGov , former Associate Lecturer at Plymouth University and a former NICE Medicines and Prescribing Programme Associate.

Version 7 Dated 25.11.2024

Revision history:

25/11/2024

Out of date links removed, information sources updated, some text & links removed. Extra explanatory text added.

03/05/18

*Following feedback from parents & carers I’ve changed some wording and added some additional wording which puts the patient first. Thank you for the feedback.

12/12/2018

Updated with link to the RPS Competency Framework for all Prescribers, following feedback from readers.

09/01/2019

Updated to include reference to diagnostic overshadowing.

14/01/2019

Updated to include allergies, sensitivities adverse reactions and feedback from teaching sessions.

15/01/2018

Updated to include specific mention the Mental Capacity Act.

20/04/2019

Notes that medicines related option should only be considered if non-medical options have not worked. Minor amendments to text.

21/08/2019

Updated following feedback re: evidence base on prescribing combined antipsychotics. Point revised, new sentence and link added, ‘There is a limited evidence base for this type of prescribing.’

18/10/2021

Updated to include reference to the updated RPS Prescribing Competency Framework for All Prescribers.