Realising Realistic Medicine: Chief Medical Officer for Scotland annual report 2015-2016 appendix

NHS Forth Valley

Initial thoughts

Realistic Medicine is a core part of the NHS Forth Valley philosophy. Leadership from Medical Directors and others will be key in supporting Realistic Medicine to continue in practice.

What have we done so far?

A number of pieces of work have been undertaken, including being supported by MacMillan to employ a secondary care consultant to look at educational and professional elements about improving decision making about end of life care. There is a real focus on primary care, with innovative practice around GP practices in particular with two large practices having a multidisciplinary work force, so patients see relevant practitioner (for instance pharmacist, Mental Health nurse, physiotherapist). A diabetic foot pathway to reduce variation has been implemented.

An area of particular focus is Pharmacy. Pharmacy and General Practice have worked together to support a mindful approach to prescribing which has resulted in excellent engagement. Successful results in reducing unnecessary polypharmacy are being prepared for publication and the next step was agreed as investigating step 2 opioid use. It was noted that prescriptions in NHS Forth Valley were higher than the Scottish average, specifically related to Tramadol. Opioids had been identified as a key factor in hospital admissions and this led to a QI approach, starting with teaching and learning on comparative doses of morphine for prescribers. An initiative was launched to focus specifically on step 2 opioids and 54 of 55 GP practices signed up to this. Patients now need to be reviewed a minimum of annually and if no improvement is noted in wellbeing with or without pain scores this leads to a review of whether opioids are appropriate. The chronic pain service has become involved and developed a tool that GPs can use. This includes a pain management patient agreement and help with looking at pain issues holistically.

What next?

The pharmacy work has now moved on to include the addictions services, looking at Gabapentinoids. A treatment pathway has been created that includes these drugs and aims to enhance a holistic view of their use and put patients at the centre of discussions about their ongoing use - including open discussion of specific symptoms and side effects. This approach to change can now be considered in the context of other frail patients. Other work will include looking at developing enhanced skills for staff to have conversations around ITU referrals and ceilings of care and developing leadership from Medical Directors and others to support the GMC in their work with doctors at all stages of their career and future doctors about professionalism and the place for the elements of realistic medicine in this.

Final thoughts

A 'building blocks' approach to change helps clinicians in the real world take a realistic approach to providing care. Realistic medicine in the context of medicines is not about stopping medication but about investigating its efficacy and ensuring that results are measured holistically, beyond simple pain scores etc.