Hospitals must prioritise ward rounds as a key element of clinical teamwork and patient-centred care, according to leading doctors and nurses.

In a joint statement, the College of Physicians and the Royal College of Nursing said a “concerted culture change” was needed to restore the team-based ward round.

Currently, doctors often conduct ward rounds on their own – wasting opportunities to share experience and insights, the colleges argued.

Pressure on hospital resources means that the formal ward round, where the clinical team visits each patient, has largely been discontinued – indeed, many wards have no distinct clinical teams.

According to the colleges, ward rounds serve key clinical functions: to make and refine the diagnosis; to review treatments and investigations; to communicate with family and other carers; to ensure safety; and to provide training.

“Ward rounds are critical to developing rapport and building trust with patients, while discharging a duty of care,” the statement noted.

“[They] also enable all individuals involved to express a shared aspiration to make the patient the centre of attention, empowered in his or her own care.”

The statement recommended that:

• Ward rounds should be led by consultants, include a nurse, and take place in the morning to allow decisions to be acted on the same day.

• Patients and carers should be given a summary sheet outlining the decisions made.

• Patients’ records should be kept centrally, and ward round teams should use locally adapted checklists.

Noting the financial barriers to these changes, the colleges argued: “Managers and the executive board bear a responsibility to protect time and resources, enabling all members of the multiprofessional team to prioritise the ward round.”

Growing pressure on specialist facilities is affecting hospitals across Scotland, with seriously ill patients regularly being ‘boarded out’ to general wards.

A lack of specialist hospital beds and consultants is putting patients at risk, the Royal College of Physicians of Edinburgh has warned.

The College’s survey found that two-thirds of hospital consultants said boarding was increasingly prevalent, while nearly all said it was harmful to patients.

Over the last decade, the average patient throughput per acute hospital bed in Scotland rose from 45 to 56 per year, while the number of acute hospital beds fell from 18,000 to 16,700 and the consultant workforce remained static.

Boarding out of patients from specialist wards used only to happen in winter, the College said, but is now the norm throughout the year.

The College’s President, Neil Dewhurst, commented: “Boarding creates a vicious circle, delaying treatment and discharge for patients and adding considerably to the workload of the healthcare teams caring for them.”

The Scottish Health Department, which has asked health boards to report on winter boarding levels since 2009, said it took the new findings very seriously.

“Boarding has always been recognised as poor practice, but now in the work that has been driven by the Scottish government we have the potential to measure the adverse impact on the quality of care, patient experience, and costs,” said Derek Bell, Professor of Acute Medicine at Imperial College London.

“As the boarding problem exists across the healthcare system, it requires whole-system solutions.”

The NHS is failing to take care of patients who have multiple long-term conditions, according to a new study published in The Lancet.

The study highlighted the growing number of non-elderly patients living with ‘multimorbidity’ and called for a more patient-centred approach.

Difficulties in primary and secondary care management of such patients combines with a lack of relevant clinical research, the authors said.

The study looked at 1.75 million people across Scotland, and found that 23% had two or more chronic diseases such as heart disease, diabetes, cancer, stroke or depression.

Only 9% of people with heart disease and 23% of those with cancer had no other long-term condition.

The incidence of ‘multimorbidity’ was higher in areas of economic deprivation, where it tended to have an earlier onset.

The study noted that care of such patients was often poorly co-ordinated, with patients being referred to a number of specialists who did not work together.

It also noted a lack of health data on ‘multimorbidity’ due to the limitations of clinical trials, where patients with comorbidities are normally excluded.

Calling for “radical change” in the health system, the authors said: “Existing approaches need to be complemented by support for the work of generalists, providing continuity, co-ordination, and above all a personal approach.”

“The status quo isn’t an option because it leads in the wrong direction,” commented lead study author Graham Watt, Professor of General Practice at Glasgow University. He noted that there is a major unmet need for “someone who can oversee all the problems of a patient”.

In an accompanying article, Dr Chris Salisbury of the School of Social and Community Medicine at the University of Bristol observed: “Expenditure on health care rises almost exponentially with the number of chronic disorders that an individual has. This economic burden heightens the need to manage people with several chronic illnesses in more efficient ways.”

He suggested that the caseloads of GPs in more deprived areas should be reduced, and that hospitals should assign patients with ‘multimorbidity’ to a generalist consultant who would co-ordinate their care.

How well do you understand the various priorities of a key element of your customer-base: the payer? Omar Ali pens Part II of a typical day in the life of a Formulary Pharmacist.

10AM : GP REFUSED PRESCRIBING OF A PAIN DRUG/ACTION ASAP
OK, we have been here before – this product is non-formulary. It has never been applied for. The GP is well within rights to refuse prescribing. The consultant knows it is non-formulary and has ‘requested’ via a letter – actually stating it is non-formulary, so would the GP kindly prescribe it.

The GP is irate, and the patient is now confused and unhappy: “why wont you prescribe what the expert/consultant has asked for?” There is a stalemate. Not a great scenario – this call is backed up with emails going back with two PCT advisers, a commissioner, a GP and a pain nurse. This will mean going to see the consultant and being firm: these are the rules of engagement, this is the financial framework, this is how I can help you manage your patient.

Thoughts for pharma

We call this ‘lockdown’. It’s a process by which redundancy is built into the formulary processes to ensure compliance, limited loopholes and consequential policing. What’s crazy is I know the brand, and I know the rep. Every month she asks: “when is the next D&T?” I tell her – and nothing happens. Next month, she asks again. So what’s happening?

The representative knows she needs a consultant to bring her brand to the D&T but can’t/won’t affect it. The representative then considers ways around the D&T; KOL to find loopholes, write to the GP, prescribe on FP10(HP), do a non-formulary request, try IFR, etc. In fact, exhaust all opportunities except the one that is needed: D&T approval.

Sometimes the pharma company has a brand philosophy which doesn’t press the right buttons: they have representatives calling the wrong people, the quality of the representative is not good enough, the seniority/decision-making-abilities are lacking.

This ‘lockdown’ effect will usually mean that the company goes round in circles. It focuses on new materials and a wonderfully articulated campaign – usually around ‘Edith’, a 50-year-old patient who is suffering from constipation and can’t enjoy her grandchildren. “If only you would prescribe the brand for her. You would if it was your own grandmother”.

The ‘payer avoidance’ strategy will not work. Lockdown is getting tighter. With Clinical Commissioning Groups it will be even more so. The financial framework will be more akin to trying to prescribe a non-formulary drug whilst working for BUPA, who would neither tolerate nor reimburse because the formulary is under a financial restrictions.

Indeed, the pain market has also intensified. This means numerous brands shouting for a louder voice in an intense market. Neuropathy, Opioids, Fentanyl/breakthrough Ca pain – add these up and you have pharma running around competing for a slice of the pie. Given all the warnings we had with COX-IIs, now we have them with NSAIDS, and of course even the weak Opioids have ‘addictive warnings’ all over them.

It is not surprising we are caught in the headlights of where to go in the name of safety and analgesia. Please someone, be it a brand manager or someone with payer access, see the bigger picture. Help us with the whole pathway. See our needs and work in partnership with us.

11AM : MEETING WITH PHARMA BRAND MANAGER
It’s not often I get a visit from a brand manager! We have been struggling for some time attempting to commission a funding pathway for an osteoporosis product – see earlier Matrix Revolutions. However, we may have a solution now with a variety of process mapping models.

I have finally received a number of options and interestingly the applicable HRG codes for activity within this domain. This has been a headache, despite a NICE TAG within the context of this ongoing saga. A resolution is long overdue. After a lot of liaising and a lot of technical HRG work-up, we may end up up with a streamlined prescribing pathway which lines up the PCT, the GPC, the acute trust, and fracture liaison service.

Thoughts for pharma

There is an intriguing change of paradigm when I am sat having an adult conversation with a brand manager compared to a ‘rep-call’. I realise that brand managers can’t go and see all their customers face-to-face.

But the paradigm shift is palpable. Why? Here we have it: The representative is ‘detailing me’ – that is never going to compare with an adult conversation with a brand manager who gets the bigger picture.

But something else, potentially more devastating: the brand manager is able to vocalise the ‘brand story’ in a far more compelling way than the ‘local rep’. That’s interesting, because the local rep is trained in the ‘brand messages’.

Even if you put aside that the brand manager has a ‘big picture understanding’, the fact that the value of the brand was unbelievably clear means that somewhere along the factory chain of sales force effectiveness and tier upon tier of managers, the message is lost in Chinese whispers. Why? I don’t actually know.

The representatives that are sent to see me are not in the same locator of food chain as I am. In effect, pharma is sending people of a certain authority that doesn’t fit with where I am. Even with account management. Remember, I talk clinical, I talk financial, I do commissioning maps, I do total drug budgets – I still have a boss.

However, pharma send people to see me with the following authority: “I need to get my medic to answer that…I need to get my line-manager to answer that…I need to call in my health economics person to see you…I need to call my regional account manager to approve that…”

When will I see all these people? Why do I need to see them all? Is it all ABPI, is it internal compliance, or is it sales force design? I’m not all for it, but I do see where some industry leaders are coming from in proposing authorised account managers answerable to MDs with budgets run at their own liability and expertise.

I recently did a ‘Payer Process Mapping Day’ for a pharma company/team of Executive Healthcare Development Managers. It fascinated me. Pharma has spoon-fed even higher NHS teams to such a level, that if you clear the playing field and ask them to come up with solutions to landscapes, they go blank. at day, the summarising  suggestions was simply: “we need a toolkit from head-office”. It was worrying. My conclusion?

We need to innovate within the NHS. Pharma companies are stakeholders. We should be asking you to help us innovate, but the people you are sending me… while I’m wanting them to look at the traffic jams I have ahead of me, and help navigate local influencing factors, they are waiting for a tool-kit from head-office!

11.30AM : CARDIOLOGY CONSULTANTS FORUM
Cardiology prescribing has so many focal features right now, I’m struggling to keep up with payer issues. This is due to a mixture of NHS demands, D&T processes, a sizable shift in coronary intervention work – and the drugs required within such units) and recent launches of new products that are proving challenging to implement within our health economy.

The format takes place as follows: I basically ‘gatecrash’ the forum and hijack a section of the agenda to use the opportunity for both information flow – in both directions, buy-in – to various prescribing initiatives, D&T processes and budgetary issues, and input to a number of shared-care-prescribing guidelines.

The aim is to open GPC/CCG cluster prescribing. A lot of this is about supportive communications; managing up – to my Chief and Director of Finance, and managing down – to pharmacy team on formulary policing. I need to take the consultants from ‘one place to another place’ within each micro-managed sub therapy. It’s a give-and-take scenario.

Thoughts for pharma

Cardiology has never really left the ‘priorities’ list. Right now, although there are some exciting and challenging implementations, I foresee a rocky road ahead. Antiplatelets. With the onset of generic clopidogrel’s price suddenly dropping like a stone – Plavix was £40 pcm, generic clopidogrel is now £2.50pcm, the Director of Finance is looking at the cost savings that we have built into our financial planning.

But here’s the catch – not only do we have branded prasugrel, we also now have branded ticagrelor, both pushing upward of £50pcm+. So how do we manage this? I have potential new pipleline antiplatelets which have offerings to interventional cardiology versus a savings plan that I will need to explain if I renege on. Tough. After much consternation, we’d put prasugrel onto our formulary, and now we have displaced this with ticagrelor.

We still have the generic clopidogrel as first line – but we always, always need a second line drug. Interestingly, neither company appears to have come forward with a QIPP line yet. One of them have thought about patient access schemes. NICE looks like it will be happy to support either. Cardiac networks play an important role – the cardiologists just want somewhere else to go after generic failure.

This was a learning curve for me. Whilst the clinical ‘story’ for either brand never really did magical wonders for the payers, the cardiac network is influential, and I think the companies are now maybe reconciling a ‘payer value story’.

There was a scary moment for one of the companies – a serious hospital discount nearly had us giving away one of the brands as a 12-month supply on the rucksack of a patient discharged from the angio suite – with a cost-saving share with the PCT. The company in question quickly made that disappear! It’s fascinating and like a game of chess sometimes…

Dronedarone. Even with a NICE TAG behind it, this has not been easy to implement. It really does take some serious ‘heads-together’ and I have never seen such fierce debate between clinicians and payers. Affordability and the increasing prevalence of AF makes for a great D&T discussion.

The next meeting I have with the directorate is to implement the use of this agent in young patients – outside NICE who recommended in 75yr+ – as the clinicians see greatest benefit here. This is where the payer’s approach needs serious consideration. All being well, I’ve managed to create an amber/shared care with PCT funding to keep all happy – let’s see what happens at the formalisation and authorisation meeting.

NICE chest pain implementation. There are significant stakeholders here with a number of large meetings across the PCT – payers, consultants, commissioners, coronary care units, etc. The implementation involves a number of small ‘mini-projects’, putting different drugs into the formulary for specific uses to help implement NICE.

That’s the way proper process mapping occurs. It’s more about the drug assisting the pathway, not about the drug per se. I see a lot of work to be done here. But I also expect to see consistency across the PCT.

Read Omar’s previous article in this series on Account Management in pharma.

Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust and sits on the External Reference Group for Cost Impact Modelling for NICE. He may be reached on omar.ali@sash.nhs.uk