Pharmacy services for vulnerable patients

Victoria Crabtree

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.

Pharmacy services for the elderly

By 2025, one-quarter of the British population will be over the age of 60. Many older people lead active and independent lives late into old age; however some older people will become frail and increasingly rely on the NHS and social services.

As people age, their bodies undergo a number of changes. This increases the number and range of diseases that older people suffer from and changes their response to certain drugs. Older people may find that as family and friends move or pass away, they become more socially isolated and therefore vulnerable, as they may rely on others for their basic needs.

Older people are one of the main users of pharmacy services. Pharmacists may find themselves carrying a large proportion of medicine use reviews and New Medicine Services for older people, as it has been estimated that four out of five people over 75 take at least one prescribed medicine. In addition to these services, pharmacists can be involved in influenza immunization programmes, fall prevention programmes and full medication review services.

Pharmacists can be involved in ensuring that the elderly receive the influenza vaccination via a local enhanced service. It is recommended that all people over 65, those living in long-term residential care homes and those that care for elderly or disabled people receive an influenza vaccination.

Falls in older people have serious consequences and often result in a healthy active older person becoming vulnerable. Falling has been shown to be a major cause of accidental death in older people and many patients who suffer a fracture never live independently again. The fear of falling can limit what older people do in their day-to-day lives.

Older people are at an increased risk of falling, as their muscle mass is decreased, which results in a loss of physical strength and a reduction in mobility. Medicines have been implicated in causing older patients to fall. Hypnotic drugs such as benzodiazepines can cause drowsiness, and antihypertensives may cause hypotension and dizziness. Particular care should be taken when an older person suffers from osteoporosis, as these patients are much more likely to suffer fractures and consequent deterioration in quality of life. The National Service Framework (NSF) for older people states that if older people can be prevented from falling, they may live longer, healthier lives, not become vulnerable and therefore ease pressures on the NHS. Many pharmacists have undertaken specialist training to become fall prevention pharmacists. The fall prevention pharmacist reviews a patient’s medication, and suggests strategies to withdraw drugs that can predispose a person to falls, and they may suggest the introduction of medicines to prevent osteoporosis. They also advise on how to avoid OTC medicines that increase the risk, such as sedating antihistamines.

When undertaking full medication reviews in older people, there are some factors with regard to drug handling that should be considered. Older people experience slower intestinal motility, reduced total surface area for absorption and decreased gastric emptying. Although these factors do not usually have a large effect on total drug absorption, they can slow the rate of drug absorption, resulting in a delayed response. Older people experience a decrease in muscle mass and a gain in adipose tissue. This can sometimes cause problems as lipid-soluble drugs are stored in the adipose tissue, increasing the chances of side-effects and toxicity; therefore lower doses of lipid-soluble drugs should be prescribed. The elderly experience reduced blood perfusion of the liver, resulting in the slower metabolism of some drugs; lower doses of these would therefore be required. The elderly may also require reduced dosages of some drugs as renal filtration becomes slower with age, increasing the chances of drug toxicity occurring.

For some older people, community pharmacies are not only places where prescriptions are collected, they are a source of advice, OTC medicines and social contact. When considering OTC medications, care should be taken to check for interactions with prescribed medications; it is good practice to record OTC sales in the patient medication record where appropriate, and it is important to remember that not all OTC products are suitable for the elderly. For example palatable thrush treatments should not be provided to those over 60 as the incidence of vaginal thrush in this group is low and symptoms would require investigation.

Pharmacy services for those unable to care of themselves

This group of patients relies on carers to support them living at home or they live in a residential care home and pharmacists deliver a number of services to support the patients, carers and the homes.

Some patients who need support to care for themselves are still able to live in their own homes with the help of carers or family. Pharmacists can often support this group of patients by providing multi-dosage systems, and pharmacists can carry out medicine use reviews in a patient’s home with appropriate permission. Many patients and carers find pharmacy collection and delivery services helpful; however it is important that pharmacists maintain regular contact with the patient, especially if they are not visiting the pharmacy premises.

Some patients need to live in a care home to ensure that they are adequately looked after. There are a number of different types of care home in the UK which provide different levels of service. Residential care homes provide meals, accommodation, help with personal care such as dressing and bathing and support through short illnesses. This type of home often accommodates the frail elderly or those convalescing after illness. Nursing care homes have a qualified nurse on the premises 24 hours a day and therefore they are often used by those with more severe illness or a disability that requires frequent nursing care. Specialist care homes are available for those who have specific disabilities or needs such as dementia, where specially trained staff or adapted facilities are required. Pharmacists can provide different levels of service to care homes to help them look after their residents.

Pharmacists are involved in the provision of medicines, dressings and appliances to care homes. In some homes, residents have complete control of their medication, which includes ordering their medicines, choosing a pharmacy to dispense them and taking responsibility for taking them. If residents are able to do this they should be encouraged to and be provided with a lockable cupboard to store their medicines in. However, in many homes the staff take some responsibility for medication use. If a home takes responsibility for the residents’ medication, then a suitably trained person orders the prescriptions from the residents’ prescriber. The home usually has a local agreement with a pharmacy to supply all the medicines, dressings and appliances for the residents in that home. Although this reduces the residents’ choice, it is much more convenient for the care home staff, and has benefits for patient safety.

When pharmacists supply homes, they can provide medicines in the manufacturer’s original containers or they can put medicines into monitored dosage systems (MDS). MDS is a method of repackaging solid dosage forms into individualized blister packs and this is done to help residents or carers in the taking of the medicines. MDS is time-consuming to prepare; however, they may reduce administration errors as carers and residents can clearly see when to take the medication. Not all solid dosage forms can be repackaged into MDS. Drugs may deteriorate quickly if not in their original container, and before putting medication into an MDS, the manufacturers should be consulted.

It is important that adequate records of drug administration are kept, especially in homes with large numbers of staff, frequent shift changes and large numbers of residents. Medication administration record (MAR) charts are official records of the medicines that a resident is taking and should be completed every time a drug is administered. MAR charts are provided with the MDS and are kept up-to-date to reflect any medication changes.

In addition to providing medication to care homes, pharmacists can also provide care home advisory services to help homes reach the standards set by their regulator. The UK regulators include the Care Quality Commission (England), the Care and Social Services Inspectorate for Wales, the Scottish Commission for the Regulation of Care and the Regulation, Quality and Improvement Authority (Northern Ireland). Pharmacists may receive payment for these services via a local enhanced service.

When providing advisory services, the pharmacist usually makes an initial visit to the home, and then further annual visits to give advice. These visits entail checking that good practices are followed regarding the supply, administration, storage and destruction of medicines. The pharmacist should be aware of the regulatory body requirements and any advice given to the care home should be recorded. Pharmacists should use these opportunities to talk to the residents; advice can be given about medicines and recommendations added to each individual’s care plan. Pharmacists can also use these visits to help the home develop safe policies and procedures for drug handling and help train the staff to adopt safe practices, e.g. helping homes develop protocols for dealing with medication errors. Some pharmacists provide training courses for care workers up to NVQ level, for which extra payment can be claimed.

While visiting a care home, the pharmacist may encounter a scenario where they suspect the residents are at risk of abuse from the care home workers. If a pharmacist becomes concerned that a vulnerable adult may be being harmed, they have a duty to act upon their concerns.

How pharmacists can help protect children

Children and young people are considered vulnerable, as they may not be able to protect themselves from people who harm or exploit them. Pharmacists may become involved in child protection if they have concerns about the welfare of a child and wish to report those concerns. Pharmacists could be asked to provide information on a child or young person to the police or social services, or pharmacists may be involved in a child protection plan.

All healthcare professionals have a duty to safeguard and support the welfare of children. If a pharmacist suspects that a child or young person is being abused, they have a legal duty to act upon their suspicions. Abuse can be physical, emotional, sexual or due to neglect. A pharmacist may suspect physical abuse if a child’s injuries could not be accounted for by an explanation provided by the parent or carer, or a pharmacist may notice that a child or young person often presents in the pharmacy with injuries. Emotional abuse is more difficult to identify; however, pharmacists may have concerns if a child or young person becomes withdrawn, shows signs of self-harm or appears fearful of an adult. Pharmacists may encounter children or young people who are suffering from sexual abuse when they are supplying EHC, or the young person may describe sexual activities that are inappropriate for their age. Signs of neglect include failure to provide adequate shelter, food or clothing, which may become apparent to a pharmacist.

A pharmacist may notice behaviours in a parent or carer that are of concern. These may include a parent or carer delaying treatment, appearing detached from a child or not showing concern for injuries. Parents may appear reluctant to provide information or a pharmacist may witness aggression or violence towards a child.

If a pharmacist suspects any form of abuse, then they must follow the local child protection procedures. To find out your local child protection procedures, it is best to contact the local safeguarding children board within the local authority. If you believe that there is an immediate risk to a child, then it is appropriate to contact the police. It is not recommended that pharmacists investigate any suspicions of abuse themselves, but they should record their concerns and any actions taken.

Pharmacists may be asked to give information to social services if a child protection investigation occurs. It is important for pharmacists to cooperate with the police and social services, as all agencies involved in child protection should work together if abuse is suspected.

Pharmacists may be directly involved in a child protection plan. These are plans written by social services to help protect a child from harm. An example of how pharmacists can play a key role, is within the protection of children who are cared for by drug or alcohol-dependent parents. Pharmacists may be asked by social services for feedback on whether a parent is complying with a drug recovery programme, as this would have a positive impact on the safety of the child.

In situations such as these, conflicts of confidentiality may arise. However, if disclosure is necessary for the protection of children or to prevent serious injury to a person’s health, then information should be shared.

How pharmacists can help protect vulnerable adults

It has been identified that the frail, some elderly and some adults with disabilities can be considered vulnerable, in addition to those in abusive relationships and some substance misusers, who can also be considered vulnerable.

As pharmacists may be a point of contact for these groups it is imperative that pharmacists can recognize any signs that would prompt intervention. Signs of physical abuse could include unusual injuries that are not easily explained, bite marks, scalds, fingertip bruising, fractures or repeated injuries. Vulnerable people who rely on others for their basic needs could show signs of neglect such as malnourishment, poor hygiene or appearing dirty and unkempt. When pharmacists are involved in conversations with patients, emotional abuse may come to light or pharmacists may notice evidence of self-harm or self-mutilation; signs can also include inappropriate verbal abuse or patients displaying a fear of certain people. During sexual health consultations, sexual abuse and rape may be identified or disclosed; signs can include repeated requests for emergency hormonal contraception or signs of sexually transmitted diseases.

Pharmacists may find themselves in a situation where they suspect a carer of abusing vulnerable adults. Signs could involve a carer delaying access to treatment for a vulnerable adult, showing detachment from them or a lack of concern for their injury or illness. Carers may appear reluctant to give information or a pharmacist may witness aggressive behaviour towards a vulnerable adult.

If a pharmacist suspects abuse, then knowing what to do can be difficult. The adult’s wishes should be taken into account at all times, and consent to share information should be sought. Pharmacists should not attempt to undertake investigations or discuss their concerns with the alleged perpetrator. If a pharmacist’s employer has a safeguarding procedure in place this can be helpful when making decisions around disclosure. If a vulnerable adult is in immediate danger, then disclosure of information without consent may be necessary to ensure the safety of the patient and/or others. When sharing information around the safety of vulnerable adults this is usually with the local social services authority, NHS trust, police or GP.

Key Points