Impact case study database

There are 370,000 older people living in 10,000 care homes in England, many being frail, vulnerable and taking many medicines. Work at Leeds (2006) introduced the concept of clinical medication review in care homes and led to collaboration with teams in London and Surrey to carry out the DH-commissioned CHUMS study. We showed that for 70% of care home residents (taking on average eight medicines per day), there was one or more medication error on any given day, resulting in an estimated 98,000,000 errors/annum in the sector. Errors were found in prescribing, monitoring, dispensing or administration, and there was a lack of teamwork from the health and care professionals involved. The publication of the report led to a ministerial summit with Alldred and others, to discuss the findings and develop a way forward.

In 2010, the Chief Pharmaceutical Officer and the Director General of Social Care jointly wrote to all Directors of Adult Social Services and PCT Chief Pharmacists drawing attention to CHUMS as “an important research study” which “strongly indicates there is considerable scope for improvement” in how medicines are used in care homes. At the same time an ‘immediate action’ DH Alert was issued citing the findings of CHUMS, requiring PCTs to work with care home staff, GPs and pharmacists to determine how medication errors in care homes can be reduced. This led to changes in practice and the commissioning of new services across the country.

The Centre for Pharmacy Postgraduate Education (CPPE) developed learning programmes prompted and informed by CHUMS and this has been delivered to over 2000 pharmacy staff across England as of 2019 [ A,B].

Commenting on the significant impact the CHUMS study has had on the development of these learning programmes, the CPPE Director, Head of National Pathways, and Senior Pharmacist for the CPPE Medicines Optimisation in Care Homes training pathway said:

“The findings of your CHUMS research heavily influenced how the content of the learning programmes was created. We looked at the findings and issues in your research and addressed these systematically throughout the pathways...Your research has undoubtedly had a positive impact on how medicines optimisation roles in care homes are being carried out and has been vital in improving the safety and care in care homes throughout the country” [ B] .

In March 2014, NICE published ‘Managing medicines in care homes’ [ C]. Alldred was a member of the Guideline Development Group and the guidance cited five papers from our research. In addition, NICE published a Quality Standard (QS85) along with other resources. This standard cites CHUMS https://www.nice.org.uk/guidance/qs85/chapter/Introduction. The Care Quality Commission use this guidance when inspecting care homes nationally and assessing quality of care provision.

In 2016 our underpinning research which identified integrating clinical pharmacy as part of the solution to reducing medication errors in care homes (and improving medicines use more widely) directly led to the conception of the GBP20,000,000 NHS England Medicines Optimisation in Care Homes (MOCH) Programme [ D,E]. Alldred sat on the NHS England Steering Group and shaped the development of MOCH by presenting evidence of the effectiveness of pharmacists working in care homes based on CHUMS, the Cochrane review and CHIPPS. Alldred significantly contributed to the model of clinical pharmacy provision for the programme and the logic model for MOCH was based on the CHIPPS logic model [ E]. Launched in 2018 across every Sustainability and Transformation Partnership/Integrated Care System, MOCH has integrated 356 new pharmacists and pharmacy technicians into existing primary care and social care teams across England. Alongside the programme, a bespoke national training pathway for 600 care home pharmacy professionals was introduced. The CHIPPS Core Outcome Set contributed to the development of the programme’s evaluation plan and Alldred has had ongoing input as an expert adviser into the evaluation plan.

According to the NHS Care Homes Pharmacy Lead for NHS England:

“[CHUMS] was a call to action for the system to urgently develop solutions to solve widespread issues facing care home residents such as prescribing errors and lack of structured review. The CHUMS study helped shape many initiatives across the country… Your research identified major areas of concern in the prescribing pathway and through pilots across England and then the NHS England Vanguards, we now know that integrating clinical pharmacy into care homes improves quality of care and reduces risk of medication harm/ errors in care homes…The MOCH programme led to England wide support for care homes residents with medicines optimisation through structured medication reviews, which now feature as a core part of the new Primary Care Network Enhanced Health in Care Homes Framework and service. Your work directly aligns to the fact that over the last few years medicine organisation reviews improve the quality and care and safety of care in residents across the UK” [ E].

The influential 2019 NHS Long-Term Plan [ F] stated that all care homes will be “ supported by a consistent team…including named general practice support” and “ care home residents will get regular clinical pharmacist-led medicine reviews where needed”. There is a direct thread between these plans, and the findings of the CHUMS study, including our recommendations for a lead GP to co-ordinate prescribing and monitoring of medicines, and for clinical pharmacists to regularly review residents [and their medicines]. These recommendations will now be enacted nationwide through Primary Care Networks as specified in the GP contract 2020-2024 [ G].

The influential report on the Prevalence and Economic Burden of Medication Errors in the NHS in England used CHUMS as the index study to estimate that there are 98 million medication errors in care homes per annum, with 91 million administration errors [ H] - this represents 40% of errors in primary care. NHS England's Medicines Safety Improvement Programme (MSIP; 2019-2022) is part of the NHS Patient Safety Strategy [ I] and is a specific response to the WHO Medication without Harm Global Challenge [ J]. Due to the error rates found in CHUMS, the MSIP has prioritised reducing medication administration errors in care homes and Alldred has provided expert advice to the project lead for the 15 English Patient Safety Collaboratives (PSC) to design a national project, informed by CHUMS and CHIPPS, to achieve a reduction in such errors in 2020-21. This advice contributed to the investigatory work the PSC undertook in 1102 care homes and the planning on how to test interventions to make medicines use safer.

The instrumental role of CHUMS and CHIPPS in informing the work of the MSIP has been confirmed by the Clinical Improvement Lead for Medicines Safety for NHS England and NHS Improvement:

“[Alldred’s] research allowed us to understand that there was a gap around how the administration of medicine in care homes could be supported and improved. This directly led us to design a national project with the Patient Safety Collaborative, and the Academic Health Science Network was commissioned to look for positive interventions that could make a significant difference to the administration of medicine in care homes. The Patient Safety Collaborative produced a national report, and this report in addition to the CHUMS and CHIPPS research was instrumental in our understanding the situation. Most recently we have commissioned the Patient Safety Collaborative over the next 18 months to take forward tests of interventions that can be done in care homes, all aimed at administration in medicine, and your research is to thank for this. If your research into CHUMS and CHIPPS had not been carried out, we would not be investing the amount that we are investing in medicine safety in care homes over the next 18 months. It has been instrumental in changing the safety of medicine administration in care homes both now and in the future” [ K] .