The Sheffield COVID-19 End of Life (EoL) Medicines group is a collaborative group of health commissioning and provider organisation medicines management representatives from Sheffield CCG, Sheffield Teaching Hospitals NHS Foundation Trust and St Luke’s Hospice. The group was established in the early stages of the city’s COVID-19 response; various pathways and guidelines to support the timely use of EoL medicines were developed or firmed up. A collaborative approach was needed as each organisation had different skills and expertise to help share and implement changes agreed.
The group had been meeting weekly from the end of March to mid-June, from then meetings are currently held fortnightly via video link.
The purpose of the group
The aim of the Sheffield COVID-19 EoL Medicines group, informed by local needs and national policy, is to work together to plan and implement medicines management solutions for EoL to ensure all dying people in Sheffield can make the last stages of their life as good as possible, with everyone working together confidently, honestly and consistently for them, and the people who are important to them, including their carer(s) during the COVID-19 pandemic.
There are two overarching responsibilities of the group:
- Strategic – ensuring actions taken during the COVID-19 pandemic align with local and national strategic direction for medicines management and EoL care.
- Operational, working with the organisational governance command and control structures/executive teams to implement the necessary service developments around medicines management at the EoL in all settings including primary care, community services, secondary care and specialist palliative care.
Some of the key challenges in achieving this shared aim and these shared responsibilities included:
- Access to and supply of EoL medicines and other equipment. There were shortages of EoL medicines in pharmacies and wholesalers/distributors due to unprecedented demand.
- Moral dilemma: take actions locally or await national guidance (e.g. repurposing of medicines in care homes due to high demand on supply and urgent need).
- Rapidly changing environment e.g. access to healthcare services, government guidance, use of virtual and remote technologies to gain consensus and approval of guidelines.
These challenges were overcome in a number of ways:
- A willingness of group members to cooperate with staff across the health and care system to get things done.
- An audit trail and action log to ensure work was on track and delivered to agreed timescales.
- Clear communication to stakeholders on activities of the group through attendance at numerous meetings, COVID-19 Practice Bulletin, e-mail communication within their own teams, development of a webpage to host all key resources.
- Robust networks built to understand the situation ‘on the ground’ and a two-way feedback loop developed.
- Shared learning through networking and attending regional and national meetings to understand national priorities.
- Terms of reference for the group; each member taking agreed guidance/pathway through their own internal governance arrangements.
- EoL prescribing guidance produced and shared with patient-facing clinicians at key meetings (ECHO for care home staff), Prescribing Leads Forum and Practice Bulletins.
- Guidance on alternative medicines that could be used at EoL by family carers in the community in case supplies of injectable medicines, equipment or staff were problematic to ensure timely symptom management. Also, development of shared guidelines to support palliative care in community settings.
- Management of EoL medicine supply issues by agreeing extended stock list of EoL medicines at designated community pharmacies. Additionally, set up systems to get rapid feedback if supply issues occurred, and better communication across different organisations and independent contractors to enable timely response to stock shortages.
- GP practice system (SystmOne) was updated with new doses and smaller quantities for EoL medicines when prescribing for patients dying with COVID-19 (confirmed or suspected)
- Progression of an electronic ‘pink card’ for community administration of palliative care medicines to ensure timely administration of EoL medicines.
Implications: How we may work differently in the future
The group came together to respond to immediate issues relating to EoL medicines management during COVID-19; in turn has developed to providing leadership and advice on a range of EoL medicines issues that are not necessarily COVID-19 related.
Good collaborative cross sector working, responsive and proactive approach; this has provided a framework in which other projects could follow to be delivered across the health and care system in Sheffield.
Testimonials from those in the group, and those supported by the group
It became apparent early on in the COVID-19 pandemic that there were a number of pathways and guidelines that needed to be firmed up to ensure patients had timely access to EoL medicines at their preferred place of care. This work required experts and colleagues from a range of organisations. The coming together to meet regularly has provided an excellent platform to allow discussion, decision making and monitoring of progress of the different work streams and issues. The group has bonded well and all are willing to go above and beyond to ensure the outputs are met in timely manner. Everyone respects each other and what they bring to the group. Relationships (new and existing) and individuals have flourished as people have felt empowered to ‘just get on and do’, working within the governance frameworks of the ACP.Heidi Taylor, Clinical Effectiveness Lead Pharmacist, Sheffield CCG.
In April 2020, we encountered several problems with obtaining end of life medicinesdue to shortages, and also quotas applied by the manufacturers after the high level of use during COVID-19. The Sheffield EOL group was a timely and helpful resource for solving problems, setting up a pathway for obtaining unavailable medicines via secondary care, and helping us to liaise with manufacturers when we had reached our usual quota for ordering medicines in the exceptional times we were experiencing. This enabled all EOL patients’ prescriptions to be dispensed (at least in part) immediately. The whole setup was one of the positive outcomes of COVID-19 from our pharmacies perspective. It improved medicines availability for end of life patients and saved time for clinicians. The pathways setup during COVID-19 will be useful in the future when other medicines become unavailable. The experience has helped develop a good working relationship between primary care, secondary care, the commissioners and the local hospice.Ellie Bennet, Managing Director, Wicker Pharmacy.