Umda Dawa (good medicine)- a new approach to using medicines effectively
Written by Musmirah_Shahzada on Tuesday, April 3, 2007 11:40
In Bristol's South Asian Community
Martin Howard, Joel Hirst and Alaster Rutherford describe the pilot pharmaceutical service.
The service
Umda Dawa can be translated from Urdu as 'good medicines'. In brief, Umda Dawa has just completed as a twelve month pilot NHS service offering medicines advice to the South Asian population in Bristol. The idea for the service arose from research and also anecdotal evidence that cultural differences (not just language) mean that people from a South Asian background can be disadvantaged in understanding their medication, its intended medical purposes and how it fits into diet and other areas of life. The outcome can be poor or incorrect use of medicines with diminished or adverse effects. Bristol Primary Care Trust is seeking a way to deliver a new approach to the prescribing and taking of medicines, based on partnership. An article in The Pharmaceutical Journal (14 may, 2005, p585), describing similar issues in Glasgow inspired the team and showed that these issues could be tackled, and the Umda Dawa service started in November 2005.
Project aims
The aim was to trial a pilot service to support clients by providing advice on medicines in a non-medical environment, leading to improved management of medicines. The service would be available where people congregate, in local settings outside of GP practices. It would provide culturally sensitive advice to people on:
- How their medicines work
- Dietary advice
- Practical aids to medicine taking
- Sources of information & help (e.g. patient groups)
How the service worked
The service has been run by two pharmacists, Saeed Kamal & Uzma Iqbal, who are employed by Bristol PCT for a day a week each, whilst their other roles are as community pharmacists. The choice of a male and female pharmacist was deliberate, in order to reduce gender barriers in the service. The pharmacists offered one-to-one professional pharmaceutical advice and medication reviews to any adult from the south Asian community who might benefit. Because of their own background and training, Saeed & Uzma offered in their consultations a way of bringing together Western approaches to medicine, diet and health with the clients' own understanding of medicines. What they encouraged was a dialogue that allowed clients to use and understand both their medication and their medical consultations to best effect. It was not a language interpretation service (which the PCT already has), but more of a cultural interpretation.
Finding the clients
Three methods of finding suitable clients were trialled. The initial vision was that this was a service that was to be offered outside of the usual settings of healthcare, in order to find people in their own community. The model was to be similar to the Glasgow service mentioned above. Early weeks of the project were occupied with speaking slots at community social and religious gatherings. There was interest from the audiences, but the follow-up by potential clients was poor, and it was soon realised that this was a valuable but slow way of starting. Alongside this, the marketing strategy included the more traditional circuit of professional staff meetings to raise awareness and referrals, particularly from GPs, practice pharmacists and practice nurses. The third plank in our strategy, which is now the main one, was 'case-finding'.
The case-finding method
Whilst ethnic origin is not reliably recorded in practices, the pharmacists have been able to intelligently scan GP lists to find patients who are likely to be of South Asian origin by name, and then narrow the case finding by a number of criteria to give a list of possible clients. Criteria included: adults over 40, three or more medications and clinical indicators including CHD, blood pressure, asthma and diabetes. These potential clients are then telephoned by the pharmacist from the practice and offered a face-to-face appointment after the service has been explained. The appointments are, to date, all within the clients' own GP practice. Additionally, the pharmacists occasionally acted as advocate in the client's appointment with their GP or nurse.
The pharmacists Saeed and Uzma spent important time building up relationships in the practices they visit, and it is these relationships that generate professional referrals. However, potential clients may be missed through this method, and so combining it with case finding brings the most thorough approach.
Readers may wonder how this has been possible over an urban area (formerly Bristol North PCT) that covered half of Bristol, with 220, 000 patients and 31 practices. From census data and local knowledge it is known that a very large majority of the population with a south Asian background live in one area. The district of Easton in Bristol is a condensed inner city area with little green space. The area has three times the Bristol proportion of Black and Minority Ethnic population, with large Pakistani, Indian and Bangladeshi communities. The area is also in the worst 10% of areas in England for deprivation. So once the cooperation of the eight or so local GP practices had been obtained it has been relatively easy to find the population who might benefit.
Initially the scope of the project was broad, testing which medications, acute or long-term conditions or types of people for whom the service would best work. After time our targeted case-finding approach has meant that most of the clients invited to attend had long-term conditions. Diabetes was the most common in this category.
Governance
We wanted specifically to respond to the local community. Hence part of the governance of the project was a community reference group, comprising eight representatives from local groups, such the Asian Women's Group and the Bristol Muslim Cultural Society. It was chaired by a PCT non-executive Director, and the project steering group chaired by a PCT Director. The project leaders were clear that the service, if it proved successful, needed a high profile to have the greatest chance of sustainability.
The 'NHS Live' Programme
Umda Dawa is part of the NHS Live programme. NHS Live brings together diverse projects around the country whose common thread is improving patient services with a high degree of user involvement. Having Umda Dawa within NHS Live has given the opportunity for a commercial partnership. The partnerships do not involve exchanges of cash or resources and Bristol's with AstraZeneca was set to reap greater benefits. Our 'skill-swaps' included support in marketing and the chance for AstraZeneca better to understand the changing landscape of NHS primary care.
Evaluation
In the first twelve months the Umda Dawa pilot provided 1:1 consultations for about 150 people with a south Asian background.
From the start it was clear that our evaluation would need to include both quantitative and qualitative measures. The latter include collecting stories from clients to illustrate the service, and their views on the value, convenience and experience of the consultation. These were collected in an evaluation phone call made later by one of the pharmacists. In addition, after each review meeting with a client the pharmacist completed an evaluation from that scores clinical outcomes and the pharmacist's perception of the quality of the intervention.
The evaluation indicates that the service was valued by the large majority of these clients and appeared to lead to better understanding of medication and better communication with GP practice professionals.
Two key learning points for the PCT were the value of: a case-finding approach and of language and culturally-specific 1:1 services in revealing and addressing some serious misunderstandings around medication use. Our original intention was to offer the service in community settings, which has been successfully done in Glasgow, in for example, a mosque. However we have also learnt that the conjunction of the Umda Dawa service alongside mainstream NHS health centre services appears to give certain credibility in the initial phone call and concordance in the consultation.
Next steps
It is proposed that the lessons learnt be built upon by creating a new service, one which combines other professions, case-finding and a 'follow-up' approach to some clients. The PCT is considering how a business plan could be developed around this.
Such a service would join up other associated health resources in the community to work with a case load of individuals who are at least partially identified by a case finding approach. Health trainers, the PCT's Healthlinks service (interpretation and advocacy) and dietitians would be important other players in the team.
The new more integrated approach is in recognition that one-off interventions are often not sufficient for long term change with individuals, and also that a combination of approaches, skills and professional knowledge could give even better long term outcomes.
Case Studies from the pharmacists
Both clients had diabetes, the most common long term condition encountered for the clients identified by the case-finding method.
Case Study 1
A 35 year old woman of Asian origin was diagnosed with type 2 diabetes a fortnight ago. Since then she has been avoiding food because she thought that it would increase her blood glucose levels, and she lost 3kg. She has also been very stressed with the diagnosis as she is the only member in the family to have the disease.
During the consultation I educated her on the importance of healthy eating, exercise and regular blood glucose monitoring in order to control and prevent deterioration of her diabetes. As her diet consisted of mainly Asian foods I told her what to avoid and the foods which she could eat. After the consultation she felt much more relaxed and had a better understanding of controlling the disease and the lifestyle changes she had to make.
Case study 2
This patient's diabetes was not controlled over the last few years, and his surgery had found this problematic. The GP and Practice nurse couldn't find the core problem of his uncontrolled diabetes.
During my medication review with him I couldn't find the problem either, as his medication concordance is 100%. So I asked the patient what he ate in his daily routine. For his breakfast he drinks five glasses of lassi, an Asian drink made with yogurt, with 10 spoons of sugar. I asked him whether he had told his GP about this drink. His answer was interesting. He said that his GP or Nurse would not understand this drink because it's not available in this country, and so he had never told them. He explained to me as I spoke with him in Punjabi, his own language. .I asked him to stop this drink as soon as he could - apart from this, his diet was very healthy. I think this was the main factor in his uncontrolled diabetes.
Martin Howard MA, is service improvement manager for long-term conditions, Joel Hirst, MPhil, MRPharmS, is quality improvement facilitator for medicines and pharmacy and Alaster Rutherford, BPharm, MRPharmS, is head of medicines management, all at Bristol Primary Care Trust.
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