Sampling prescriptions

The prescription sample was taken as the first thirty sequential palliative care prescriptions submitted to the participating community pharmacies for

dispensing, or in pharmacies with less than 30 cases all palliative care prescriptions, during the data collection period. As community pharmacists may not be aware of whether a patient is receiving palliative care, especially if they are not under a specialist palliative care team, it was felt necessary to have a consistent definition of how to identify a palliative care prescription.

The following criteria were used to identify palliative care prescriptions eligible for inclusion in the study.

A prescription could be included if it was for an adult aged 18 years or over and contained one or more of the following:

 A long acting strong opioid whether oral or transdermal, co-prescribed with a short acting opioid which is not for acute pain, dental treatment or substance misuse. This could include prescriptions where patients had recently received a short acting opioid which was not on the same prescription.

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 PecFent®, Abstral®, Effentora® or other fast acting fentanyl;

 Syringe driver or subcutaneous use of an opioid such as alfentanil, diamorphine, methadone, morphine, oxycodone, or non-opioids such as clonazepam, cyclizine, dexamethasone, furosemide,

glycopyrronium bromide, granisetron, haloperidol, hyoscine hydrobromide, hyoscine butylbromide, levomepromazine metoclopramide, midazolam, ondansetron, or ranitidine;

 A prescription issued by the specialist palliative care team at St Luke’s Hospice;

 An unlicensed medicine used in palliative care – ketamine (oral or subcutaneous), lidocaine 0.2% mouthwash, antacid and oxetacaine, morphine hydrochloride 10mg/5ml, tranexamic acid liquid 500mg/5ml, sublingual use of lorazepam (genus brand), midazolam oromucosal 10mg/1ml;

 Methylnaltrexone injection given every other day or less frequently It was also necessary to identify urgent palliative care prescriptions within the sample. The criteria for identifying urgent palliative care prescriptions utilised a combination of pre-defined categories and customer2 _{input. Urgent}

prescriptions were identified as those where:

 the customer advised the prescription was urgent;

 the customer advised that the prescription was for a new medicine and therefore was needed urgently for new symptoms and the patient did not have a previous supply of the medicine;

 the customer stated they had run out of their medicine, or expected to run out before the medicine was delivered;

2

Anyone presenting a prescription to the pharmacy for dispensing is referred to as a customer including patients, carers or their representatives.

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 the prescription was for a syringe driver;

 the prescription was for anticipatory subcutaneous medicines per the community last days of life algorithms (diamorphine, haloperidol or levomepromazine, hyoscine and midazolam);

 the prescription was from an out-of-hours GP;

 the prescription was from the specialist palliative care team;

 the patient had previously taken the prescription to another pharmacy and been referred on because the medicine was not available.

Anticipatory medicines are those medicines prescribed in advance of symptoms towards the last days of life to cover symptoms of pain, anxiety, sickness, secretions, and breathlessness. According to the Sheffield EOLC algorithms, this is normally prescribed as diamorphine, haloperidol, hyoscine butylbromide, and midazolam; however, there may be exceptions if the patient has been discharged from hospital or is under specialist palliative care. GPs can be reluctant to prescribe pre-emptively in advance of symptoms as identified in a UK study by Faull et al. (2013); so classifying these prescriptions as urgent within the study simulates the time taken for carers to obtain these medications in a crisis.

The sample of 30 prescription forms for each pharmacy was calculated using NHS Digital prescription data. In 2012-13, the NHS supplied 1,030 million prescriptions in primary care; 0.6% of which were prescriptions for opioid analgesics for the treatment of pain, or midazolam (BNF sections 4.7.2 and 15.1.4). In 2012-13, the average monthly prescription items per pharmacy in South Yorkshire and Bassetlaw was 7780, equating to an average of 39 opioid/ midazolam items per pharmacy per month (Prescribing and primary care Health and Social Care Infomation Centre (HSCIC) 2014). There may be some duplication where both a slow release and immediate release opioid is prescribed on the same form so choosing 30 forms per pharmacy would ensure that the average sized pharmacy would be able to complete the

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required data collection within a four-week period allowing a greater number to potentially participate and not just those within the LCS. Collating data across a number of pharmacies ensures sufficient data is collected to reliably analyse factors within the research.

Collecting data from 30 prescription forms from each of fifteen pharmacies meant a total of 450 prescription forms were intended to be sampled. The total number of medicines or prescription items was significantly higher since often more than one item is prescribed on each form.

The data collection period covered all opening hours for the participating pharmacies, including weekends and bank holidays to ensure prevalence data for palliative care prescriptions could be calculated accurately and eliminate sample selection bias. This also ensured data was collected during the OOHs period when it is expected there may be more issues with

accessing palliative care medicines or with contacting GPs when there are problems with prescriptions.

It was recognised that various confounding factors could limit the data for instance the time of day the prescription was presented the number of staff working, whether the pharmacy held the medication in stock. It was intended to account for these factors through having a pharmacy specific variable in the analysis.

3.3.4.3 Development of customer survey

The short customer survey consisted of seven questions taking less than five minutes to complete, providing feedback on the customer’s experience of accessing and obtaining medicines on one occasion against a palliative care prescription. The survey was modified using questions from the PSNC national Community Pharmacy Patient Questionnaire (CPPQ) and piloted with three customers in one pharmacy before being further refined and

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(TARC) at St Luke’s Hospice (SLH). Feedback was also obtained from the Hospice Patient User Co-ordinator, Hospice Risk Manager, and LPC

Pharmacy Secretary. The modified customer survey is available in Appendix H, Form A.