Trust develops a care pathway to reduce inappropriate psychotropic drug prescribing in learning disability inpatient service, reducing length of stay by over 70 per cent

* Please describe the challenges or problems your solution set out to solve.

Antipsychotics and antidepressants are often prescribed for people with a learning disability without appropriate clinical indications and a substantial number who are prescribed drugs for the purpose of behavioural management can safely have their medication reduced or withdrawn.

Prescribing often starts at a specialist level and is then passed onto primary care resulting in GPs overseeing the management and prescribing long term, often unnecessary, medications. The aim of this project was to improve the quality of life of people with a learning disability admitted to our Assessment & Treatment unit by reducing the potential harm of inappropriate psychotropic drug use.

* Please describe the actions you took to achieve your result.

After working closely with commissioners and colleagues in the local authority to agree the required reduction in bed numbers in accordance with NHSE guidance, a new inpatient care pathway was developed (see attachment: A&T Timeline Overview) setting out our ambition for a maximum three month average length of stay for all new admissions.

Our revised clinical model is underpinned by a Positive Behaviour Support framework driven through our Challenging Behaviour pathway (see attachment: Learning Disabilities Challenging Behaviour Care Pathway Screenshots) for a high level summary of content) which incorporates best practice guidance from the STOMPLD (Stopping over Medication for People with a Learning Disability) campaign. To support our implementation of Positive Behaviour Support on the unit, we were a key partner in developing a West Midlands Region Positive Behaviour Support Organisational and Workforce Development Framework (see weblink).

This framework was used to develop our staff training programme across the LD Directorate – ensuring that all our staff have the necessary skills at the right level for their role to provide person centred care, delivered in the least restrictive way with the primary outcome of improving quality of life. A comprehensive functional assessment is undertaken with all inpatients involving family, friends, carers and key professionals.

Discharge planning is then focused on the development and implementation of a Positive Behaviour Support plan to teach new skills, provide enabling environments and reduce restrictions placed on individuals (including the use of medication) enabling them to maximise their quality of life. The revised clinical pathway was co-produced with staff on several away days as part of the inpatient service transformation work.

This was then shared and agreed with commissioners and the regional Transforming Care lead at our LD Service Development Group. Our LD service user group are actively involved in service developments and contributed to a questionnaire as part of the oversight and scrutiny process related to the reduction in bed numbers.

Service users were also consulted on their understanding of the discharge planning process which resulted in the development of an accessible information leaflet to better meet their needs. The changes to our inpatient pathway have enabled us to significantly reduce our average length of stay and to reduce the level of medication prescribed.

*Please list the most significant results

Data from 10 discharges in 2016/17 showed that medication was reduced or stopped for 5 patients saving approx. £4000 per year and 4 patients who were not on medication at admission remained medication free at discharge. Average length of stay for new admissions reduced by over 70% from 248 days in 2014 to 71 days in 2016 resulting in a cost saving of £85,314 per admission.

* Describe how your project has spread to other teams, departments or organisations

Following discharge, patients are supported by our Intensive Support Team and Community LD Team. Positive Behaviour Support clinics are run across the Directorate with input from Non Medical Prescribers to ensure there is a continuing focus on medication monitoring and reduction for all service users. Our Health Facilitation service also plays a key role in working with local primary care services – providing training, consultation and guidance on the STOMP initiative and alternatives to medication use.