Care and Treatment Reviews – Medication (including STOMP)

Last modified: February 28, 2019
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Psychiatry is a medical specialty concerned with the diagnosis, treatment and prevention of mental health conditions. Psychiatrists use a range of psychological treatments in their work, including medication.

During assessment and treatment, Psychiatrists will sometimes prescribe powerful drugs as a part of a patient’s treatment plan, and of course have a responsibility to use medication safely and appropriately. While medication may be an essential part of treating severe mental illness, there have been concerns that powerful medicines are sometimes being used excessively, and in some cases inappropriately: for example, as a ‘chemical restraint’ to control challenging behaviour, in place of other more appropriate treatment options; or for the management of core symptoms of autism.

During the CTR, information will be sought by panel members on specific diagnoses and formulations, including physical health care problems, the use of medication and any restrictive practices. The panel will ask to see the patient’s medication chart, will explore and gather information to confirm the right use of medication (KLOE 6), and to confirm that full and regular reviews of medication are taking place. In doing so, they aim to make sure the patient is not taking medicines that they don’t need and to find other ways of helping them. This will all go some way towards confirming KLOE3: ’Is the person receiving the right care and treatment?’.

As some of the drugs used can potentially cause side effects (for example, weight gain, diabetes and constipation), the Panel will check if these have been considered, assessed and managed appropriately.

As you will see on the following page, the issue of the inappropriate use of psychotropic medication has become a significant issue, which is now being addressed by NHS England and its partners.

Introducing STOMP

The acronym STOMP stands for:

Stopping the Over-Medication of People with a Learning Disability, Autism or Both.

STOMP is a health campaign to stop the over-use of psychotropic medication particularly to manage and control patients who exhibit challenging behaviour.

Research carried out in 2015 concluded that there was widespread inappropriate use of antipsychotic and other medications in treating mental illness in people with learning disabilities. As a result, a National campaign and Toolkit targeted at clinicians in hospitals and general practice is trying to address this.

A key aim of STOMP is to ensure that clinicians only offer antipsychotic medication in combination with psychological or other interventions including positive behaviour support.

A pledge, guidance, and a self-assessment and action planning template for social care has also been launched (April 2017) to further embed the philosophy. 

There is little doubt that experienced clinicians have very difficult choices to make where the causes of sometimes profound and traumatic symptoms may not be clear. However, we all hope that in time the STOMP will help us ensure that powerful drugs are the last tool out of the box, not the first.

Further Information

Medicine advice for patients

https://www.england.nhs.uk/learning-disabilities/STOMP/

Stopping the Over-Medication of People with a Learning Disability, Autism or Both

https://www.cppe.ac.uk/wizard/files/publications/leaflets/stopping%20over-medication%20of%20people%20with%20a%20learning%20disabilitiy,%20autism%20or%20both%20nhs%20leaflet.pdf

STOMP Campaign from VODG

https://www.vodg.org.uk/campaigns/stompcampaign/

STOMP it out! (Easy Read)

https://www.cppe.ac.uk/wizard/files/publications/leaflets/stomp%20it%20out%20nhs%20leaflet.pdf

STOMP Guidance for Social Care

https://www.vodg.org.uk/wp-content/uploads/2906234-STOMP-Guidance-for-Social-Care-DP-ACCESSIBLE-10703-v1_1.pdf

STOMP Best Practice Guide, (Care Management Group)

http://cmg.co.uk/wp-content/uploads/2017/06/STOMP-Guide-Final-version.pdf

Psychotropic Medication Review example form – format may vary

https://www.england.nhs.uk/wp-content/uploads/2017/03/medication-review-form.docx

 

Coping with the medication enigma

Medication is a very difficult subject for us parents, and our loved ones, to understand and cope with. This may be for various reasons including the medical complexities of mental health treatment, the sometimes profound effect that powerful medication can have on our loved ones (and us) and the statutory power of clinicians over their patients. 

No doubt that the presence of a learning disability and/or autism significantly complicates assessment and treatment. Particularly when challenging behaviour is involved, doubts (based on our lived experience) may arise in our minds that using powerful medication may not be the most appropriate way to treat presenting behaviours that could be the result of a number of triggers other than a mental health illness.

An ongoing crisis may require urgent temporary psychotropic intervention to help with initial recovery. However, it is important that continuing assessment and treatment addresses the causes of the behaviour and not just the symptoms.

It can be difficult for families to work with care staff, psychiatrists and others. Busy teams have their focus (hopefully) on their patients and communication with families is sometimes not seen as a priority. However, the relationship between us and the professionals is very important, and needs to be nurtured. Here are some tips:

• The lead Nurse or care coordinator is your main contact and source of information, who can also help liaise with the wider care team and share information with consent. Maintaining goodwill is very important.

• Each hospital and ward will have their own ways of managing the day-to-day routine, so adapt accordingly for best effect and minimum distraction.

• Try not to cross-examine or be openly critical of treatment. You have so much lived experience to share, tell them that you want to help as an equal partner. 

• If you feel that the needs of your loved one are not been addressed effectively or taken seriously, talk to the care coordinator, stating your concerns clearly and respectfully. 

• If you have concerns, try to deal with these informally. Keep copies of all correspondence and keep you diary record up to date. 

• Each hospital or Clinical Commissioning Group will have a complaints policy. If you need to make a formal complaint, try to keep it brief and specific, copying in the care commissioner.

During the CTR, the independent clinical expert will lead on medication questions. S/he will ask to see the medication chart, the treatment plan and check evidence of appropriate medication reviews. S/he will also check what steps are being taken to minimise any psychotropic medication. This will all help confirm the right use of medication (KLOE 6) or otherwise. 

Both experts are there to help make sure that care of a high standard is being delivered and an important part of their role is to challenge the professionals positively when necessary. 

The chair is expected to make sure that the CTR is Person-centred and family-centred, and that everyone is treated with respect and given the right amount of time to take part. 

A checklist for carers of people with mental health problems

http://www.rcpsych.ac.uk/healthadvice/partnersincarecampaign/checklistforcarers.aspx 

 Accessible Information about Medication

How medicines to treat mental health problems are used for people with learning disabilities

https://www.england.nhs.uk/wp-content/uploads/2015/07/ld-med-advice-letter-easy-read.pdf

Advice for patients, families and carers

https://www.england.nhs.uk/wp-content/uploads/2015/07/ld-med-advice-easy-read.pdf

Easy-read Health Leaflets

http://www.easyhealth.org.uk/categories/health-leaflets/

Medication Reviews

Royal College of Psychiatrists – Antipsychotics

http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/antipsychoticmedication.aspx

Psychotropic drug prescribing for people with intellectual disability, mental health problems and/or behaviours that challenge: practice guidelines (RC Psych)

https://www.rcpsych.ac.uk/pdf/FR_ID_09_for_website.pdf

Psychiatric drugs: an alphabetical list

https://www.mind.org.uk/information-support/drugs-and-treatments/medication-drugs-a-z/#.WUrCzYWcF9C

What do I need to know about side effects?

http://www.mind.org.uk/information-support/drugs-and-treatments/medication/coping-with-side-effects/#.WPtqlIWcF9A

Patient involvement 

Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence.

https://www.nice.org.uk/guidance/cg76/chapter/1-Guidance

Discharge standards

Section 10 of the updated CTR/CETR Code provides a detailed list of discharge steps and standards to help everyone plan the discharge process.

https://www.england.nhs.uk/publication/care-and-treatment-review-code-and-toolkit/

With regard to medication, Standard 7  says:

‘While I am in hospital and before I am discharged, I will have full and regular reviews of my medication to make sure I am not taking medicines that I don’t need and to find other ways of helping me”

Page 18 https://www.england.nhs.uk/wp-content/uploads/2017/03/my-care-treatment-review-symbol.pdf

This will be measured by:

‘Medication reviews will be shown on my discharge documents, letters to or from my GP, responsible clinician and community team”

The same Standard can be found on page 18 in the My Care and Treatment booklet which is a guide to CTRs that all patients should be given – 

https://www.england.nhs.uk/publication/my-care-and-treatment-review/

Physical Health considerations and health record

Physical Health considerations and health record

Maintaining physical health is vital and the CTR panel are required to ask a number of questions and see evidence that there are appropriate checks and procedures in place to make sure that the person is safe and that the Care being provided  is meeting their needs. This will be confirmed or otherwise by direct questioning about on-going health care and a review of documentation including a health action plan, Communication and Hospital passports, assessments and reports. (Key CTR questions: ‘is the person safe’ and ‘Are they getting good care now’ plus KLOE 3, 5 and Standard 4.4 refers).

Further Information

Providing links to resources for supporting the physical health of people with mental health problems and learning difficulties, and the mental health of people with physical health problems.

http://www.rcpsych.ac.uk/mentalhealthinfo/improvingphysicalandmh.aspx

My physical health A physical health check for people using mental health services.

https://www.rcpsych.ac.uk/pdf/RethinkPHchecklist.pdf

Physical health resources

https://www.rethink.org/about-us/health-professionals/physical-health-resources

The Use of Medication (Challenging Behaviour Foundation)

http://www.challengingbehaviour.org.uk/understanding-behaviour/use-of-medication-sheet.html

Managing medicines for adults receiving social care in the community NICE guideline [NG67]

https://www.nice.org.uk/guidance/ng67

Learning Disabilities Hub

https://www.cppe.ac.uk/services/ldhub

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