PRSB publishes new guidance to support personalised, safer prescribing

Genetics is changing medical practice including prescribing, and the Professional Record Standards Body has published guidance to help prescribers use this information effectively to improve patient care and promote greater choice and involvement in decision making.  

The guidance sets out how information about a person’s genetic makeup can be shared with prescribers working in any care setting and patients themselves so that patients receive medications that are safer and more effective because they are personalised.  

Genomics – the study of our genetic makeup – is yielding a wealth of information that can help determine our individual risk of developing numerous diseases, detect illness earlier, and determine the most effective interventions to help improve our health.  

The PRSB was asked by NHS England to develop guidance for alerting prescribers about drug-related genetic information which may affect the medication a person takes, the dosage, or the way in which they need to take it.  

PRSB’s new guidance will ensure that this information is available and can be shared using a combination of clinical decision support tools and existing alerting systems. 

PRSB recommends:  

  • piloting an alerting system to test the guidance  
  • developing standards that support sharing drug-related genetic information 
  • working with partners in the health and care system to ensure clinical training is available to prescribers  
  • educating the public about genetics and the benefits of personalised medicines so they can be more involved in decisions about treatment choices 
  • ensuring local guidance for prescribers is developed in line with national guidance 

“If you went to your doctor and an alert came up to say that you had a genetic mutation that changes the way that you handle a certain medication, it can then be altered for you,” says Dr Reecha Sofat, clinical pharmacologist at University College London Hospital and clinical lead on the project. “It’s important that this information is shared between health providers, but we also believe it is important for patients to be aware of their genetic information and how it could impact their medications. The overall goal is to improve the prescribing of medications for better healthcare outcomes.”

“Pharmacogenomics has the potential to transform how we personalise treatments. An individual’s genetic make-up can predict whether certain medicines are likely to be effective or cause side-effects, and this information can support clinicians and patients to optimise treatment choices,” said Professor Dame Sue Hill, Chief Scientific Officer for England and Senior Responsible Officer for Genomics in NHS England. “Effective communication of pharmacogenomic information via digital clinical systems is essential to realising these benefits across the NHS. This report by the PRSB provides an important foundation of recommendations for communicating pharmacogenomic data across the digital health care record.”

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Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.