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So welcome everybody to another of our Learn with nurses in conversation sessions. My name is Michaela that all founder here at Learn with nurses. And I'm delighted that uh for those of you that are live tonight with us that you can join and also delighted for those uh that you those of you who are watching on demand. So I'm also delighted. There's a lot of delight that's going on, but it's been a good day. Uh But I am joined by Helen Williams. Now I've known Helen for many, many years and it's been fantastic just watching everything she does and um her, how her career has progressed. So before we get into the topic of tonight, of a spoonful of sugar, um obviously helping the medicines go down rather than rot your teeth and give you diabetes is what we're talking about is I do want to give a little bit of background on who you are. Helen, what's your name? And where are you from? Hi, everyone. My name's Helen Williams. I am from Manchester originally. I lived in London for many years and now I am beaming in from the depths of West Wales so I've only got Northern Ireland and Scotland to do and now I've finished most areas that are important. Do you want me to talk about what my job is? Yes, please. Ok. So I am a pharmacist by background. I have been working as a consultant, pharmacist for cardiovascular disease for about 15 years now in South East London and also work with the academic health science networks, looking at innovation and clinical practice. and how do we speed up the adoption of innovation. And my most recent role is working with N HSE as the National specialty advisor for CBD Prevention, which is all about England. NHS England's strategy for CBD and how we can improve, improve outcomes for patients. That's a lot, that's a big bad, but a moving moving target is harder to hit as it was. So before we jump in, I'm just gonna start with the end if it's all right for people. So don't forget at the end of this session, we're gonna run for a, a bit of an informal chat, Helen and I have had a, a few things, a few thoughts of what we'll talk about. Um, but, er, don't forget we've got the opportunity for an evaluation at the end. I'll be clicking that button and you will get a certificate for joining in with us. Now, do use that chat function as well. Let us know where you're from, what your role is. And if you've got any questions for Helen. Please do start popping them in for anybody who's watching on demand. You won't be able to see the chat function. What that means is Helen or I will read out the questions and then we'll be able to talk through the answers that are there. So, don't worry if you, if you're joining on demand, you think I'm not going to be able to see them, we will let you know and I can see somebody's already put something in the chat and that's Kathleen, who's saying? Hi from Suffolk. Hi, Kathleen. Hi, Helen's got rain in Wales and we've got a nice clear sky out there. So, as we said, oh, and asked me, so was she from Derry? Then I start mentioning everybody because I get very excited about it all. So, so really we started, so Helen and I, I was visiting Helen in Wales as I do quite regularly. Actually, I said, let's do something, let's do it another session together and let's, you know. So we, we came up with the adherence and so as a nurse, I often hear different terms, I hear adherence, I hear compliance. I hear concordance. Helen, what do we mean? What are the differences and what should we be saying? Now we got Paul of from Liverpool. Sorry. So we started off with the concept of compliance, I think in the seventies and eighties. But that's a little bit sort of paternalistic. We'll tell you what to do and you just have to comply. There was no sort of acknowledgement of the patient's role in clinical decisions. We moved on to adherence which has sort of stuck and adherence implies that you are adhering to something that you've agreed with. So some form of discussion with the clinician, whoever that might be a nurse, pharmacist doctor, we did go for a while towards concordance, which is probably more what we really want. People really involved in shared decision making. You can't be concordant with something unless you've actually been involved in the decision itself. So you do hear the terms a little bit interchangeably often we talk about adherence. Um but we should be moving very much more towards shared decision making and a more concordant relationship between the, the physician, the clinician and, and the patient to support um better medicines outcomes, I would say. So we're definitely not saying compliance anymore then. No, I know, but it still probably gets used a lot because terminologies change, people don't keep up with it and stuff and then I think, you know. Yeah, so that was really good. Thank you very much for sort of sort of explaining that a little bit more. So what we wanna do is adherence or compliance even better because of that. Concord. Concord. I've got a, it's OK, it'll be all good in clinical trials. They often look at adherence because you can measure how well someone's adhering to the recommendation, you can't really measure how well someone's Concor because you don't know whether there was ever a concordance at the beginning for them, you know, did they even agree in a freely shared decision making way? So we can't really measure concordance because it's partly about how that first consultation happened and how the decision was made to start a medicine and, you know, taking fully into account what the patient's perception of that was and their, their involvement in the decision. And so I'm gonna take on that, that terminology, shared decision making because it, it gets used a lot now. But I'm not entirely sure everybody really fully gets shared decision making or gets the time or the opportunity to be able to do it. So, um do you want to expand a bit more on, on in the terms of in the, in the terms of pharmacology, shared decision making? What do you see as the, the dream way of doing it? I'm not sure whether there's a one size fits all. I think it's partly um explaining to a patient what their options are responding to whatever questions and concerns they have and hopefully making them feel involved in the decision about how they want to go forward. The challenge. Of course, with shared decision making is you have to allow the patient to refuse if they want to refuse. And as clinicians, we really struggle with that if we think, well, that's not the best thing for you. We're not going to get the best outcome this way. But yeah, really, it is about allowing patients to be fully informed and involved in their decisions. I don't think we've got in the decisions about their care. I don't think we've got it perfect at all in, in the UK. Really a lot of our resources that we develop are quite medically orientated rather than patient orientated. And we probably need to have many more discussions with people who experience these medical conditions to really understand what drives their motivation and their decision making. And um then we can really engage in a proper equal shared decision. Yeah. And in fact, you just reminded me of um a session I was just doing recently. So, so for anybody that knows where involved, we share the pressure, which I know you were supportive of us doing it in Southeast London. And we have a lovely guy that's part of the team and he does, he's gonna do some sessions soon with LA nurses, David Aro. And he talks about when he was first diagnosed with hypertension and he says I was just, he was just told by the doctor you've got hypertension. This is the tablets, go away, take the prescription and come back and have a BP check in six months. And no one explained to him why, what it was all about how, you know, and he really struggled with that. He would say he really struggled with it because he wanted to know. Well, do I have to take them forever? Is there anything else I can take? What is the benefit? Is it lifelong? There was just so many questions and, and that wasn't that long ago, I will say, you know, so we're really not up to date now. I think one of the reasons why we want to focus on um concordance or adherence is really trying to get people to take the tablets or whatever form the medicines are in. So what are we, what, what, what, what proportion of people actually do take these medicines? So the often quoted figure is that 50% of people take the medicines in the way they were intended. So we often define that as taking it as prescribed more than 80% of the time. So we're not talking 100% even with adherence. So generally adherent to the schedule. Um But uh one particular study looking at long term conditions found that within 10 days, 30% of people were non adherent. So no longer taking the medicine and of those that were adherent at 10 days, a further 30% were no adherent at 30 days. So there's a big drop off in the first month. And we always say if you can get people to engage with their medicines and adhere for the first three months, you've often won the battle. It's those first few weeks and months partly because they maybe don't understand why they need them partly because they, um, don't have any symptoms and they might get side effects and they might think they're on a course of medicines that once they feel better they don't need them anymore if they did have symptoms. So there's lots of drivers for why people don't adhere in those first, you know, 6 to 12 weeks. But that's really where we should be investing a lot of our time. Wow. Now I've learnt something new already tonight about that. Sweet. Oh, someone's just screeched up outside in the van. I expect it's a delivery for somebody. Sorry, I've never seen such a fast delivery driver up here. So, um, sorry, um, you were at the corner of your eye, I saw this ban slam on. So, um, I've learned something and I didn't know about that sweet spot of the first sort of six weeks. That is really significant and I'm going to add that into everything I do now and particularly as we get given prescriptions. So I just think I've just changed my recently, um, and I've just been given three months worth now. I'm going to be quite adherent to that because it, I can feel the benefits of it. I slap my patch on on the way I go. And, um, but yeah, a lot of us. So what is the first, you know, if you're starting on a new prescription? Say what is, what normally happens. How long does somebody get a dose, you know, get a prescription for something and what usually, usually people are given a sort of month's supply. But often that's, then I'm routinely rolled into a repeat. If they don't come back and complain, they don't come back three weeks later. Go. Oh, this medicine has made my ankles swell up and give me a headache and I can't possibly take it if nothing, uh, if nothing bad occurs and there's no reason to not continue often. It's continued without a further consultation. But actually we know that that in itself, um, causes problems because, um, if people don't follow them up, patients lose a bit of interest and don't think it's that important and think, well, it can't be that important. They're not checked whether it's working for me. So, send a message to patients about the importance of the medicines going forward. Yeah. And actually just popped in the chat. Is this an opportunity to have a telephone follow up at day 10 and day 30? Um, is there any way that does that already that, you know of Helen? And does it have to be the prescriber? I would wonder. Well, is it in England? And I can't speak for the other nations. But in England community, pharmacists are actually commissioned to check to enroll patients with a new medicine and it's very specific medicines, but it's quite a wide range like most CBD medicines, respiratory diabetes, like long term conditions, mental health enroll them at the time. They get the new medicine, follow them up after a couple of weeks to see how they're getting on. And if there is an issue that's coming up, make an intervention with the GP, you know, speak to the patient's GP and sort it out and then follow the patient up. So they are commissioned to deliver that a lot of people aren't aware of the service. And one of the challenges for pharmacists is patients often see picking up their medicines as quite transactional. Now, I'm just running in to grab them. I don't want to sit and talk to you for 10 minutes even though we know that, that that intervention cause it increases adherence by about 10% which is significant and everything, all those little 10% will really add up, they, they will really add up. So if we can explore a bit further and you did just touch on them then on one of the main reasons and some of the sort of maybe more slightly off the wall reasons why people really, I want to say, do they decide to not adhere or does it just happen by accident or, or is it? Yeah. Why do people not take the tablets? I think there's two cohorts, there's sort of the practical issues that we often refer to as non intentional nonadherence. So I didn't mean not to take them. I just couldn't, it might be because they forget it might be because they didn't understand. So, a lot of people when we started using statins thought it was just a month course and their cholesterol was sorted, then they didn't need any more. That was all done dusted. So there's an understanding issue. There's a, um, there's a, um, what was my first one? Or my brain's gone dead now. No, that's ok. He can't remember. Can't remember, can't remember. And often we do things like put things in de set boxes. But I think someone I can see in the chat has put about dementia patients. Even a des sette box is not necessarily going to solve the problem of forgetfulness in a dementia patient because they won't remember to look for the deet box. So we need, you know, bigger, better practical solutions. And I particularly remember one patient who was referred to me for hypertension control because she was poorly controlled BP. And I noticed that the last visit she'd had her anti hypertensives up titrated and her thyroxine for two previous visits. And I was starting to think, well, you can't just keep adding these drugs on and nothing happens if the patient's put them in the mouth. So I rang the, the Community Pharmacy um and they said, oh yeah, she has a Des Sette box, but it usually comes back half full or nearly full and it turns out it transpires that she did have early stage dementia. So then we were like, well, how do we help this patient? And you've got to come up with some practical solution and she didn't want to care. Her. She had no local family. She lived on her own, but she did accept her friend and neighbor coming in every morning. Just have a quick check of a de set box and a little chat. And that's how we sort of resolved it for her. And it's finding those individual solutions. Clearly, we could keep giving her more and more medicines. It wasn't going to make any difference to her outcomes because unless the tablet goes in, it has no effect. So that was one example, a very sort of extreme example of non intentional, non adherence that really could have been caught earlier. But everyone was just thinking the drugs aren't working, add more as opposed to why the drug's not working. We've added loads more and it's still what happened, especially for thyroxine going up in an elderly woman. Usually your thyroxine requirements go down. So, you know, that's what made me think. This is a little bit weird. Yeah. Yeah. Absolutely. And so, um, now is Sara that I'm going to explore this bit a bit more. So, of course, you know, my, you know, my husband, my Neil, um, and he hates tablets, doesn't believe in them and says, oh, you know, he has this weird belief that your body should learn to deal with everything itself and, and not need tablets because it, when it gets to a point where you finally need those tablets, they'll really, really work. And I sort of come back and again. So, if you were going for an operation, would you not want an anesthetic because that, you know, your body should be able to do. But is that, is that quite common that you get? Yeah. So, yeah, intentional non adherence. There's been a deliberate decision made not to take medication and that, that might be because you think it's unnatural that um you want to save them for when you really need them. I always think, you know, hypertension is a terrible example for that, isn't it? You're going to wait to have yours till you've had your stroke. Is that what we expecting to happen here? You know, so we do need early intervention when they're preventative strategies. Sometimes it's side effects that they've had or heard about. So fear of side effects that they haven't necessarily experienced and a drug that comes to mind for that is statins, the lay media, the, the mass media pain statins as the most horrendous things you could ever take. And um a lot of um a lot of people believe that if they take a statin, they're just going to have horrendous side effects. So I guess it's all us to understand what the risk is. So a common side effect to us is one in 10 to 1 in 100 people will experience it. A common, common side effect to the general public is most people get it, let's say nine out of 10 people. So our terminology in theirs just doesn't match up and sometimes that causes a lot of confusion. And do you and do, let's stay on side effects for a moment. Do some people seem to get more side effects than others? You know? Um yeah, do they definitely, yeah, some people definitely get more side effects than others. And uh you may take a different strategy with medicines like statins. If you know, your patient has had real problems with other medicines in the past rather than go whacking in at the of that, the guidelines recommend you might decide to start at the lower dose and work your way up slowly to see what they can tolerate because there is definitely some patients who will not tolerate, you know, usual doses of antihypertensives, usual doses of statins and some of these drugs is better than none of these drugs. So even if they're small doses, they, they work, they work and one of my colleagues who, you know, Sara, he works in the hypertension center at Barts and they do what they call fractional doses of antihypertensives. So we might think a normal dose of amLODIPine is five, they'll be given to these patients with lots of side effects. 1.25 of that with a little tiny bit of this and a bit of that and see if they can get them controlled, using, you know, what we would consider very small doses, subtherapeutic doses. But in combination can still be, have a significant effect, hopefully without all those side effects. Yeah. Yeah. And I guess people will sort of know those patients know who they are because they're, the people who will always seem to get side effects, you know, they will always do. And I think there is something, I mean, there is something out there, isn't it in recognizing people who do commonly get side effects from, from very small doses and across a range of medicines. Um, that's there. Oh, before I go on a bit further, I've seen another question coming from z roughly how many people and will have problems with excipients of tablets and should be changed to oral solutions. Do you know that one good question off the top of my head? I mean, a lot of are lactose intolerant and many tablets, lactose is included, but often there are non lactose alternatives. So if you think of, for example, the anticoagulants and most of them have lactose in, but I happen to know that Edoxaban doesn't. So rather than having to think, oh, I'm going to have to find some alternative solution here and move them back to Warfarin or then give them a liquid. Um So it's really understanding the different formulations and all of that is in the data sheet for these drugs. I'm trying to, you know, find out if you can, what the exact precipitant of the problem is. And then looking for an alternative that doesn't contain it. Lactose is a particular one that I'm aware of. We also have issues with some of the capsules that have gelatin in and where that gelatin is derived from. I'm thinking of some of the different religious reasons why people want to consume different animal products. So does that mean then you actually it should, we should take a lot more time when we are and and is there more time in the system? Because this is starting to feel very complex now and it's not just as simple as here's a quick script, there's actually a lot more that might be looked, need to be looked at. Um I think the sort of pharmaceutical elements, the pharmaceutics of the different tablets, the formulations, et cetera, obviously as pharmacists, we're really interested in making sure we can try and tailor things to the individual patient. But I think often pharmacists aren't asked and people are struggling away in their clinic rooms thinking I don't really, I want to give this patient when there's a community pharmacist or you know, maybe even a practice based pharmacist who can really help. So I do think, you know, this is what our bread and butter is. We spend a long time learning about formulations. We often ask about them anymore important elements that we can really help with. So if we swing this on a little bit further, then because I think we're doing a journey for adherence, concordance and I'm getting rid of the word compliance. I even accidentally, I'm working really hard with my brain to get it out. And we've looked at actually what we recognize or what is, what is sort of an acceptable number of tablets to take or percentage of tablets and sort of how interventions can happen. And maybe some of the reasons that, um, the, the intentional and unintentional. And so just before I slip off on to some solutions, um and I'm going to ask you and you've already come up with a really good case study of the lady whose friend and neighbor was doing it. And I've been doing some work recently on, um, health literacy and that is the more I get into it that's so immense, particularly when it comes to, um, taking medicines. Are you able to touch a bit on health literacy on the impact that has on medicines? Yes, certainly. Well, I think I would go back to where we were with COVID with vaccinations and the sort of hesitancy that there was cross certain cohorts of patients around injectable specifically. I think people do have, don't like being injected with stuff, but even oral meds, you look at statin hesitancy, there's a lot of misinformation out there, I think it's very easy for people to pick up on a message that aligns with what they might think even if it isn't necessarily evidence based because there's every message out there if you want to look for it. Um So we, we automatically assume, I think when we're, you know, educated in health that everyone else has some level of knowledge that actually your average person on the street may well never have had a conversation about why high BP is, is um is dangerous for them and why the medicines are useful to them. Um And we need to have those conversations, not in a scientific manner. And I struggle with this as a pharmacist because we're brought up on the science and the evidence base. But translating the why and the how into a way that the average person can understand without any other underlying knowledge, I think is a really important skill that we need to practice a lot more. Um I don't know what your thoughts on it. Yeah. So I've been, I've been getting involved with different community groups and actually working with the community groups who work with others within the community can really help. So I did some, some amazing work down in South West London on a, on a Korean population, a Korean community group that was there and it was really working with of their lead members to then go back to the rest of the community. And we see that in the South Asian groups or, you know, whether it's refugee groups, it's really working very, very differently in a much, I would say, in a much slower pace and, and you need the luxury of time there and you hit on something really key about changing our language and it's not because it's really easy just to say the stuff we know really well and then give a script if we actually could pause and think about what we're saying. And it's not just what if we said, but has that message landed. And if it hasn't, and you started that with the beginning as saying, when you're spending time and that you're going to check that people have understood what you meant. And I saw a lovely, I was reading a lovely study where it said it showed and I can't remember the exact numbers on health literature. But when people could describe what they had to take said it was two tablets twice a day, ok, two different tablets, twice a day. And they had to describe it. They could, you know, a lot of people with high health literacy could describe it quite well. People with low health literacy, um we really couldn't describe it at all when they had to demonstrate what that looked like. That's me tablets out when they have to demonstrate, even those with high health literacy with much lower and those with low health literacy even more so. So there is, yeah, I think there's something that we really probably don't take it off on is thinking about health literacy, but I'm going to try and switch you now into some of that. I want you to give us some really good examples of solutions that you've come across. I'm loving the one with the neighbor. Um Have you got, have you got some more for us? These, these solutions? Well, one particular patient that I remember was a patient in our heart failure service at King's. He was on 12 medicines. He was under us for heart failure and he was had diabetes, various other things. And I remember one time he came to us, he was on 12 medicines, which is a lot for anyone. And I was thinking, well, what can we rationalize here? They've been to see the dia the diabetic clinic in the morning and I had a full review there and came to us in the afternoon and maybe in heart failure, we have a luxury of a bit more time with our patients. But it became quite apparent that there were only two of his 12 medicines he was taking regularly and again, diabetes, you know, escalated his meds because his HBA one C was poorly controlled. And you know, the next step is more medicines obviously. And I was just so worried if he took all of his heart failure tabs and all of his anti diabetic medicines. That actually it, you know, it precipitate acute event. He'd be very unwell. I have to go running down to the diabetes clinic and come to some kind of, you know, decision about. Well, which ones is it safe for him to take? Assuming he's not taking any for the past three months? I know he's taking, for some reason he's chosen to take Aspirin and bisoprolol. So those are the ones we're continuing on the heart side for his heart. He's not taking his ace inhibitor, he's not taking various other ones. And if, if I let him walk out of here today and take that bag of medicines and one day he decided to be fully compliant, it, it is really dangerous and we're sort of colluding with it by continuing to allow patients to have these medicines prescribed when we know that they're, they're actually not really taking them. Um, so we went right back to about three months, right back to the beginning and, and started again. If he was willing to take those three, then we would see him again a month and see how he was doing. And you know, hopefully we start to see the HBA One C improving. He starts to buy into the fact that there is a benefit here. Maybe his cardiac function improves a bit and he feels a little less breathless and, you know, we can really start to think about, well, what do we add in next and can you try that for a month? It's all a negotiation. I think for some of these, these patients that are pretty resistant to taking medicines and it, it is hard to make those decisions because, um, you know, it's a risk when people go to hospital, if they've not been taking their medicines at home, she just put that in the chat. And that was something we were discussing the other day was, um there was, I was at UK conference and one of the um consultants there, we were having this sort of discussion with that was the roving microphone person. And they were saying that a patient had been admitted and actually was then given all of the tablets and you know, while it's ok to take your statins when you haven't been taking them for a while, all of these antihypertensives that they've been never been taking BP was in their boots. They were very unwell because they were taking them. And so Rasin, you're absolutely right. This does become a really big challenge when people are in hospital. One of the things that is routine now, is that what pharmacists or pharmacy technicians do what we call medicines, reconciliation. So they find out what the GP has prescribed, but they also have a conversation assuming the patient's capable with them or sometimes with family members to find out what they've actually been doing because they're two different things so that we can establish actually, although they prescribed 10 drugs, they've really only been taking two or they've not taken any for two weeks because they ran out or whatever. So the GP list of medicines doesn't necessarily reflect how people are behaving and what we actually need to make sure is embedded. It's getting better is that, that happens when people come home from hospital because I've seen multiple patients where reconciliation hasn't happened at the GP level and things they were on before that have been stopped, continue because they're on repeat and, and they end up back in the hospital again. So it has happened on both sides. And I think again with more pharmacists working in general practice and being slightly obsessive about medicines, let's put it that way. There is someone casting an eye over a lot of these discharge summaries to make sure the medicines, the electronic record is accurate. And that's so that's quite a really good safety thing I would suggest, you know, that's really good safety thing. So, um so I just see another comment coming in and this is from Kathleen. I'm going to read it out for you, Helen so that everyone can, who's watching on demand can, can hear it and then that gives you time to formulate your your answers. So Kathleen says I work with adults with challenging behaviors and mental health issues and concordance compliance is extremely challenging even with covert. So any thoughts comments. Yeah, I mean, this is really tricky, isn't it? Because it's about capacity as well, isn't it about? Well, are they capable of making a decision that they don't want to take their medicines or what are the consequences of that? Er, clearly with those that are having covert, covert administration, the decision has been taken for them. But I don't have any easy solutions. In fact, I'm sure you have much better ideas about some of the things that work. Kathleen, if you work with these sorts of adults on a regular basis, um, it is really, really challenging and not with, you know, dementia cases as well where patients start to not be, you know, wanting to engage and take their medicines and care home, struggle with things like covert administration. When should they, when shouldn't they engage in that? So I don't think there are easy answers for these individuals because you can't necessarily have a rational shared decision and it might be much more about, um, you know, M MDT decisions about in the best interest of the patient, which is obviously what happens with the covert administration. Absolutely. Absolutely. Kathleen says, thank you. It is this and I think that's the bit, isn't it? We're having this half an hour, 40 minute chat about looking and exploring medicines a bit, a bit more differently and trying to think about why, why people don't take them for multiple reasons. And I think that's the bit, but I think, do you think it's almost right to assume, should we, when people get given prescription, should we almost assume, would it be safer? To assume they're probably not gonna take, to work with it rather than we give a prescription and they're probably gonna take them. Yes, we, we underestimate how much we explore the patient's views of taking medicines. We think we do it, but often we don't if we actually watch the consultation. So we're very good at instructing people. Really, we should be saying. So, you know, this is a medicine for X or Y. This is why we think you should take it. This is another option. In some cases, you might be able to offer options. What do you think about that? It needs to be taken once a day or twice a day. How do you think you'll manage that? Trying to build some kind of routine? What do you do twice a day and I brush my teeth? So maybe trying it to brushing your teeth. So you remember to take your medicines if it's once a day, what do you do once a day? I might get an orange juice for my breakfast or have my first cup of tea thinking about where the medicines can be. So you're prompted to take them with something you do regularly um is, is one way to, to build it into a routine for people. When we're asking questions to patients, we should use very open questions rather than say, can you do that? It's a yes or no answer. How would you do that? Well, how do you feel about taking a tablet all the time? It is, take more time, but actually an extra five or 10 minutes in that first consultation is potentially going to save you a lot of time over the next 345 years where you're then trying to wind back on why they don't want to take their meds. It gives you an early insight on their attitudes and if they've heard terrible things on the news or my mate down the pub said or yes, my friend was on an anticoagulant and they had a terrible bleed and, you know, it gives you a chance to have a conversation and bring that to light and explore what that might mean for them. Um, sometimes you find family members have had good experience, which is always a bonus and if you can hook on that one, any good experience that's there. Totally. Totally. And I, I'm just trying to think back to, um, anyway, I won't distract on trying to think back. So, um, so we've got a question coming from your machine are shortage of medications a frequent thing. And because this makes patient choice difficult and we do get lots of, but it feels like having a lot of shortage of medicines at the moment. It is a massive problem, um, on a day to day basis. For community pharmacists and for all, all the prescribers, it, it has become more and more difficult over the past three or four years. I don't know whether it's specifically related to Brexit, but there may be something associated with that because obviously medicine supplies are slightly different now, but it does make patient choice difficult. Um I often think as long as you've got the patient bought into the concept of taking, say an anticoagulant, they're probably not that bothered between the four different do a. They can have, they might not want warfarin because it requires more monitoring. But once you've got the idea that they're taking a statin, they may not be that bothered between Atorva and resa so keeping it generic about the class helps a little bit if you do end up having to switch medicines. But obviously that's, it's not ideal. And unfortunately at the moment, there seems to be nothing much we can do about it, but deal with it at the time, we are trying to empower pharmacists and community pharmacy where there are very specific shortages to do a substitution and have that conversation with the patient because clearly if they get told in the pharmacy, go back to your GP to get another prescription, then bring it back to me. Chances are they'll disengage and won't bother. Um So we want to make it as easy as possible for patients to access their meds and to have a conversation about why it's had to change and whether that might be temporary or longer term and can they do a substitution then? Because I, I know that. Ok, so they DH C says that, you know, there's a specific problem with this drug at the moment and this is a new thing in the last couple of years because we've had so many shortages that in this circumstances, these are the options you can substitute without having to go back to the prescriber to get a new prescription. You know, the pharmacist knows what they've got on the shelf and what's suitable alternative. And it's just a sort of transactional thing to get the prescription, but it, it frees them up to have the conversation sort out for the patient there. And then, rather than, um, the back and forth, that's really annoying for patient, for lots of people getting appointments. I mean, getting the prescription is often easier, but then it's still a hassle of, you know, I adore my practice to bit and I just have, we just, they only take email requests now. Um, so they won't do telephone, they did cavi, but that's really quick. So I can just quickly email them. But it still takes a good week from that to be able to then because by the time it gets issued and then let the pharmacy, you know, you never see a quiet community pharmacy. So they take quite a few days. So the cycle can go on some. So has popped one in the chat saying vegan actually able to open the packages or trigger devices can really impact on people. So and there are, there are um like tools AIDS, things you can get to help you with devices. But again, often people aren't aware that they exist. Um I've done a lot of work with stroke patients who have obviously got disability in many cases, post stroke and you can get things that help you put eyedrops in because imagine if you've got some physical disability and you're trying to get an eye drop in, it's bad enough for me. And I don't think I've got a physical disability. I'm just useless of putting eyedrops in uh people with weak hands and being able to do the inhalers. There are different types of inhaler or things you can click on the inhaler to make it easier uh for them to use them. And it, when you know, it's only when I went to a young stroke patients group that I realized how, how their medicines taking, you know, was limited because of their disability and that we needed to come up with better solutions. Often we think the solution to people who can't swallow is just give them liquids. Actually, if you've got a swallowing problem, you often need um purees or thicker fluids, not just a liquid medicine as it would normally come. So really try to think through what would be the solution for that individual. Again, community Pharmacy have a lot of these resources but patients with physical disabilities often are at the Community Pharmacy, you know, someone goes and gets the meds for them. So no one knows that actually they need and would they available? So it's a bit of a catch 22. And what about helping with injectable devices then? So some of them, some of them, you know, you have to push and push. So the the needle has to go and the thing has to, is there anything extra or is that just, just, I mean, the, the pens for patients with diabetes now are relatively simple, but some of the devices have quite a big volume of stuff in them. Like I have an EpiPen in case because I have a nut allergy. You can't just whack it in and pull it out. You've got to hold it in the leg because it takes a good two or three seconds for it to go in and understanding that technique is really important because I think people think, oh, I just want it I/O and you're not getting the whole dose. I don't know if specific devices because they are very um drug specific. And obviously licensing is an issue around doing different things with injectables. But at least we've moved away from the days when people had to do needles and syringes and vials to get their insulin out. That you say that I'm going to ask you a personal question now. So Annabelle gives herself a B 12 injections. So if anyone that doesn't know that is my daughter and we've just um the latest batch, sorry, this is probably gonna be really un about the latest batch every time we break off the, oh, I give her the injection. Sorry. Well, she does. And so I just say, and I, so when you break off the top, the vial shatters. So, and those vials, I'm surprised I still able to make them because you get glass charts all over the place with some of them. I know, I know they're absolutely awful vials. You know, that that might, might, you'll send me off right here. Personal consultation. Now I'm getting, I can see my light is rapidly going here and we are at 20 to 8. So Helen, I'm gonna sort of let's think about wrapping this up now for people, but I'm delighted that you've come and join me on this. Oh, we've got another 10, Paula's got a really good one. The last question from Paula. So Paula says its availability of dispensary labeling in different languages. Um And how can we get round this? There is a company that has software that goes onto pharmacy systems to um label in different languages. One of the challenges that the pharmacist has is knowing that the language translation is accurate to what's on the prescription because if you can imagine lab up, you can't really check. It says 13 times a day if you can't read the language. So that's been a little bit of a barrier. But there is a company that we're working with to try and make different languages, sorry, different labels available in different languages. And the other thing that a lot of places have developed a sort of tools to have conversations with patients even when you don't speak the language. So pictures of when to take the meds in morning and evening, you know, to take people through that, even where you can't physically tell them, you can show them that may not be the um the ideal would be to get different languages. Although again, there is issues of literacy in, in some different languages that um it's not like, you know, 100% normal to read. It's much more of an oral tradition, particularly for older patients. And you may find that even in their language they can speak and, you know, fully literate that way, but reading becomes a problem. So it's really tricky to give away a drug. But you don't know if it's labeled correctly because you can't read the label, done it properly. It's, and that's where we are at the moment. We need to work out how to get over that and, and put all the governance in place. That means people don't feel nervous that they're going to get pulled up for mislabeling something and potentially problems as a result, Paula says, thank you. And um, so just in the wrap up, uh Zoe's saying, uh this has been brilliant. I'm very interested in thinking about those 10 day and 30 day follow up and the medicines reconciliation. Well, she is saying great discussion and Kathryn said, very engaging. So I'm just going to, um, and before I ask you to summarize Helen, I think my two takeaways is one that, that sweet spot is that first sort of 4 to 6 weeks we need to think about. And actually, we need to make the assumption you give a prescription, they're not gonna take it. And if we start from that one, how can we bring them back from? They're probably not gonna take it to turning them into taking it rather than giving a script thinking and they're going to take it. So they're my two sort of takeaways and I'm going to pass it to you now to think of your, you can do a little final um wrap up. Although I see you've also put something in the chat saying, speak to your pharmacist about the new medicine service for me. I think it's open questions exploring any underlying beliefs. They may be cultural, they may be religious. They may be just generally as you said, your husband Neil. He just doesn't want to take medicines and then we can start having a much more open and honest conversation about why they may or may not be good for them and how we can get over it and sometimes negotiate. What about taking it for a month? And then we'll see how you are in a month rather than assume you're going to get all the bad side effects. You know, you might come back to me in one say, I don't feel any different and I can say to you, well, you don't feel different but your BP is lower and you have a lower risk of having a stroke. So it's all about engagement, negotiation. Sometimes you have to let them do a, a better lifestyle first. Yeah. Yeah. Yeah. Brilliant. Well, thank you very much to everybody that has joined us tonight and thank you to anyone that's joining us on catch up. Hell as always brilliant to spend a bit of time with you. Um, we're certainly gonna have you back and do some more. Um, what we might do is put a call out and see what topics they would like you to come and talk about that. You, you know, particularly around the medicine side and any other bits and Bob that's there. So I've just put the feedback in the chat for anybody that wants to get a bit of give us a bit of feedback. Of course, you will get your evaluations as well, your certificates that way. And for anyone who's joining us on catch up, um, catch up on demand. What am I on? I'm watching the telly for a moment. Er, I hope you found this really useful. So, Helen, thank you very much. I'm just going to press the stop broadcasting button now and if you just hang fire there, I'll have a last minute catch up with you. Thank you everybody.