CALL FOR A NATIONAL SERVICE DELIVERY MODEL
The petitioner is calling on the Scottish Parliament to urge the Scottish Government to implement a national service delivery model for warfarin patients who request the option to self-test or self-manage their condition. Currently no such model exists for Scotland's 80,000 warfarin patients.
All warfarin patients require regular monitoring of international normalised ratio (INR): daily at the start of treatment and, once stable, every 6-12 weeks. INR monitoring is normally managed by local anticoagulant clinics, but suitable patients can be trained to self-test (where patients record their readings to send to clinicians to review) and/or self-manage their condition (where patients are completely responsible for their readings and dose). Both arrangements can be safe, reliable and more convenient for many patients.
It is imperative a national service delivery model is created to support suitable patients who wish to self-test or self-manage their condition. The petitioner is already working with Greater Glasgow and Clyde Health Board to create a local service delivery model for warfarin paediatric patients moving to adult services within the area. The petitioner believes a plan of this type should be developed at the national level for all warfarin patients, including those moving from paediatric to adult care services. Ultimately, the aim of this model would be to improve awareness, training and support for clinicians and warfarin patients who wish to self-test or self-manage. The petitioner believes a national service delivery model should incorporate the following:
An immediate review of those patients on warfarin who request the ability to self-test their INR and/or self-manage their condition:
Although there is funding for INR testing devices in Scotland, only 1% of people receiving warfarin therapy undertake self-testing. It is not clear why the number of patients self-testing is so low, or why suitable patients encounter resistance to self-test or self-manage. It could be attributed to a number of different factors, which will have very different consequences for what a national model should address and these issues must therefore be investigated.
Create effective training and safe clinical support services to be delivered in every NHS Board for NHS staff and suitable patients (or their carers) who are assessed as both physically and cognitively able to self-test and/or self-manage:
Clinicians across our Health Boards remain reluctant to support individuals to self-test or self-manage. The Scottish Government therefore needs to provide training and relevant infrastructure for clinicians, so that they feel confident and able to properly provide a patient-centred approach, to assess requests for self-testing or self-management from suitable patients and to support those who do.
A national service delivery model for warfarin patients would align with many of the Scottish Government's policies, such as the Health Directorate’s 2020 Vision initiative; and "Gaun Yerself", a policy written by patients with long term conditions that seeks to "Cheer a person as they embark on a challenge, a vote of confidence and a message that the person has your support".
A national service delivery model could also result in significant savings to NHS Scotland (approximately £600,000 or more), as studies have shown self-testing can reduce costly complications, such as thromboembolic events.
Update the Evidence Note in accordance with the latest evidence and recommendations:
The Scottish Government's Evidence Note on this issue has not been updated to include the latest evidence and recommendations from relevant bodies, including:
- SIGN Guideline 129 makes the following Grade A recommendation: “Self monitoring and self dosing is safe and effective and can be considered for some patients”;
- The Royal College of Physicians Edinburgh Consensus Statement states that “Anticoagulant control may be improved by near patient testing and engaging patients in their own care; patient education should be supported at every stage”; and
- NICE recommends the use of some coagulometers by people taking long-term anti-blood clotting therapy if they prefer and are able to effectively use this type of monitoring (see guideline published in September 2014)
An outdated Evidence Note undermines the confidence of NHS staff in self-testing or self-management and must be amended accordingly.
Incorporate a care support plan and infrastructure to provide co-ordinated and uninterrupted health care services for warfarin patients who move from paediatric to adult services:
All children and adolescents (or their parents/guardians) are offered support/training to self-test, as there is no alternative service in place for regularly testing their INR readings. However, when they move to adult care, many encounter difficulties because there is no co-ordinated infrastructure, or service delivery model, in place to ensure a consistent and uninterrupted care plan for them. This can cause many negative consequences for young adult patients, ranging from psychological distress and anxiety, to medical catastrophe.
As noted above, the petitioner is already working on a local service delivery model for these patients with NHS Greater Glasgow and Clyde. This has been very well received. Her work demonstrates that it is possible to develop such models and they are welcome at all levels: Board, staff and patient. A national service delivery model which addresses this issue would provide support, education and confidence for NHS staff and young adult patients to ensure warfarin therapy and delivery continues to remain safe and effective.