Long-term drugs need monitoring

Caring for patients with long-term conditions can be challenging, as they are often on long-term medications and have complex needs. Diane Baylis advises on how to manage these challenges and ensure patient safety.

There are 15.4m patients living with a long-term condition (LTC), in England. The conditions are defined as one ‘that cannot, at present, be cured but can be controlled by medication and other therapies’.

The number of people with LTCs is set to rise due to an aging population and unhealthy lifestyles. 

With healthcare litigation increasing across all providers, and patients rightly expecting safe care, it is paramount that private doctors are aware of the risks and take steps to mitigate them – especially those related to managing the medication of those with LTCs.

Clinical negligence claims linked to long-term conditions

A review of Medical Protection’s high-value (£1m+) clinical negligence claims revealed that a poor standard of chronic disease management is a frequent factor. 

Deficiencies in chronic disease management made up 11% of these high-value claims, identifying that, over time, suboptimal management of LTCs can cause more insidious development of complications.

Systems failures were found to be a main contributory factor, particularly:

 Inadequate monitoring of the disease progression;

 Inadequate assessment of the patient’s condition;

 Failure to adjust treatment where necessary;

 Failure to monitor and act on tests results.

Examples included:

  • Inadequate monitoring of renal function in a patient with hypertension, leading to the development of chronic renal failure requiring dialysis.
  • Inadvertent continuous long-term use of oral steroids in the treatment of severe asthma, leading to osteoporosis, back pain and disability.
  • Failure to monitor a patient’s full blood count during carbimazole treatment, leading to the development of neutropenia.
  • Doctors must ensure they have a robust system for appropriate monitoring of LTCs, including: 

1 The management of LTCs should be evidence/research-based in line with national guidance; for example: NICENational Guideline CentreBritish Thoracic Society guidelinesGMC prescribing guidance.

2 Systems for follow-up and review. Patients taking potentially nephrotoxic medication long-term should be regularly reviewed and consideration should be given to the need to monitor renal function.

3 Systems to ensure patients attend for blood monitoring and reviews. A patient known or suspected to have chronic kidney disease should be monitored and managed according to guidelines.

4 Systems to ensure abnormal blood results are appropriately followed up and advice  communicated to the patient, including the stopping or adjustment of medication/treatment.

When undertaking an LTC review, you may also find it beneficial to consider the following:

The disease/condition:

 Check the patient’s understanding;

 Monitor disease progress.

Monitor and review:

 Adherence to treatment (compliance, concordance);

 Effectiveness of treatment;

 Side-effects (symptoms);

 Adverse effects.

Secondary prevention:

 Check the patient’s understanding; 

 Assess and monitor the risk factors.

Effect on the patient:

 How is the illness/condition effecting the patient’s life/work?

 How is the illness/condition effecting family/carers?

Consent

When prescribing a new medication or re-issuing a prescription, issues relating to the consent process – for example, risk/benefits of the medication – should be highlighted to the patient as well as documented in the patient’s record. 

Discussion of all the issues surrounding the treatment is an integral part of the patient’s clinical care. 

These discussions may take place over several consultations, all forming part of the consent process. Provision of information is key to obtaining valid consent and the use of patient information leaflets can be used as a part of this process.

Globally, the population is living longer and presenting with multiple comorbidities that demand increasingly complex interventions, therefore the prevalence of LTCs will continue to grow. Patient expectations are changing, and this means that patients may be more likely to be dissatisfied and complain about their care. 

It is likely that private doctors will increasingly be the focus of the care of these patients and it is imperative that they adopt a culture of safety and ensure safe systems for monitoring and managing patients taking long-term medications.

Diane Baylis (right) is clinical risk educator at Medical Protection