View the full poster here.

The researchers identified a need for improved access to medicines information amongst patients at Central and North West London NHS Foundation Trust (CNWL) and decided to tackle the problem using information videos that are accessed by means of QR codes.

Working together with patients and carers they identified a list of priority topics. This included covid-19 vaccine and high-risk medicines used in mental health – lithium, clozapine, valproate in women of childbearing age). The scripts for the videos were jointly prepared with patients and carers. The videos and QR links were developed in collaboration with Dr James Ohene-Djan and QR Video Solutions.

QR codes were displayed on posters and also on stickers that could be applied to dispensed medicines. The information videos were hosted on a dedicated website. Since the launch at the end of February 2022 there have been more than 3,500 views. The most recent video covers the pregnancy risks associated with valproate and the Valproate Pregnancy Prevention Programme.  Data from April 20220 show that the valproate videos were accessed 54 times directly via the website and the QR code for valproate has been scanned 195 times. Feedback from staff and service-users indicates that the videos are helpful and informative.

Further evaluations of the impact of the video information are planned and additional topics are under consideration.

Watch Anshu Rayan and Yogita Dawda talking about this project here.

Ms Dawda is an independent prescriber who runs a mental health clinic for patients with complex medication needs. She notes that ever since its introduction in the 1970s sodium valproate has carried a warning about the risk of possible birth defects and the warnings have been updated over the years as more evidence has emerged. “The most recent evidence suggests that [for] children exposed to valproate during pregnancy, there’s a one in ten … risk of birth defects and up to four out of ten are at risk of developmental disorders – so the risks are really, really high”, she says.

Although regulations introduced in 2018 banned the use of valproate for women and girls unless a rigorous pregnancy prevention programme was in place, compliance turned out to be patchy. “The patient actually needs to sign [a detailed Risk Acknowledgment Form] to say that they have been informed of the risks and understand the need to avoid pregnancy whilst they’re on treatment”, explains Ms Dawda. However. the 2020 Cumberlege report – First do no harm – concluded that, “Despite these measures, hundreds of women are still becoming pregnant on valproate while unaware of the risks”.

Important new measures include the requirement to dispense valproate in the manufacturer’s original pack that bears a warning message on the outside, an annual review at which the risk acknowledgment process is repeated and the establishment of a national valproate registry.

At CNWL a local valproate register is used to monitor their own practice. CNWL also participates in a national POMH (Prescribing Observatory for Mental Health) audit that is led by the Royal College of Psychiatrists.

In a bid to communicate more effectively with patients the team at CNWL has developed emotionally engaging valproate information videos that can be accessed via QR codes attached to medicines’ packaging. They report positive feedback from both patients and healthcare professionals.

Anshu Rayan, Deputy Chief Pharmacist at CNWL explains that a key feature of the video-based medicines information project is that it has been developed in collaboration with patients and carers. In addition to valproate, videos about other high-risk mental health medicines such as lithium and clozapine have also been developed.  However, the concept could be further developed to include other topics such as pre-exposure prophylaxis (PrEP) for HIV and opioid substitution therapy and prevention of overdosage.

Future applications of the video-based information could include over-prescribing and de-prescribing and also provision of tools to help people remain well after discharge from hospitals to prevent readmissions. Training for healthcare professionals in the use of a good checklist for counselling patients about high-risk medicines, could also be tackled in this way.

Ms Rayan and Ms Dawda would like to see video-based information of this type being recognised and taken up by the MHRA and the pharmaceutical industry in the interests of improving patient care.

Yogita Dawda BPharm, PGDipPsychPharm, Independent Prescriber, MRPharmS, MCMHP, is the Clinical Lead for Mental Health Pharmacy, Central & North West London NHS Foundation Trust (CNWL). She is also Education Lead (UK) for the College of Mental Health Pharmacy (CMHP). In addition, she is a lecturer at Aston University, Birmingham and a peer reviewer for QWNA RCPsych.

Anshu Rayan BSc MRPharmS is Deputy Chief Pharmacist, Central & North West London NHS Foundation Trust.

Read and watch the full series on our website or on YouTube.

Community pharmacists and others could also have access to the information and videos that have been developed. Ms Rayan says, “the information and the videos are freely available on our website…  [Regarding high-risk mental health medication] we have some films on clozapine and lithium. These were, as I mentioned, designed really for our population, however if people did want to use them, they could contact us”.

Updating of content behind the QR links is straightforward for the team.  Ms Rayan explains that the QR code remains unchanged but the content on the platform behind it can revised and updated. “We do have a governance risk process whereby we have to review the content and make sure that it’s accurate at the time and so, we can actually tweak or reshoot the videos and depending on the feedback we get”, she says. “For example, we did have some videos on the covid

vaccine which was back in June and actually we had to put a caveat to say this was filmed in June – obviously [there have been] a lot of developments since then”, she adds.

The approach that has been developed could now be applied to other topics. Two topics that the team has in mind are pre-exposure prophylaxis (PrEP) for HIV and opioid substitution therapy and prevention of overdosage.

Ms Dawda says that the team would like to look at over-prescribing and de-prescribing and also trying to provide people with tools to remain well when they’re discharged from hospitals [and] so prevent readmissions, which are very common in mental health services.

Next steps

In future, Ms Rayan would like to see the concept utilised more widely, particularly by the MHRA and the pharmaceutical industry. It would, of course, be important to preserve the co-production aspect and ensure that input from patients and carers continues, she emphasises.

Ms Dawda foresees a number of potential applications. One idea would be to use the approach to train health care professionals in the use of a good checklist when counselling patients about high-risk medicines.  The approach would also lend itself to tackling the special needs of people with different ethnic backgrounds or people with disabilities, for example, those who need braille to access information. “So, just not excluding anybody really – to make sure that they have information at their fingertips”, she says.

Yogita Dawda BPharm, PGDipPsychPharm, Independent Prescriber, MRPharmS, MCMHP, is the Clinical Lead for Mental Health Pharmacy, Central & North West London NHS Foundation Trust (CNWL). She is also Education Lead (UK) for the College of Mental Health Pharmacy (CMHP). In addition, she is a lecturer at Aston University, Birmingham and a peer reviewer for QWNA RCPsych.

Anshu Rayan BSc MRPharmS is Deputy Chief Pharmacist, Central & North West London NHS Foundation Trust.

Read and watch the full series on our website or on YouTube.

Ms Rayan explains that the team at CNWL has worked in partnership with Dr James Ohene-Djan from the Computing Department at Goldsmiths University to develop videos to provide medicines information to service users, carers and other healthcare professionals. The videos can be accessed in several ways including via QR codes that can be attached to medicine packaging.  The videos, which have tackled not only valproate and pregnancy risks but also other high-risk mental health medicines, have subtitles and also a facility for translation into different languages, she says.

When medication is dispensed at CNWL a QR code is applied to the pack to allow patients to go straight to the video.

Ms Rayan says: “When they receive their medication, on the packaging – and Yogi’s mentioned that it’s the original packaging for valproate – we add a sticker which says, “Please read for further information”, so we’re not only relying on the physical patient information leaflet we are enabling patients to scan the QR code link straight to the video. [It] has some narrative about valproate and the risks that Yogi’s outlined as well as a dialogue which makes it really emotionally engaging, because it’s a conversation between a pharmacist and a patient asking questions about what to expect with valproate and what the risks are, so that they really know what they’re being prescribed and the risks around it.”

Inevitably the team has faced some challenges as the videos have been developed. Ensuring that they have accurate translations into other languages was one challenge and helping people to understand the concept was another. Now they would like to see recognition by the MHRA and the pharmaceutical industry that this method for providing information is helpful. “We’ve had extremely positive feedback not only from service users and carers but also our healthcare professionals – because it could also be used as a tool for training so, for example, if a

practitioner was unsure about all the facts around the pregnancy prevention program and what needs to be included in that conversation, this is there to support them as well”, says Ms Rayan.

The most commonly-required languages are Hindi, Spanish, French, Arabic, Bangladeshi, Mandarin Chinese and Russian.

Yogita Dawda BPharm, PGDipPsychPharm, Independent Prescriber, MRPharmS, MCMHP, is the Clinical Lead for Mental Health Pharmacy, Central & North West London NHS Foundation Trust (CNWL). She is also Education Lead (UK) for the College of Mental Health Pharmacy (CMHP). In addition, she is a lecturer at Aston University, Birmingham and a peer reviewer for QWNA RCPsych.

Anshu Rayan BSc MRPharmS is Deputy Chief Pharmacist, Central & North West London NHS Foundation Trust.

Read and watch the full series on our website or on YouTube.

The details of the valproate pregnancy prevention programme (PPP) are set out in guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA).  The first provision is that valproate should only be used if there is no alternative, for example, this could be because other treatments are ineffective or cause intolerable side effects. If this criterion is met then the health care professional (prescriber) needs to confirm that the patient has a negative pregnancy test and talk the patient through a detailed Risk Acknowledgment Form. “The patient needs to be present; the patient actually needs to sign to say that they have been informed of the risks and understand the need to avoid pregnancy whilst they’re on treatment”, emphasises Ms Dawda. “The health care professional must provide information in the form of a ‘prevent patient guide’ as well, so that the patient knows exactly what is required of them and that includes also …. [using] highly effective contraception throughout treatment. In addition to this, the healthcare professional must also review the patient at least annually to make sure nothing’s changed and at that time repeat the Risk Acknowledgement Form to make sure all the checks are done again”, she adds.

Other measures have also been introduced at national level.  The Cumberlege report – First do no harm – was an independent medicines and medical device safety review. It acknowledges that there were many women who had received valproate during pregnancy and been exposed to the risks.  “Amongst other recommendations, there was a requirement to establish a valproate safety implementation group. Now, this group works with patients to reduce harm and improve the safety use of valproate – that’s really, really important”, says Ms Dawda. Manufacturers have now added warnings about the risks in pregnancy on the outer packaging of valproate products.

“When the pregnancy prevention programme came into place there was guidance from the Royal College of Psychiatrists …… but also [the] MHRA and Chief Pharmaceutical Officers wrote to pharmacists explaining to them that they need to issue a patient information leaflet each time they issue a prescription or valproate. Sometimes that worked well – unfortunately other times it didn’t. …Now there”s

proposals being put in place to make sure that valproate is actually dispensed in the original manufacturer’s packaging and not in a white carton so that that warning that’s on there is actually provided each time a patient is issued a prescription”, explains Ms Dawda.

A valproate registry was also established “to make sure that we can identify those women and girls who are prescribed valproate. I guess there’s lots of very good practices – it’s just about having that joined up approach”, she adds.

CNWL activities

CNWL participates in a national POMH (Prescribing Observatory for Mental Health) audit that is led by the Royal College of Psychiatrists. This helps to benchmark practice at CNWL, says Ms Dawda

“We also have a valproate register [with] which we have developed a real-time report using a data analytics tool called Tableau which allows us to monitor our practice and compliance against the pregnancy prevention program requirements.  More recently we’ve also implemented an exciting initiative – a co-production project [with patients and carers]”, she says.

Yogita Dawda BPharm, PGDipPsychPharm, Independent Prescriber, MRPharmS, MCMHP, is the Clinical Lead for Mental Health Pharmacy, Central & North West London NHS Foundation Trust (CNWL). She is also Education Lead (UK) for the College of Mental Health Pharmacy (CMHP). In addition, she is a lecturer at Aston University, Birmingham and a peer reviewer for QWNA RCPsych.

Anshu Rayan BSc MRPharmS is Deputy Chief Pharmacist, Central & North West London NHS Foundation Trust.

Read and watch the full series on our website or on YouTube.

As deputy chief pharmacist at Central & North West London (CNWL) NHS Foundation Trust Anshu Rayan is responsible for the management of medicines optimisation and pharmacy services across the division.  Yogita Dawda is the Clinical Lead for Mental Health Pharmacy at CNWL – a post in which “no two days are the same”, she says.  As an independent prescriber she runs a clinic in community mental health, mainly for patients with complex medication needs. She is also a member of a multi-disciplinary team (MDT) that “looks at patients who have frequent readmissions or long lengths of stay or just generally are difficult to treat”.

Sodium valproate

Ms Dawda explains: “There are various forms of valproate … sodium valproate, [valproic] acid and valproate semi-sodium. It also has various different brand names ….Epilim is probably the most common one. Valproate is most commonly used to treat epilepsy or as a mood stabiliser”.

Ever since its introduction in the 1970s sodium valproate has carried a warning about the risk of possible birth defects and the warnings have been updated over the years as more evidence has emerged. “The most recent evidence suggests that [for] children exposed to valproate during pregnancy, there’s a one in ten … risk of birth defects and up to four out of ten are at risk of developmental disorders – so the risks are really, really high”, says Ms Dawda.

This led to the introduction of regulations in 2018 and guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA) “that banned the use of valproate in women [or] girls who are capable of becoming pregnant, and that’s regardless of age or indication and no matter how unlikely or how careful they plan to be unless they are under what’s called a pregnancy prevention program – also known as ‘prevent’ – and all of the conditions of that prevent program need to be met as well”, explains Ms Dawda.

Yogita Dawda BPharm, PGDipPsychPharm, Independent Prescriber, MRPharmS, MCMHP, is the Clinical Lead for Mental Health Pharmacy, Central & North West London NHS Foundation Trust (CNWL). She is also Education Lead (UK) for the College of Mental Health Pharmacy (CMHP). In addition, she is a lecturer at Aston University, Birmingham and a peer reviewer for QWNA RCPsych.

Anshu Rayan BSc MRPharmS is Deputy Chief Pharmacist, Central & North West London NHS Foundation Trust.

Read and watch the full series on our website or on YouTube.