Pill swallowing in children

RCPCH and Kizmed podcast | Pill swallowing in children
Episode 1: The secret of pill swallowing, with Sister Ailsa Pickering
Full transcript of podcast 2022
RCPCH: This podcast is brought to you by KidzMed, a programme set up at the Great North
Children's Hospital in Newcastle. And by the Royal College of Paediatrics and Child Health.
Emma Lim: Good afternoon. So, this is the start of all pills swallowing podcasts. And we really
want to tell people about the nitty gritty of what went right. What went wrong. What we've
still not done. What is left to do and how to avoid all the mistakes that we've already made. For
this first episode, I've got one of my favourite people locked in the room here with me so she
can't escape. Sister Ailsa Pickering. Hello, Ailsa.
Ailsa Pickering: Hi, my name is Ailsa Pickering. I'm a specialist nurse here at the hospital and I
work in infectious diseases in paediatrics. And one of my main roles is dealing with children
with HIV.
EL: You and I started at a time where paediatric HIV was very different to what it is now and at
the beginning of that time, there weren't syrup's for children or they were so utterly disgusting
it was impossible to swallow them.
AP: Yeah, that's right. So, I've been in HIV for more than 15 years. We won't say exactly how
many years. But yes, you're absolutely right. The syrups were really intolerable. And the
amount that the children had to take along with the taste was just something that they could
not tolerate. So, teaching children with HIV to take tablets extremely early, much earlier than
you probably would have originally thought, is really important.
EL: Yeah, I think you've got the record. I think you taught your own child. How old was she?
AP: She was three. She's now 18.
EL: She was three!
AP: She was three and I taught her how to take tablets and she wouldn't touch Calpol from
that day forward. Which was always a little bit challenging when we went to the GP.
EL: You see, Ailsa. Nobody would say no to you, not even your own child.
AP: It's very easy and it's very important to teach children to take tablets for a multitude of
reasons. I've mentioned two already, the taste and the volume of liquid. But there's lots of
practical sides of taking it as well or learning to take tablets. The expiry date on liquids is way
shorter than tablets. So, for parents having to get repeat prescriptions, that's massively
important. For the children themselves, not having to take a bottle of medicine around with
them to grandmas, or even to school if they're on it regularly, is so important where a packet of
tablets, again, is easier to transport. And going abroad goes without saying that a liquid is just
not allowed these days in hand luggage in any sort of volume. That's so important. And then
just the children feeling that they have some control, that they're not taking such a horrible
tasting liquid.
EL: So It's important to learn to swallow pills because it's easier. Because it tastes better.
Because it's safer. It is safer to take the right dose. You're less likely to make a mistake. The
medicine expires, so you don't have to get medicine so often, you don't have to put them in
the fridge. You can travel with your medicines. Most importantly, you said, because actually,
children feel that they are in some ways in control of a little part of their health really.
AP: Absolutely. And I think that's important from a very young age is that they do feel that
they're in control and that they can have a say in what they're doing. And for the parents to feel
like they are less coercive in that they're trying to get their child to take a liquid which tastes
horrible, they understand why it's so important for the child to take the liquid but the child is
too young to understand. And so it becomes a real battle often between parents and their
children and if we can take away that bottle and give that child some power, if you like, in
being able to actually take the tablets and not having to face take in the horrible taste of
medicine, then that's excellent. You know, that's all part of them being able to control their
disease, particular with long term diseases like HIV, they have to take tablets their whole life.
EL: That's like so important. I think pills swallowing is a skill for life. It's even better than riding a
bike.
AP: And we use riding a bike because that's a skill that a lot of children at this age have learnt.
Even children of three are on their stabilisers and are learning to ride a bike. Swimming we
sometimes use as well. And so teaching them a new skill and explaining this is a new skill, just
like those skills that once they've got it, they've got it, is really important.
EL: Give me three top tips.
AP: So, my three top tips would be number one, use a sports bottle and their favourite liquid. It
doesn't have to be water. So, let them choose which liquid they want to take and take it from a
sports bottle with a sports bottle lid.
EL: What is a sports bottle?
AP: So, it's a sports bottle with a pool top cap that the child can control the rate that the liquid
comes out of the bottle with it. It comes out almost in a stream rather the child sipping it from
a cup.
EL: Great. So, you need a sports top bottle, tip 2?
AP: Tip 2 would be to have no distractions around. So, a lot of the tablet training we do is with
very small children who are quite easily distracted. So not having toys, distractions and trying
to find a quiet place when they've been to the toilet and they're not distracted is really, really
important.
EL: Literally, that is the story of my life. If I had no distractions, no phone, and I'd been to the
loo, I would be so much more productive. OK, so tip two, no distractions. We could all learn
from your Top Tips, Ailsa. Tip 3?
AP: Tip three might be a little bit controversial, shall we say. So, I think tip three is to try to do it
without the parents there. So, there's a number of reasons for that. Children love to show the
parents their new skill and to learn something if they feel comfortable with the person that's
doing the training away from the parents and then going back is a real drive to succeed. But
quite often, parents have negative feelings towards taking tablets. They've struggled in the
past to take tablets and they can actually subconsciously pass them feelings onto the child.
And so trying to do without the parents is actually one of my main top tips.
EL: And it's been really interesting because, you and I have been around the hospital for years
teaching other people how to teach children to swallow pills, and so often we have to teach
them to swallow pills first. And whenever we go into the room and you look around, there's
always somebody who's struggling to swallow pills. We have this fascinating story. It was one
of the nurses that we were teaching in one of our units, and she said, ‘oh, I can't do this. I can't
swallow pills.’
AP: Yeah, she actually tried to get out of the training by the fact she couldn't swallow pills so
she wouldn't be able to take part in the training.
EL: And we said, ‘no, listen, we'll teach you’. And then I went over and I worked with her. And,
you know, in a very short time, we got up from her saying, I can't swallow anything to swallow
something the size of an amoxicillin. And then she couldn't do the next thing. So I said, look,
that's fine. Just go away, have a break, come back. And when I came back, she turned to the
group and she said, “I don't think you realise what happens to me. I have to take pills every day.
I usually break my pills into quarters, and I take 20 minutes to swallow one quarter. And I've
been doing this since I was twelve years old because when I was twelve years old, my mom
said, ‘can you swallow pills now?’ And she made me try. And I spat up all the water all over her
face. And her mom said, ‘Oh my gosh, you are an idiot. I can't believe you can't do this.’ And
from then on, I never could. And even when I qualified as a nurse, she said, I can't believe you
are a nurse now and you still can't do that. And she said, I've carried this all my life since 12:00.
And this is the first time I’ve swallowed a pill.”
AP: And she demonstrated in front of the whole room that she could swallow the pill, which
was absolutely fantastic end to that teaching session.
EL: And then she turned into our champion pill swallower. And then no child who went through
that unit ever failed to swallow a pill again.
AP: Which is fabulous .
EL: End of story. You think people can swallow pills, but often people have developed really
funny ways of doing it. So, one of our doctors here, a very senior doctor, came to see us and he
said, ‘oh yeah, I can swallow pills’ and I said ‘what do you do?’ And he said, ‘well, I put the pill in
the back of my throat and then I push it down with my finger.’ And I was like ‘that is not safe!’
And so, I said ‘well, would you like to try our methods?’ And being a doctor is quite competitive
and she took the largest pill, literally picked up the sports cut bottle, swigged it down and went
‘Oo, that's easy.’ And from then on, he has also been quite a champion. And you’ve got another
story about how people’s past experience has meant that they passed this fear on to their
child?
AP: Yes. So, I had a case, where it was a very small child that she was only three and a half. So
even the doctor said, I think he's probably too young. But do you mind having a try? Because
he was not taking his liquid whatsoever and he needed it regularly twice a day. Both parents
were happy for me to do the training. But dad was less positive than mom shall we say. He
didn't say anything to his three-year-old child but in the room as we were doing the training,
the little boy really did not do very well. I think he managed hundreds and thousands. We did
start with something tiny. But as soon as we'd got on to progress to a bigger sweet, it really
didn't., he didn't cope well. He then went off and had his lunch and came back and we
swapped mom and dad around. Dad hadn't said anything through the whole procedure, other
the making grunts and noises in the background. In the afternoon, the child sailed through the
training and got to the largest capsule with mom beside him, which was really interesting to
me because the child was obviously picking up them negative vibes from dad and not from
mom. Even though the parent didn't say anything.
EL: As with learning anything, it's about understanding the child, the family and all their
experience past and present.
AP: I think sometimes parents can be absolutely helpful don’t get me wrong. Sometimes
parents can be really helpful, as can siblings. So, teaching a group, two siblings together works
amazingly well because of the competitive side of things.
EL: So just to recap. Swallowing pills. Really easy. Really important. You need a sports cup
bottle. You put the pill in your mouth. You suck the water down. Down the pill goes. You
practice. You need to be positive. And you need to take into account the experience of the
child, the family, the parents, everybody around.
AP: Absolutely. So, check the child has no swallowing difficulties to start with. Get them to sip
the water to start with to check they are complying and there's no problems. That's a really
important start and an obvious start to it. But yes, absolutely. Make sure that the child is on
board with the idea and that the parents are onboard with the idea. I had a child referred to me
who is seven, who the staff on the ward were desperate to get this child NG tube out. But the
child loved the NG tube because all his medicines went down the N.G. Tube. So, by learning to
take tablets, he would get the N.G. Tube removed so straightaway he refused. When you've
got that sort of situation, you have to get the child on board. It doesn't matter if the parents
and all the staff are desperate. The important thing is the child.
EL: So, once you check that they can swallow water. We always start on hundreds and
thousands because it is physically impossible not to swallow hundreds and thousands.
AP: We also give the child some control. So, hundreds and thousands are different colours so
they can choose the colour. But importantly, they can also choose your colour. They have the
control in the session. The control is not the person who's teaching. It's the child who's in
control. So, they've chosen the liquid, they've chosen which colour of hundreds and thousands
they are going to take. And also, which one you're going to take.
EL: Great. I prefer the chocolate ones myself. So, you both have hundreds and thousands. We
know the child can swallow water and so you just say pop it in the middle of your tongue and
have three sips of water. One, two, three. And then we go. And then we go ‘Ah surprise! What's
happened to it now? It’s gone.’
AP: Absolutely. And a sticker, of course, is really important. And lots of praise. Like you said, it's
impossible not to swallow hundreds and thousands so they're always going to achieve with the
first size.
EL: So what do you work up to next?
AP: So, we usually use a sweetie again. We use sweeties, with the parents’ consent obviously
from the sugar side of things, because they are familiar to children. They're not something
that's scary. And to take away the fear of tablets and the fear of swallowing a tablet is really
important part of the session. So, we'll use a sweetie that is a slightly bigger than a hundred
and thousands. And it really doesn't matter what it is.
EL: I would say Tic Tacs, because they've got that tablet shape and they come in a variety of
colours which everybody knows. But obviously, other sweets are available.
AP: Cake decorations are marvelous. So recently I was in Tesco and I think the lady thought I
was some crazy baker because I bought 100 different bottles of different toppings for cakes.
But they come in all different sizes. They're nice colours and they're pretty. And children love
them.
EL: Other supermarkets are available as well as Tesco.
AP: Absolutely.
EL: Yeah. So, it is as simple as that. It's about saying having some water, having a quiet place,
putting a small tablet in the middle of your tongue, having your three sips and then working up
through the sizes.
AP: Yeah. And can I add a fourth tip. Fourth tip. Don't call them bigger.
EL: Really important.
AP: Yes. Really, really important. And it's a natural thing to say as an adult. So, you'll say, right,
let's try the next size or let's try the bigger one or. And you say it without even thinking about
it. So, it's really important to say let's try a different colour. Let's try a different cake topping,
but not a bigger one.
EL: Yes, I always say let's see what's next. And I always say that when you have worked your
way from hundreds and thousands to Smarties, anybody who can swallow a smarty can
swallow more or less any kind of pill.
AP: Yeah. And also, don't go to a huge pill if you're trying to get the child to take something
very small. It's a skill. Once they've started swallowing a tablet on a regular basis, they will be
able to swallow any size, but there's no need to do it in that session. So, if you're trying to get
the child to swallow something tiny, like an amphetamine or a thyroxine. Don't get them to
swallow a huge, huge dummy pill. Just go to the size larger. So, you need to order a variety of
the gelatin capsules because you need to move through the different sizes, from a very small
one. They are clear so fill them with hundreds and thousands, or whatever the child likes,
chocolate strands, it doesn’t matter right up to the largest. We order them through pharmacy.
We order them as an empty capsule. Some pharmacies desperately try to fill them with lactose
powder but we like them empty so we can fill them with sweeties.
EL: And we also have non gelatin capsules, which you can order in case for religious purposes
you don't want to use gelatin.
AP: Yeah. We did discuss that with the pharmacist because, whether or not as part of the
teaching sessions, we should have them available. However, the pharmacist informed me that
the tablets we were trying to get the children to take were actually made of gelatin and that
the parents were in agreement that the child should be allowed to take that tablet, even if it
was against their religious beliefs or if the parents were vegan and because they were going to
take the tablet, that the training tablets were equally as okay.
EL: Now that’s important. I didn’t know that.
AP: See you learned something. It's really important to be positive all the way through. If a
child fails, I would try the same size again. And if the child fails again, I would go back to the
previous success and always finish the session on a success. Most children will achieve this
within one or two sessions.
EL: Yeah it’s so true. And the other thing I find, this is a really, this is awful, but when I finish a
session I always ask ‘why do you think you’ve done so well? and they always say ‘I don’t know.’
And I always say to them ‘you have worked in the NHS for years, when was the last time
somebody said to you, well done, you've done really well.’ And everybody goes quiet and
literally nobody can remember the last time somebody praised them. And the power of that
praise, often, if we've had somebody who struggled to swallow and everybody's watching
them and everybody goes, ‘yeah, well done’ and they're all clapping. It is literally so powerful.
AP: It is a lovely training to do because nine times out of ten, more than nine times out of ten,
it's really successful. And it's very rare that as nurses and doctors, we can do something in such
a short period of time that can be revolutionary to that child's life and actually be praised for it
and do something nice.
EL: It's so true because often we're having to give people long courses of medicines because of
chronic diseases and actually this is the one time you go and do something and it's fun and it's
nice and it's got sweets and it's got stickers. And so, there is no bad thing about pill swallowing
in my opinion.
AP: Absolutely not. And they get a certificate, of course, at the end, which is very important for
show and tell.
EL: So given that we've talked about pill swallowing, we've talked about how easy it is, we've
talked about how important it is, we've talked about how it gives children a bit of control over
their illness. Why hasn't this, why has this remained a secret? Why doesn't everybody do this?
AP: I think it's a number of reasons. I think one of the initial reasons is that people don't think
about it. People think under 12 liquid, over 12 tablets and they don't check that the over 12 can
take tablets and that the under 12 can take tablets. It's really, really important to never just
assume from the age what they can do and actually check. We would never give an inhaler and
just assume the child would know how to use it. And I know that is a scenario you use quite
often. We would never send a child away with a piece of equipment and not explain how to
use it. So why do we do that with tablets and medicine?
EL: It's so true. You would never be sent home with an inhaler without instructions. So why
send somebody home with pills and no instructions? Yincent, who we will talk to later who is
one of our doctors here, in his department he started this pill swallowing training. So, they took
all the nurses and all the doctors how to teach children to swallow pills. And after a month, I
said to him ‘how are you doing?’ And he said ‘Oh, we're doing fantastically. You know, we've
converted half of our children already’. And I said ‘that's brilliant Yincent’. I said ‘Yincent, how
many children did you actually teach yourself?’ And he looked a bit shifty and he said ‘none’.
And I said ‘why?’. And then he looked even more shifty. And he said Well, Emma, actually, we’d
never asked the children if they could swallow pills. So, we just went after the children and said
can you swallow a pill or not?’ And it turned out half of them could, but we'd never ask them.
So, we just carried on giving them medicine. All those years. Shame.
AP: That's a really good example of just asking the child. Never assuming and just asking, can
you take tablets? And if they can't put them into tablet training.
EL: Totally. So our first question should be, when you prescribe medicine is, ‘can you swallow
tablets?’ and if they say no and if they're old enough, you say, ‘would you like to learn?’.
AP: Absolutely. And old enough, we would say around about four.
EL: Yeah. I mean without a doubt you and I have no problems from four or five onwards. Nicola
Vasey, our pharmacist, told me more shame tales here, that when doctors write prescriptions,
15 percent of doctors actually write tablets or liquid at the end. So, most people will just write
amoxicillin 250 milligrams three times a day. Nothing else.
AP: That's so interesting. So, it is really down to the pharmacist then who decides if they
dispense liquid or tablets.
EL: It's down to the doctor, really, to be more specific when they write the prescription. I think
electronic prescribing has helped this because you are forced to choose tablet/liquid/what
kind of preparation. And I think what doctors don't realise is how much money is in this. I do
think money should come late down the line. It's not the primary importance, but what is it?
What's our favourite example?
AP: So the example is back to Yincent and the renal team. So, the renal team converted 30
children, from liquids to tablets. Admittedly, some of them only need simply to be asked if they
could take a tablet. But lots of them went through the tablet training and they saved within a
quarter of the year, they saved something like thirty thousand pounds.
EL: It was worse than that. We only looked at swapping them from tacrolimus liquid to
tacrolimus tablets, and they saved fifty thousand pounds in six months. And these are recurring
costs. Yeah, I know, you can all fall off your chairs now. And nitrofurantoin, a really common
antibiotic, one bottle, how much?
AP: £212
EL: Oh. You knew that. How much is the pill Ailsa?
AP: I think it works out at about a pound.
EL: No. 15p for a packet. So, I think it's shocking. I don't think people realise how expensive
liquids are. And oral prednisolone is another one. Prednisolone syrup, really expensive.
Prednisolone tablets, cheap as chips. So, we've talked about why everybody should do it,
because it's good for kids, because it saves money, because it's actually empowering. But
trying to get one child is easy. But trying to convert a whole hospital or a whole department is
much harder. Tell me how you found this.
AP: So how we did it was to target large groups of particular people to actually roll out the
training. And we decided upon the nurses and the nursery nurses and the play specialists to
actually rule this training out. And they were all really enthusiastic. The teaching was so well
attended. I think the negative of doing that has been that some people think it's not their role
because we've trained play specialists. And so therefore, when the play specialist isn’t there,
the tablet training doesn't take place. And tablet training should be done by everybody. So, I
think, thinking back in hindsight, maybe that was a mistake and we should have had much
more mixed groups of people.
EL: There are no mistakes. I think that we are trying to change the whole culture.
So actually, we went back even further, and we went and trained mixed groups of nurses and
medical students, and they did joint training so that they would come in the system knowing
no other way, indoctrinated from birth.
AP: It worked really well. And the mixed training worked well. So, I think that would be a good
way forward.
EL: I think that doctors and nurses learning skills together sets a really important precedent
because we have to work as a team and there's no better or more senior person or team. A
team is just a team. So, when you learn together, then you work together better in the future.
AP: We also targeted the pharmacists. I think that was a really important thing to do and I
think, had we done it again we would definitely do that again. We talked at pharmacy
conferences and we spoke, and pharmacists were very, very eager to learn and also pass the
message on. We've had lots and lots of enquiries from pharmacists all over the country.
EL: Oh, that's so true. And it was really interesting, Nicola, our pharmacist said to us, ‘do you
know it's really nice to get out to the pharmacy? It actually brings us out of pharmacy and gives
us a chance to have some face to face time with a patient’. Oh, we've been really positive. But
actually, there have been times where I really hated this project and I still get really frustrated
because I feel that we've spent years, until I'm actually sick of saying the same things again and
again, and sometimes I go down, I say ‘can anybody teach tis child how to swallow a pill?’ And
still nobody who can do it apart from me. And I find that quite frustrating sometimes.
AP: Yes. I come across that all the time on the wards or I get phone to go and do tablet training
with a child when there's lots and lots of staff who've gone through the training who are able
to do it. I think doing it quite frequently because it's building up that confidence as a trainer as
well. I think people think this is really complicated and quite a difficult thing to do. And it's not
at all. It's very easy. And I think once you've done one or two, you realise how easy it is and it
gives you that confidence.
EL: Oh, that's so true. With really junior doctors, I teach them early on, they're just like, ‘Wow.
Yeah, I can do this’. And then they go off and do it by themselves and they make that decision.
AP: And one of the things we've said to people is, at the end of the training, go away now and
train somebody. It doesn't even have to be a patient. Go and train your sibling, go and train
your child, anybody, because that will give you the confidence that this actually works and is a
great thing to do.
EL: Yeah, well, like one of those awful pyramids selling Avon ladies. But it is true. We always say
that, learn yourself and then go and teach your friends.
AP: So, one of the parts, one of the things we've done in the training is actually split people into
pairs and get them to train each of them. So, one, be the child and one with the trainer and
then swap around. And that gives people the confidence to do it. But it's really, really
important that they go away knowing that they've actually practiced the skill.
EL: My biggest obstacle is just inertia. General institutional inertia.
AP: I think one of the main problems as well is people being able to get their hands on the kit.
They feel like they need a special kit. And really, it is a very simple thing to put together. Any
ward or department can put it together. You know, it's cake toppings and some sports bottles.
And most children actually carry sports bottles and have their own sports bottle, which they
can use. So, it's not a difficult thing to put together.
EL: Yeah, I have a secret stash of sweets. Ailsa, what would you do differently or what will you
go on to do now?
AP: I think keeping up the momentum. I think it's very easy to let things slide. And then you
come across people who say that they've never seen it, they've never heard of it. So, keeping
up that knowledge and that training. Go into areas that have done the training and make sure
that everyone is happy. Things like that. I think that is where I'll go on from here to do.
EL: You're so right. And actually, I think I really couldn’t do it without you Ailsa. In so many ways
but I think it's something about keeping up that energy of doing it again and again. And that's
what works with our team. So, we work in a team with doctors, nurses, pharmacists, and we
kind of need each other because there's always somebody who's feeling really energetic and
somebody who's just had a bit too much.
AP: And I think getting out there like doing this sort of thing with the podcast, but also getting
awards and doing a paper on it. I think all of these things a way to spread the word.
EL: Absolutely. So. Right. Sister Pickering and the pill swallowing secret. What are you will last
words?
AP: My last words are. Try it. It's easy and it works.

Episode 3: The secret life of pharmacists, with Nicola Vasey and Lisa Clark
Full transcript of podcast 2022
RCPCH: This podcast is brought to you by KidzMed, a programme set up at the Great North
Children's Hospital in Newcastle. And by the Royal College of Paediatrics and Child Health.
Emma Lim: My name is Emma Lim and I'm a general paediatrician. I work at the Great North
Children's Hospital in Newcastle upon time. And we here to talk about KidzMed and the art of
pill swallowing. So, this episode is about learning why we should all love our pharmacists. And
we'll be talking to some of our pharmacy staff and thinking about how they can help us work
on teaching children to swallow pills. And I guess that's one of the things I think that it's kind of
like the secret life of pharmacists, because I don't really think we know much about what you
do.
Nicola Vasey: Hello, my name is Nicola. I'm the lead pharmacist in the Great North Children's
Hospital, and I have worked here for just over 10 years and worked as a paediatric pharmacist
in a large teaching hospital in London before I came here. So, I've probably worked in Children's
Services for about 15 years now.
NV: So, we have worked together on the pill swallowing project, both in terms of the secret life
of a pharmacist. I guess my introduction to this project came about because pharmacists kind
of, as well as checking the drug charts and telling nursing staff how to get infusions in hospital,
are quite often the backstop of helping to sort out any problem which is medication related.
And, what we've certainly noticed in the children's hospital over the last 5 to 10 years is that as
they see the developments in medicines have evolved and we've got better at treating
children, we have started to have more challenges in terms of actually getting medicines into
children.
EL: OK, so you're like a troubleshooter. When we messed up, we don’t do something right,
you're going in, fixing the problem, and come out before we even noticed that you were there.
NV: Sometimes. Yes. And I think pharmacists sometimes get a bad rep. So, you know on
Twitter we are seen as people who come along and nitpick at drug charts and tell doctors what
they've done wrong all the time. It's more that we want to be really helpful and help to solve
problems and make sure that we can reduce errors and stop anything bad from happening. As
a personality trait, we're all fairly risk adverse individuals.
EL: I think you're right. I think the doctors hate being told the wrong, in any way. We're really
bad at taking criticism, even positive, constructive criticism. So, your ringing up and saying, ‘oh,
you know, you prescribed this wrong’, we are immediately like ‘oh’. OK, so let's go back. We've
talked about pharmacists and their role. The paediatric pharmacists are actually very specialist
kind of pharmacists. Tell me how you got involved in the KidzMed projects.
NV: So we have children that are on lots of different and complex medicines. And we know
from feedback from families that they have a lot of problem getting hold of these medicines.
So sometimes the GP's won't prescribe an ongoing supply. So, we set up a project to sort out a
process for getting medicines to families and we were kind of at a point in time where we were
wondering what step to take next. And then Yincent, who was the doctor running on of the
projects, bumped into you in the corridor and said, we have loads of children who are having
problems getting hold of their medicines. And you said, ‘whoa, whoa, whoa. Why are all of
these children on liquid medicines? Why are they not all on capsules?’ And we said, ‘well,
because they're children and they need to be on liquids’. And you said. ‘Well, do you not train
them how to swallow capsules and tablets?’ and we said ‘no’. You said, ‘why not?’. And we said,
‘because we don't know how to’. And that was the kind of door that opened to KidzMed. That's
when we realised that actually we had a hospital full of children that were taking liquids, that
had never been taught how to swallow capsules.
We had never considered that, actually, the solution to the problem that we had was not about
supply, it was about the kind of medicine that we were trying to supply to them. And that
actually, if we give capsules, you know, as opposed to give them one bottle of liquid that might
have a very short expiry date, then actually it can give months and months’ worth of medicines
to somebody. And that actually quite often we have liquids that are unlicensed, and so this was
where pills swallowing came about. We had a group of physicians and specialists who were
doing it in HIV clinics and going about their job and doing that very, very well and assumed that
the rest of the hospital was doing the same. And we weren’t.
EL: That was so true. So that assumption that because one of the departments knows what to
do, that they've talked to any other departments.
NV: Absolutely. And I think you said to me, ‘do you know how to train somebody, how to
swallow capsules?’ And I kind of, you know held my head and said ‘no’. Being a paediatric
pharmacist for years and years and years, I know how to do inhaler counselling and I know how
to do wardroom counselling and adults and all of the other things that we got trained as a prereg pharmacist and as a junior pharmacist and things that went into our clinical diplomas. But
nobody had ever taught me how to teach somebody how to swallow. Tablets are capsules.
EL: I know the irony that pharmacists, who spend their life making pills, are not taught how to
help people to swallow tablets or to teach other people how to swallow tablets. How did that
make you feel?
NV: Oh, I felt really, just quite bad about it. I think particularly once I had been shown how to
do it, I was like this is so simple. Why had I never been shown this before? And why is it not
more widely taught? So, so I felt really bad and a bit embarrassed, and then I was like, actually
this is going to open up doors, so let’s totally embrace this. Let's get the pharmacy team on
board and let's roll it out.
EL: Fantastic. So, tell me some of the obstacles you faced?
NV: Finding the time. So, you know, getting everybody together to do the training session and
then rolling it out. And the other thing is that people from other hospitals have come to me and
said, ‘how have you done it?, How have you made it work?’ and actually, I think the difference
at our hospital has been that there's very much been a driving force behind it with yourself and
Ailsa. But it's not just a pharmacy project and we've gone to individual teams and taught them
how to do it. And the nurse specialists and the play specialists have really embraced it and
taken it on and can see the benefits of doing it.
EL: So, Nicola, I think that's really important. One of the obstacles is time, is always time. Time
and money. One of the other obstacles was getting the teams together. But one of your
successes was because this was a multidisciplinary project, not just through pharmacy. It
involved doctors, nurses, play specialists. Everybody. Did you have any quick wins that you
want to share?
NV: I think because we hadn't ever ran it out across other specialties, we did a test, a pilot, with
the renal team. And of course, they had a lot of immunosuppression, and so actually when we
did it with them and we converted things like Tacrolimus suspension across to capsules, we
saved a lot of money very, very quickly.
EL: That's so true. So, we just picked this one department. And we chose one pill. We targeted
Tacrolimus. And just changing from Tacrolimus syrup to tablets, how many people did we
convert that first time. Was it like 10?
NV: Something like that, yeah.
EL: Yeah, ten children. We saved fifty thousand pounds a year recurring cost.
So, I think that was one of the classic things. In that pilot, we just looked at the renal
department and we focused on changing them from Tacrolimus syrup to tablets. And I think
we converted tens of children, not that many. And just with that alone, changing from syrup to
tablets, we saved tens of thousands of pounds every year. Like in the region of 30 to 50
thousand pounds a year.
NV: Yeah, and the cost saving was a side effect of the fantastic project. So often because of the
NHS finance at the minute, we have to go out with cost saving projects. Whereas with this one,
the cost saving was a perk, a benefit and one of the many benefits. And that was the first time I
come across a project like that.
EL: Yeah, I think that you can't be driven by cost savings. You've got to be driven by doing the
right thing.
NV: Exactly.
EL: And then money will follow. Yeah. All right. So, we talked about, how did, how did it change
you?
NV: It made me much more open minded to be challenged. So, from when you challenged me
about did I know how to do it? It made me realise the power of a corridor conversation. And
working with these fantastic people that individually are all doing great things, we need to tie
all of those up together. And it made me realise how quite a small thing, like teaching
somebody how to swallow capsules, can have such a large knock-on beneficial effect in their
life.
EL: And what would you like to see happen next?
NV: So I think the thing with this project is it's been fantastic, but we need to keep the
momentum going. We need to continue on making sure that we are, as people and children
come into hospital, training them how to swallow capsules and tablets. And we need to embed
this as part of the pharmacy psyche. So, by working with the local university to make sure that
their undergraduate students are trained.
EL: Fantastic, and I think that's so important. In fact, we put it with our teaching fellows, we
embedded it into the medical students and nursing students training where they did a session
jointly, nurses and doctors together. So, they're learning a new skill together and they all really
enjoyed it. And it helped them develop that relationship that they're going to have to have the
whole working life, just working through problems together. So, everybody loved it. They got
to eat sweets; they were happy. All right. Excellent.
And we talked about the secret life of pharmacists. But I think there's something about the
secret power of pharmacists, because certainly I was like, I was ignorant of the breadth and the
depth of pharmacy and what it covers. And since we started this project and I've met lots of
pharmacists, lots of different pharmacists, specialists, pharmacists, pharmacy technicians and
academic pharmacists.
NV: Absolutely. Yeah.
Part 2: Emma Lim and Lisa Clark
EL: Hi, Lisa. So nice to meet you today. You are a pharmacy technician. What does that actually
mean? What does a pharmacy technician do?
Lisa Clark: So well, pharmacy technicians do a lot of clinical work with patients. We do the drug
histories, which means that we go and see what the patient was on previous, before they came
in the hospital. And we make sure that the doctors actually prescribe it correctly. We do a lot of
counselling with the patients (i.e. pill swallowing) but we do other counselling as well. We work
with families and children.
EL: Oh my god, I'm so ashamed. I feel like all the things that I didn't do in my history, that you
then have to come and do on the ward.
LC: Yes. I mean, I'm full of just making everything correct.
EL: Making everything correct. So, when I say ‘are you on any medicines?’ or ‘have you got any
allergies?’ and just put ‘nil’ and ‘nkda’ (no known drug allergies), that's all I ever write. And I feel
bad. All right. So, you said you go and you take a proper full drug history, and you check all the
previous medicines, and then you said you actually work through all sort of problems with
family, so you do face to face.
LC But we do. Yeah, we do a lot of work with families. We have like autistic children who, point
blank, refuse to have medication. So we have to try and find a solution as to how we get that
medication into them. We have obviously children who just point blank refused to take
medicines. We liaise with the play specialists. We work with different people, but mainly with
families. I'll let the families know that we are here to help them, to help the patients take the
medicines, and we have had quite a lot of success stories with the patients.
EL: So your role is to work face to face with the families?
LC: Yeah, yep.
EL: I am feeling even more in awe now. There is a lot of fear around pills and pill swallowing.
LC : There is a lot of anxiety.
EL: So how do you, can you give me an example of a time where you taught someone how to
swallow a pill? How does it change your role?
LC : It's changed massively, actually, because we do use this quite a lot. We do have a teenage
boy on Ward 1B . One of the nurses came to me and asked me if I could work with him and his
mom because he had major anxiety issues of swallowing tablets and liquids. Initially he was
having liquids, but this patient came in with ‘nil reg meds’, so he wasn't on any regular
medication.
EL: So this child has never taken any medication before in their life, and then they came into
hospital and were expected to take…
LC: So he was on an array of different medications, like anti-spasmodic pain relief, Just so
many different medications, and it was causing him so much anxiety that they asked me to go
and have a chat with him. He was on a lot of liquids and people just assume children take
liquids, but that's not the case. And obviously the taste of the liquid. Some of them are nice.
Some of them are not so nice.
EL: I think that's so true. So many doctors don't understand how bad some of the medicines
taste. Every single time, every single year I come and get a bottle of flucloxacillin and I take it
around the junior doctors and I say ‘taste this’ and they're all gagging. And I say, ‘you will never
prescribe this again as a liquid, because if you can't swallow it, how can you expect a four year
old to swallow it?’.
LC: That's right.
EL: So the taste of the syrups are bad. We're going back to this child, who is a teenager, who
was on four or five medicines. Loads of them tasted bad and he was really anxious about it.
LC: Yeah. And it's not so much the taste of the medicine. It could be the volume as well. This
obviously, we have some patients who are volume restricted. So obviously giving tablets is
more beneficial. But this particular boy, he was willing to work with me because I told him that
I could make him succeed. I would let him, not make him, but help him to succeed. And the
mom asked me, ‘why are you so confident? What if we can’t do this?’ And I said ‘We will do this.
This this is we have been trained to do this and something so simple can be so effective’. So we
set up a little meeting to have a chat, took everything and set everything up. I re-assured him.
He says ‘will I be able to take tablets by next week?’ and I went ‘no, you will be taking tablets in
the next half an hour. Easy.’
EL: That’s amazing. I love it. So he was like ‘will I be able to take them next week?’. And you
were like ‘no, you will be able to take them within half an hours time.’
LC: Yeah. And mum was quite anxious as well because she knows a son and she knows that
trying to get paracetamol into them or anything like that was a real struggle. So when we did
the pill training with this boy, he was willing to engage, which is a big thing. They need to want
to do it and he did want to do it. And I took him step by step as to what he had to do and he
couldn't understand how easy it was. So we've gone from a child who was frightened to tablets
to then he said to me, ‘I'm excited to look forward to taking the next medication now because I
can actually swallow a tablet and a capsule.’ And he went through the whole, every size, all the
way up to the end, and he was so proud of himself. And I was so proud of him as well.
But he was so proud of himself, the way that he couldn't believe what he had done. And his
mum was in awe. And he actually told me that it's actually changed his life and it actually
helped his journey in this hospital because he was spending a long time recovering. And he
actually said that you have made my time in this hospital so much easier. By working with you
from the beginning, if I never worked with you, I would have struggled all the way through my
recovery. So that in itself is a massive, massive thing. And it was huge to him. He even wrote us
a thank you card, gave me a little gift.
And I wanted to give him a hug, but I wasn't allowed. But I told him I wanted to hug him and I
did shed a little tear because he was so grateful for what we did for him and he kept praising
the pharmacy all of the time. And he says, one of the top people who helped him throughout
this, I was way up the top of that list. So that makes my job worthwhile. That's why I do my job,
because I love it.
EL: That's so powerful.
LC : It is. It has made a massive difference to him. It's all about patient care as well, you know,
and it's not about money. Obviously, it saves a lot of money switching liquid's to tablets. But
it's all about the patient and letting them know that it's so much easier to swallow a tablet than
it is to have numerous liquids that taste horrible. You know, it's, it's just so easy, so effective.
EL: The thing that stands out for me is your belief. Your absolute belief that it's going to work.
LC: Because it does work. I make it work. Because it's so easy, this, this is the thing, it's so easy.
Like I’ve got that confidence and you take that confidence into the room and show that patient
that, you know, they are going to do it. They believe they are going to do it. And they do do it
because it is so easy. And I know I keep saying it's so easy, but it is.
EL: But it's really interesting. I think the technique of teaching people to swallow pills is simple.
But you have that gift of bringing that confidence into the room. And that is a confidence that
the patient can then take away and use in other parts of their recovery.
LC: Yeah. I agree.
EL: And so, I mean, I think that as a pharmacy technician, here is a child who has spent six
months in hospital who says the pharmacy technician is the person who has transformed their
hospital stay as much, or maybe more, than the doctors.
LC: He said so, yes. He did say so, yeah. He was very grateful and that makes my job so much
more worthwhile. Just helping, helping the kids.