Pill swallowing in children

How can we as paediatric health professionals support children and young people to swallow pills? In this series of educational podcasts, produced with Kidzmed, Dr Emma Lim chats with colleagues at the Great North Children's Hospital in Newcastle to explore what's gone well and what they can learn...

Listen to our podcasts covering pill swallowing in more depth – a fantastic extension to our elearning session for those who want to know more.

  1. Episode 1 - The secret of pill swallowing

    Sister Ailsa Pickering, a specialist nurse working with infectious diseases in paediatrics, and Dr Emma Lim, consultant paediatrician at the Great North Children’s Hospital, discuss the practical side of learning to swallow tablets early on in life and how achieving this skill allows the patient some control over their health. Ailsa describes the steps in teaching a patient how to swallow pills and provides three top tips for success.

    This podcast is produced in partnership with KidzMed, a programme set up at the Great North Children's Hospital in Newcastle, and by Medisense

    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
    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
    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
    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
    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
    AP: My last words are. Try it. It's easy and it works.

  2. Episode 2 - Quality improvement and the meaning of life

    Dr Yincent Tse, a children’s kidney doctor with an interest in quality improvement, talks about the benefits of pill swallowing in relation to financial cost comparisons between liquid and pill medicines and the benefits/simplicity for everyone involved when patients are able to take pills.

    RCPCH and Kizmed podcast | Pill swallowing in children
    Episode 2: Quality improvement and the meaning of life, with Dr Yincent Tse
    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: So, let me introduce myself. My name is Emma Lim and I'm a general paediatrician
    working at the Great North Children's Hospital. And today in our Pill Swallowing podcast, we
    are going to get down to the nitty gritty and the meaning of life. And we are going to be talking
    to Dr. Yincent Tse, who is one of my colleagues. Hi Yincent.
    Yincent Tse: Hi, Emma. Thank you for inviting me.
    EL: So polite. This is not like real life Yincent. Do you want to tell me a bit about yourself?
    YT: Hello. I'm a children's kidney doctor and my other interest is in quality improvement.
    Quality improvement sounds quite boring, but really what it is, is about implementing
    something, but also measuring it so that you can convince others and yourself that it has
    worked or doesn't work. And also learning as you go along.
    EL: Quality improvement and kidney disease. That's the kind of niche interest.
    YT: Well, quality improvement is a bit like how we deal kidney disease. So, you've got someone
    with high creatinine, you intervene, and you don't just walk away and say, ‘ah I’ve given them
    some steroids’, you would actually measure your creatinine again. That's exactly what quality
    improvements. So, I think that's point why lots of mythologist go into doing quality
    EL: Great. So, the obsessive compulsors amongst us love quality improvements, and anybody
    else who wants to grind their teeth.
    YT: Absolutely. And we like numbers.
    EL: Yeah. And I think that's one of the really important things. I think people, and we've said
    Yincent that you're a big QI fanboy, and I think people kind of get put off. They think it's really
    difficult. But actually, one of the things you mentioned that is. Data. Data is king. Data is
    important. Why?
    YT: Yeah. So, if we use KidzMed as an example of how we got here. So, we may remember I
    Emma in the corridor said why don’t we try this. So, we tried in a small group off our kidney
    team and we had a really fun day. Emma and Ailsa came, and we had a great hour, two hours
    teaching about how to swallow pills. And then we went out and tried to implement it. But what
    we did was that we started with one clinic and we said, ‘okay, let's try and see what the next
    child that comes into the door, whose on liquid and you know over five years old, can we
    convince them to start to swallow tablets?’ And in one case, I think the first time, we managed
    to do two children, and actually both of them did it.
    At first, all we measured was ‘could we do it?’ And then as we went along, we thought, oh,
    actually, we could get more data. What about how many medicines that they were on? What
    about the price of medicine? Because suddenly our pharmacists got very excited and thought
    how much does this cost?
    EL: And I think that's really interesting that you counted some really basic things. So how many
    medicines each of the children you saw were on? So how many medicines were average renal
    patients taking per day?
    YT: Yes. So, it ranges quite a lot. You know, some children its 5, some its 10 and, you know,
    parents were just coming to a clinic with a big box of clunky bottles. So, that was how we
    started. Just small. You can actually just do it on a back of an envelope, but make sure you
    don't lose those envelopes.
    EL: Yeah, that is really interesting, because, first of all, you just counted the number of children.
    Then you counted the number of children and the number of medicines. And then you counted
    the number of children, the number of medicines and the actual cost. And when it got to the
    cost, that was the bit where everybody, even me, got really excited. So, tell me a little bit about
    the costs involved.
    YT: Yes. So liquid medicines is incredibly expensive. And actually, there is a lot of hidden costs
    as well. So, if you look at the BNFC, it tells you the cost of a liquid medicine. But that's only for
    licensed products. For unlicensed products, you need to ask your pharmacist. And it's
    incredibly expensive. So, Lisinopril is a very cheap blood pressure medication. In tablet form, it
    costs like 10p each and in liquid form it’s £1 per ml. So, if you on 5ml that is £5 each day. So that
    all adds up. So, in a month £150. In the year, I don't know my math is not very good, about
    EL: And I think that we targeted renal because of the cost of Tacrolimus liquid is compared to
    Tacrolimus tablets, hadn’t we?
    YT: Yes. So, we quickly found out that all our medicines were really expensive in liquid forms.
    And so, we first started with the cost, but there were other things that we can measure as well.
    First of all, you start with yourself, your own clinic, and then you move on and you say, actually,
    I've got five colleagues can I convince them to do it. So, the next thing we measured was, we
    obviously had a chat within our team, we convinced them with my own data and then we
    went, ‘okay, why don't you try it?’ And the important thing is actually to involve the team,
    because it's not only the doctors, it’s the nurses, the centuries. And once you've started and
    convinced people to do it, they actually help your project get along. So, the doctor forgets, the
    nurse will go, please, could you think about switching them to tablets? So, everyone helps each
    EL: And actually, you know, I think it was harder getting colleagues to switch than actually
    getting the patients to switch. Because, first of all, you said that renal physicians are typically
    really obsessive compulsive and they hated not being able to give .25 of a ml. So, they really
    struggled with this idea that you couldn't chop the pills into tiny weeny bits.
    YT: Yeah. So, part of the thing about quality improvement is that there's one tool called the
    PDSA, that is plan, do, study and act. And there, you know it sounds very clunky, but essentially
    what you do, what it means is that at the end of every clinic, you just had a look back and see
    what happened. So, you are right that it is really hard to convince your colleagues and we
    encounter some situations where people wanted, you know, your drug level to be exactly that.
    So, we had to sit down and go, okay, what happens if half a milligram isn't enough? And one
    milligram is too much for someone? So, we actually had a drop protocols and say, well, half a
    ml in the morning, one ml in the afternoon.
    EL: That is a real. I can't believe that you couldn't agree. You had to draw up a protocol. Okay.
    Well, I mean, in a way, I'm laughing. But in a way, in Renal, you've been better than everybody
    because you've found the problem. You've dealt with the problem. And you've come up with a
    solution that's not just for one person, but it is for everybody. Because when somebody else
    comes to that problem, what comes between half a milligram and one milligram, you've got a
    protocol to follow. But there were other funny things that people found really hard. Do you
    remember really early on, we had loads of people who said, I don't know why you're teaching
    children to swallow pills. They're much more likely to go and take worse overdoses and
    swallow pills when they shouldn't swallow pills and swallow illegal pills and things like that. Do
    you remember?
    YT: Yeah. I mean, people came up with all sorts. But one of the things is that learning, I mean,
    we all have to learn how to swallow tablets at some point, it's a skill for life. And I think you
    mentioned that you wouldn't send someone with an inhaler without actually teaching them
    how to use it. So, we are actually sending children home with tablets, expecting them to take it
    without checking that they know how to do it.
    EL: Absolutely. And, you know, riding a bike is a skill for life. But because you ride a bike doesn't
    mean you're automatically going to be run over. You give people a skill and they learn what to
    do with it. So, we talked a bit how we started to implement it. And it was quite a success in the
    renal department. And then everybody got excited because we'd saved a bit of money. How
    did you convince management, that this was a good idea? How did you move this from a
    project in one department to a project over our trust and over our region?
    YT: The project actually sold itself because it's better actually coming from ground up than
    from top down. I mean, at some point you need to involve management. So we went to
    convince other teams where they had the same issues because once children are on tablets,
    then I mean, we all know that in tertiary primary care that, I mean, I've got patients who live
    two hours from Newcastle of which I work and their GPs would prescribe regular medication,
    quanti medication, if it's on tablets. We actually went to visit some GPs and they showed us on
    a computer system that they can't prescribe liquid. They can't actually find it on the computer.
    You know, it just says 5mg or 10mg tablets. It didn't say liquid. So many of these GP computer
    systems isn't designed for liquid for children.
    What's helpful is making it easy for people. So, if you switch people to tablets, it's easy for a GP,
    it's easy for a nurse and as important is that it’s really easy for the parents.
    You know, parents used to take lots of bottles, when they go to on a holiday. And now, you
    know, they've just got box of medicine. That's really helpful.
    EL: So, it was really funny, I mean, we started this project, like you say, on the back of an
    envelope with some packets of sweets and lots of enthusiasm. And it wasn't till we proved
    with your data that we could save money that actually management started to get interested.
    So, what is it? What do you think turned them?
    YT: So, like many of our listeners, paediatrics is probably quite a small part of the whole trust.
    And one of the things that we started doing was to show how much money we were saving.
    And that really opened doors for us. So, we were invited to a talk at different departmental
    meetings. And once you convince someone that, yes, this is, this could be potentially cost
    savings. It suddenly opens lots of doors. We found that in our hospital we had a transformation
    team. They heard about it and they thought ‘fantastic, this is a nice, easy package.’ And the
    transformation team was really helpful because one of the things we struggle with is actually
    with the small costs. You know our nurses were using their own money to buy the sweets
    because procurement is really hard in the NHS. How do you pay someone five pounds? There's
    no petty cash. So, we had to say by convincing our transformation team, they actually oiled all
    that force and made it easy.
    EL: Yeah, that was actually really classic. So, because we have saved money, we were asked to
    do a big lecture to all the senior doctors and senior management. It was me and Elsa and we
    talked all about it. And then one of the CEO, the chief executives of our trust, came up, clapped
    Elsa on the back and said, ‘That's a fantastic project. Where did you get all the sweets and all
    the training things?’ and she said, ‘I bought them.’ And he said, ‘Did anybody pay you back?’
    She said ‘no, because there's no procurement code for sweets.’ And he said, ‘over my dead
    body, you will be paid back’. But it took somebody really high up, for Elsa to get her 50 pounds
    back. And it was 50 pounds, every single time we ran something. So, these amounts of money
    added up. Apart from saving money, I think the other thing that happened is somebody put us
    in for an award and the trust always likes to look good. So, once we won an award, people
    were more interested.
    YT: Yes. And actually, the award I was most proud of, was the eco award. So we won the NHS
    Sustainability Award because we worked out that not only were we saving costs, we were
    saving petrol money because a liquid, you know, the costs of transporting liquid all over the
    county was actually pretty high. We saved a lot of carbon.
    EL: Yeah. We saved plastic. We save volume. Liquids are really bad because, you know what
    people do, people tip them down the sink, and they pollute all sort of other things. We are
    totally ecofriendly.
    YT: One of the most, highest impact, ecological impact in health care is actually making
    medicine. So, making a tablet or something already costs and uses a lot of water, uses a lot of
    carbon, etc. just to get your drug intake to capsule. And then if you make that into a liquid,
    you're actually adding extra, you know, crushing up, etc. Yeah, that all adds to the ecological
    EL: So, I think one of the reasons that this project work was it was a great idea. It was simple. It
    involves sweets. Lots of people could do it. It's saved money and saved time. The patients liked
    it. There were even more sweets. And it was ecofriendly. So, once we'd roped in management,
    then they were prepared to back it and give us a little bit more money, but only a little bit more
    money. So, one of the next things we did was to sort out how everybody could have a kit and
    who would use the kits.
    YT: Yes. So quality improvement is actually about making things easy for people. And this is
    one of the classic examples. So, it's very easy to not teach someone to swallow tablets
    because, you know, you have to find your capsules, get the kit out etc. But early on, one of our
    big wins was actually thought about making a kit that's available in all our wards and the
    transformation team actually helped us. So, there was one day where in the room you had
    three or four of our staff who went and actually just filled up these kits. And now in the
    hospital, there's a kit in every ward and every clinic.
    EL: We had bottles with our logos on, plastic bottles and we had sweets; so you could just pick
    up one box with the sweets , a pop top bottle, with a sticker, with instructions about how to
    use it. So, it was all in one place. I still find that people don't know where they are though.
    YT: No. So, this project doesn't stop here. You know, we have to keep going, keep breaking the
    barriers down.
    EL: Tiring, constantly pushing. So, I think that's a really important point. Things never stop. They
    always continue. Dissemination is such an important part of this. Nobody ever would have
    known about Edison, if he'd invented the light bulb and kept it to himself. It was all about how
    you grow your good idea and spread your good idea.
    YT: Yeah. So early on, it's really important to involve more and more people and actually to get
    them to own the, to be part of the team, and actually have a flat hierarchy. Touch your own the
    project. So, it wasn't just me who would say, okay, let's have a box. It could be anyone in a
    team who said, let's do this and to be empowered to do X or to do Y. So not having, you know,
    having lose control was really important.
    EL: Yeah, that's funny you should say that because I think you and I are both a bit loose. I think
    it was really flat hierarchy in our team that anybody could say anything, and anybody's idea
    would take off. So, it was really important having pharmacists, nurses and not that it came
    from consultants.
    YT: Yeah. And I think it's very important that we shared any positive kudos that comes from it
    and actually for each of us to use our own strengths. So, for example, Nicola went to the
    national pharmacy conference and presented it. I went to medical conferences, Ailsa
    mentioned nursing commonsense and say, and as you own the project, we did it in our own
    EL: Yeah, I think it is so true what you say about kudos. It was a great project. We all knew it
    was a great project. And once we told people about it, they did as well. And there were lots of
    funny things. You had one of your first most important publications in the, which journal was
    YT: Archives.
    EL: You want to quote these archives of childhood disease.
    YT: Yes. 2020. Hopefully by now it'll be in print. Many people got their first from this project. So,
    Ailsa, Nicola, you know, they got their names in there in the paper. My medical student, who
    collected quite a lot of data, again got her first paper.
    EL: There were loads of firsts for this project. You got first authorship of a paper. Nichola got a
    pharmacy prize, that was a first. I got a free bottle of fizz. That was the first. We got a first prize
    in the bright ideas for health awards and we got a sustainability award. So, there were quite a
    lot of firsts for all sorts of different people in different spheres.
    YT: Yeah, we actually learnt a lot through this project. So, for example, you managed to get a
    guy to do the filming. To do the video, yeah, to teach people how to swallow tablets. Ah.
    Cartoon maker guy first. And that week I actually got the posters translated into 14 languages.
    EL: One of the things that made this project so successful was that it drew in people from all
    sorts of diverse spheres. For example, Louis Francis was a student at the Newcastle University,
    Documentary Film School. And he made a film for us. It was brilliant. And you can find it on
    Yicent’s website: Northern Paediatrics KidzMed. There was a great story we wanted to cartoon
    to show people how to swallow pills. And we went to South Tyneside University Graphic Arts.
    Yes, they have a degree in graphic and cartoon arts. One of their final year students, it was her
    first commission ever. And it was actually amazing. She was the first person in her entire family
    who'd ever been to university. And they were all a bit like, ‘ooo, what are you going to do with
    that?’ And she actually got a commission and got paid for her work. It was really big deal for
    her. She's brilliant. She's really talented.
    YT: Yes. this idea wasn't new. Yes, it came from you came from someone else. But what I would
    like the audience to do is say, take it back to your unit, try it. You will learn a lot from the
    journey. Like we learnt a lot.
    EL: Yeah, I think the things that you learn can be really unexpected. So, we'd started this
    project and we were actually approached by the research unit and they were running a new
    research study on Duchenne muscular dystrophy. And there aren't many treatments for this.
    There is one new treatment that's come out and to get onto the trial, you had to be able to
    swallow this in a tablet form. So, you weren't eligible for this new treatment, which was the
    only new treatment, unless you could swallow a pill. So, they came to us and asked for our
    help. And actually, we taught all the research nurses and they didn't have a single failure. There
    was no child who missed the opportunity to try and new treatment because they couldn't
    swallow pills. And for me, that was a really important kind of thing that I just wouldn't have
    thought about that.
    YT: That’s really amazing because for these children, this is their only hope to not end up in the
    wheelchair. You know if the medicine work. So, it is like five, six-year old. That's fantastic. And
    the other thing that the research department did for us is that they translated the posters into
    14 different languages. And you would not imagine how quickly that people can do this. And
    that was very helpful because many of our patients, English isn't their first language.
    EL: Yeah, that was great because it was an international trial. So, they actually paid for the
    translation costs of all of this. And that was incredible. And they went on and trained their
    research nurses across all the different sites. Yincent, when you started this project, I know that
    you wanted an award and you wanted to publish something. And after that, you were like, ‘oh,
    Emma, I've had enough of this, you know, let me let me go now. Let's do something else.’
    YT: Yeah. I think the problems sometimes with quality improvement, and we see it all the time,
    is that the early enthusiast's, early adopters, properly are the ones that get bored or something
    quite quickly. Having a team, having the, especially the nurses, pharmacists behind the project
    is very important. They keep the project going. They make it much more than your own little
    EL: Yeah, I think that's totally true. You are absolutely the example of incredibly enthusiastic,
    early adopter. And then you want to run off for another thing. But if you combine that with
    Elsa's persistence and Nicolas rigor, then that makes a really strong team that can help the
    project run for the full length. And we haven't finished yet have we?
    YT: No. And it was you guys who started it many years ago. You know, teaching children with
    HIV how to swallow tablets, so, this is your project. Well, I always say it's standing on the
    shoulders of giants because I was trained in Saint Mary's Hospital in London by a fantastic
    children's HIV team who included people like Hermione Lyle, and nurses like Jamal Hamacchi,
    who actually trained me. So, you're right. It's about passing it forward.
    YT: And it'll be fantastic if those who are listening to this podcast will just take this project
    forward. Try it. Convince your nurses, your pharmacist to do it. And hopefully you really have
    lots of fun along the journey.
    EL: Yeah. Start small. Eat sweets. Give it a go.

  3. Episode 3 - The secret life of pharmacists

    Nicola Vasey, lead pharmacist at the Great North Children’s Hospital, discusses the role of pharmacists in pill swallowing. The cost saving outcomes were viewed as one positive effect of the project and changing university and student curriculums to involve pill swallowing was proposed as the next best step for ensuring training in pill swallowing continues.

    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
    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
    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
    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
    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
    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.

  4. Episode 4 - Daniel's story

    Daniel was diagnosed with transverse myelitis, an autoimmune disease. After several months in hospital, he moved from only using liquid medications to taking tablet forms. Daniel describes how he was taught to swallow pills, provides top tips on how, as the patient, you can accomplish this and notes the benefits of being able to take tablets.

    Episode 4: Daniel’s story
    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: OK, so today I'm very excited that we are going to talk to Daniel. My name is Emma
    Lim. I'm a general paediatrician at the Great North Children's Hospital, and we're here to listen
    to Daniel’s story about learning to swallow pills.
    Daniel: I’m Daniel. I’m 14 years old, soon turning 15. I have been diagnosed with a spinal cord
    injury. So, it’s been 7 months since I’ve been in hospital. About eight months ago, I was
    diagnosed with transverse myelitis, an auto immune disease, which changed my life in a sense.
    And so, it's been a bit hard. It's been a long time in hospital. But I also quite like music. I like,
    um, sport. You know, that's kind of what I'm into as well.
    EL: That is really a lot of stuff to go through in seven months, and actually I think you're being
    really modest because you were a really good runner, weren’t you. So, you did a lot of running,
    you won medals and you've actually recorded your own raps already, haven't you?
    D: Yeah, so I am, I was, I think it was hard, especially as a runner, like right now before I was
    watching the Olympics. The 5K and the long distance and it is one of my favourite things, but it
    is quite hard. You've got to just move on and you've just got to see and open yourself up a
    different kind of sports. Like I have just found different sports and music helped me a lot during
    my time in hospital. I have just been to a studio where I recorded songs and I’m very grateful
    for the opportunity. And it's just lets me express myself. But I think it showed that it's not the
    end of the world, if you have, like an injury of your own wheelchair and stud like that. You just
    can open yourself up to so many different things. It is different now and I've got to just look to
    the future and just forget about the past. And there's nothing more. As long as I'm happy, as
    long as I can enjoy myself, that’s the main thing. I mean, just got to do it differently really.
    EL: The thing that comes across so strongly to me is you've got this incredible mental attitude,
    you're really resilient, you really able to see opportunity and see how you can change or adapt.
    And one of the things that we were going to talk about today was how you found it learning to
    swallow pills, because I think that was something that when you went to hospital, you did not
    had to do much? .
    D: My parents had said quite a few times to me, that out of all people it would be me that
    would get ill! Because, you know, I was the least one in the family who never got ill. I didn’t
    even need to regularly get like a paracetamol pill or anything. I'd never even had in my mind
    that I need to swallow a pill in my life. I probably swallowed one pill in my life. And then it was
    that transaction, when you're in hospital, and I'm still on to this day quite a ridiculous amount
    of medications. I’ve had a relapse, so it's been quite hard.
    Especially when I first arrived in hospital and they were like, ‘oh do you swallow tablets?’ And I
    said, ‘I'll have to have liquid medications as I've never swallowed a tablet in my life’. And I was
    on liquid medications for about a month and it was traumatising literally, and it's all I can think
    of. So, when I was the back in my hospital stay, they ask me what is most important, what's
    made the biggest change to me? What’s made the biggest change is definitely swallowing
    tablets because I used to get huge side effects from the liquid medications and now with
    tablets, I can just swallow them every morning and, you know, I don't worry about the
    medications, despite the fact I'm on a ridiculous amount medications.
    Looking at how much I had to take, liquid-wise, it would be horrible now. I think if people know
    the taste of the liquid medications, it isn't good and it's less effective as well. And now it's
    much easier, even if I have to swallow sometimes 20 pills in the morning, it's just, I always feel
    grateful that I'm not on them liquid medications. It was really important. Despite how much
    physio and all these brilliant changes and improvements I had in my condition, I still look back
    and think that taking pills, because I'm going to be, I'm on medication for life now. So, I'm
    going to be taking pills the rest of my life and if I didn’t learn to do it, what would it have been?
    Where would I be?
    El: So, you said to me about having to take really large volumes, it tasted disgusting, you had a
    lot of side effects. What kind of side effects were they?
    D: So, I was on really strong medication because I have an autoimmune disease. In spinal cord
    injury its different effects. So early on, I was in quite a lot of pain. So, they gave me a lot of
    strong, strong, strong pain like Oramorph and Gabapentin type of medications that were really
    strong. So, they would have quite a bad taste inside the liquid medication. But then it was also
    bladder medications because I had issues with my bladder. You know sometimes take bowel
    medication, different stuff like in a spinal cord injury, spasms. So many different things, it's like
    so complicated. It’s not just the pain itself. And then taking so many for pain as well is
    ridiculous. And then of course, the steroids, you know how would I be able to take them? l
    can't take them liquidly. And steroids I've had to take two sets of them because.
    EL: And we met somebody in one of our previous podcasts who was really important to you. It
    was one of the pharmacy technicians, do you remember?
    D: Is that, Lisa?
    EL: Lisa said you've been really nervous and worried about learning to swallow tablets. And
    then she came to see you. Do you want to tell us what happened?
    DA : When I first, when they tried to try me on taking tablets early on, I don't know if it was a
    swallowing issue because I had had problems of swallowing. I couldn't really speak a lot early
    on, but, um, I choked a few down. It was not very, it's not very comfortable and um, and that
    stays on your mind. And then when they came and said, you know, they're going to make you
    learn to swallow tablets in just like less than an hour, I was like, no way. There's no way this is
    possible. So, when she came in and by 30 minutes, I was swallowing the biggest tablet
    possible, and I never, I couldn't believe it. I was like it was, it was unbelievable. And then the
    next day I was on medication. I started to see a big impact in my recovery, actually, because
    that switch when I was in liquid medication makes me so drowsy in the morning and I wouldn’t
    be able to interact with physio, interact with school. I had I start to notice less pain. It was just
    so much; it was such a big change. And it meant a lot to me.
    EL: That's amazing. So, 30 minutes of work swallowing a tablet and the next day, the very next
    day, you already noticed the differences that you weren't drowsy. That you don't have to take
    these nasty medications. That actually because you can concentrate, everything else improved.
    D: It was so important for the physio as well, because every morning I had physio but if I was
    asleep I just couldn't interact with them (And of course, I've got a lot of credit to physio
    because that's how I managed to do so well in the movement side of things). If I was still on
    liquid medications I would be drowsy and I wouldn’t be able to interact with physio and once I
    was taking tablets and I was interacting more with physio and I was able to get my movements
    on the recovery back and I was able to start working with them. It was so important.
    EL: I don't think people realise what a difference it makes. So, when Lisa came and she said
    that you were brilliant, if somebody else was listening to this podcast, what would you tell
    them? Explain how you learnt to swallow pills and what it felt like.
    D: First thing I think is if someone, even for a week, has been on liquid medications (for me, I
    was on medications for a month) even a little bit of liquid medications, they'd be immediately
    determined to take tablets because they know, oh, my God, this tastes disgusting. In terms of
    the actual process, it's just you just need to put the tablet in. But I think inside it's the main
    determination and knowing that you can actually do it. You just got to give it a go and put the
    tablet down, in your mouth and just try drinking it down and it'll come, and it'll make a massive
    But I think if someone was on liquid medication and they did not know how to take a tablet
    before and they would on liquid for a period of time, they’d get sick of it, they'd notice and
    they'd be very frustrated. And I think it would bring a lot of determination inside you. And if
    you had a determination inside, you can get anything. You can get the job done. And that's
    what I managed to do. But all credit definitely to Lisa, because she gave me the confidence
    because I had not taken tablets ever! It was really, really, really good to be able to do that and
    to be able to try and get to the hardest tablet in just thirty minutes. It’s incredible.
    EL: I think that you've put your finger on something really important. The process is actually
    really easy. You literally put the tablet in the middle of your tongue, pick up a sports cat bottle,
    take three sucks and the tablet goes down. That's not the hard part. It's what you said. It's the
    belief. It's the worry. Can I swallow it? Is it going to be difficult? What's going to happen if I
    don't? And it's your determination and the people who support you to learn around you to get
    over that hump. That's the actual hard thing. It's just like you say, it's the belief that it can be
    done. I think a lot of people are very anxious or worried about taking tablets.
    D: Yeah, you could be worried because I was worried, and I can understand that. But if you
    keep imagining the fact that, oh, I'm not going to do this, I'm not going to do this, you're not
    going to do it, simply, It's not it's not going to work for you. If you start to just realise it’s
    possible and you’re getting closer, you're going to see improvement. You need to stay positive.
    It's going to come. Keep trying. It will go down because the actual process isn't that hard. It's
    about what's inside you. And then for me, what determined me was getting off the liquid
    medications. And even when Lisa came and taught me, it wasn't that hard, really, the process
    itself. It is just about what is inside you and what you can do to do it.
    EL: Such a life lesson for everything, and that for me is why you are so brilliant, because you
    have in a determination and that belief, so you will do things just like you said.
    So, we've talked about how you realised from being completely well to having seven months in
    hospital. From being a person who'd never taken paracetamol to a person who has to take
    medication every day of their life, you suddenly realised how important the skill of pills
    swallowing was. You've told us about how it's actually easy to learn. And what holds people
    back is something about believing you can do it and being confident.
    D: And then you know what as well, even when I was on lots of tablets, I used to get me quite
    low even because the amount of tablets I swallowed. One time, I literally counted in the
    morning twenty-six tablets and I was quite like, you know, it brings you down. But I always
    look back and just say, you know, the worst is liquid. And gradually you get lower, lower
    medications and then you start to realise, oh, you know, you start to forget about your illness in
    a sense because you're on less medications. It shows that you're getting better when you are
    on less medication. I think that's really important as well.
    EL: I think that's really, really interesting, because my background is that I have worked with
    children with HIV and the liquids are so disgusting, you literally can't take them. So, we had to
    teach children about, from the age of four, to be able to take tablets. And I think that they had
    a very similar story to you. Taking medicine every day reminds you, you are all. It's always
    there. It's just a reminder things are not right or you're different. And so, the quicker and easier
    you can do that allows you to forget that bit. And lots of people take vitamins and pills just
    regularly, so swallowing a tablet quickly in the morning, like mom saying ‘here, have a vitamin’
    that's more normal and at least it's over quickly and you can carry these pills around without
    people sort of staring at you, wondering why are you carrying so many medicines and things?
    D: Yeah, definitely. And I'm still on quite a bit in the morning, but I just take them quickly and
    get on my day literally. I mean, I have some during the day as well, but different times. But they
    are gradually going and you know, if just every morning you just take them and get on with
    your day and it does look like you are ill but you have just got to forget about it, just get on and
    live, live the best you can. Definitely medications don’t stop it, because I take ten minutes in
    the morning and I'm over and get on with my day. Instead of when I used to worry about liquid
    medications, I used to have a platter of food to get the taste away in your mouth.
    EL: That's why you have to buy so much fruit.
    D: It was horrible, but yeah, definitely now there's no taste in your mouth. Because when you
    have that taste, you carry it around and you just think about it all the time. Now, you just take
    on tablets, you go.
    EL: So if you have three tips, three top tips for any kid or young person learning to swallow pills,
    what would they be?
    D: So number one, I think, need to be definitely determined and ready. That is so important
    because you can't just say, I'm not going to do this, I'm not taking a tablet in my life, I've
    struggled to take it in the past.
    You've got to start small as well. That's also another really important thing. And find the best
    tablet that works for you, you can start with the smallest of the smallest and gradually see
    improvement. Some people don't get as quick as I did. Of course, some people might take
    time. But you're actually swallowing a tablet now. And for me there is a big variant in my
    tablets. Some are really, really small. Some are really, really big. So that means if you struggle
    with the big ones, you’ve got a small one. Lots of pharmacies can give you a smaller tablet. You
    know and that means that you're actually getting progress, even if you are not on the biggest
    of tablets. It's hard but once you gradually get used to it, you're taking tablets, you're actually
    taking tablets, you're doing it. Even if it's really small. That's pretty important as well.
    And the third thing I think it's just about really. When I had my injury, it was like a shock. And
    when you're in a lot of pain, if it's someone who, doesn't take tablets and you've taken liquid
    medications before and there is problems with liquid medications, you’ll have issues with
    them. And I think that drives you on to take tablets. I don't think it's the way that people say
    like treat it as how you swallow food, because I didn’t find that helpful. I think it's just, seeing it
    in terms of how important it would be for your medical health as well. And lots of people have
    been so, so brave to though operations and certain things, so do the same with the tablets
    because it will change your life literally.
    EL: That’s so true, I think I've heard a lot of people say, oh, you swallow a big lump of food, why
    can't you swallow a tablet? It's a different skill set, but it isn't difficult.
    I love your three top tips. So, first of all, is about your positive mental attitude. Secondly, start
    small and be good to yourself, look at your successes. Swallowing anything is a success. And
    thirdly, like you say, just be determined.
    D: Yeah, I was on an NG tube and literally I couldn't swallow. So, anything, just swallowing
    anything, let alone is hard. I was on an NG twice. So, it is such a frustrating thing not to be able
    to swallow even food let alone tablets. So, if you actually swallowing a tablet, to get to that
    moment, it is a huge success. And anyone else who does that, especially after all the trauma
    and have never taken it before, should be really proud of themselves. So, this is really
    EL: Yeah, I think that's a lesson for everybody that you, who had a nasogastric tube so you
    couldn't swallow anything at all, had a really sudden illness and had to take 27 medications in
    one morning, can go from not swallowing anything at all to be able to take all your pills in 10
    minutes. Well, I mean, if you can do that, then everybody else should be following your

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