Has medicines optimisation already failed?
This is a difficult question to answer, but my feeling is that, at the very least, it has stalled. The phrase ‘medicines optimisation’ did not appear once in the Community Pharmacy Call to Action document, making me wonder if the CPO and NHS England has dropped the language. This is despite their insistence that it is an important agenda – a view backed up by ministers and a host of others.
Where did it go wrong?
It was disappointing that there was no clear definition at the start. I said it was ‘all about achieving better outcomes for patients’, but perhaps the patient focus and the outcomes focus has been swamped by cost-containment and we haven’t fully communicated or embraced the need to think differently. I can’t say that the four guiding principles are particularly helpful and can make discussions rather difficult – trying to put our thoughts into four imperfect boxes. We should by now have ‘medicines optimisation indicators’, but rather than these measuring values and process, they seem to be altered medicines management performance indicators. How can we think differently if the framework is poor and the measures are not radically different?
Why it is still important?
There is still an issue with medicines out there. Medicines are too often the first port of call – it is too easy to prescribe something without ever considering that the patient is at the centre. It is not what you want and need it is what ‘they want and need’ to deliver the outcomes that ‘they would benefit from’. I can agree that there are too many prescribing errors, too many errors in taking medicines, inappropriate adherence, too much waste and too high a cost for the outcomes that are actually achieved. Polypharmacy seems on the increase. It is all as true today as it was when the initiative was launched with the exception of a few shining lights within the profession who might be making progress.
Putting it right
Three important starting points to putting it right:
- Describing medicines optimisation as a part of a wider concept of treatment optimisation. We must recognise that medicines are not always the right answer and prescribing to early create a dependency that may lead to unhealthy choices.
- The patient must be at the centre. It is simple to me that it is not my disease, not my outcome and not my life. Somehow we need to empower and support patients to make a decision that is right for them. Obviously there are limits on a healthcare professional’s agreement, but if you have no idea of the outcome that the patient wants you have no idea of the solution that is required.
- Not all solutions for health and wellbeing fit within the health arena. The NHS Alliance, within their breaking boundaries manifesto, recognised that not all solutions to poor health and wellbeing fit within health and the need to integrate local authority solutions with all community healthcare providers. I note that some citizen’s advice bureaus have co-located within community pharmacy and medical practices – perhaps a way forward?
I do hope that the NICE short guideline on medicines optimisation will kick start the process again, but from the scoping, I am not sure that I will hold my breath on this one. They don’t have much heritage here.
Getting some of the framework right
- Medicines optimisation as part of treatment optimisation is a cross cutting agenda that may be driven by pharmacists, but must be led by all professions who offer treatments (including medicines) to patients.
- The well informed patient at the centre of decision making. I appreciate that some people simply feel that they want ‘an expert’ to lead them. This is OK, but where ever possible the patient must be well informed and encouraged to talk about what they want to achieve.
- Outcome based decisions. Until you know what progress the patient wants to make, it is impossible to ‘prescribe’ the most appropriate treatment. I am so disappointed that medicines are still reviewed on the primary outcomes of clinical trials when they so often mean little to patients. They don’t always relate to the question – will I feel better – will I be free of pain – will I be able to go shopping – will I be able to play with my grandchild? So medicines should be properly assessed as to their ability to achieve the outcomes that patients want. Formulary processes and the general use of medicines need a real shake up to be fit for purpose.
- Support to treatments and outcomes. Naturally community pharmacy has an important role in ensuring that patients continue to have access to the medicines that they need to achieve their outcomes. But even here we must think about things differently. The community pharmacist is often the first Healthcare Professional that recognises that something is wrong. It is sad that we pay the pharmacist to dispense the medicine, but not to chase the prescription that does not present for dispensing. It is good that the ‘call to action’ has arrived and it is time to radically rethink what we need community pharmacy to deliver.
- I also talk about support groups for patients that could be primary care, particularly community pharmacy led, but charity or patient advocacy group run. What happened to the expert patient program? How many pain clubs are there? How many respiratory or diabetes clubs are there – particularly when we know the value of pulmonary rehabilitation, exercise and losing weight to achieving outcomes. I believe that medicines will achieve better outcomes if lifestyle choices and targeted support are improved.
I appreciate that medicine’s optimisation has not got off to a good start. But it is actually far too important an agenda to let die. Patients need it and the health service needs it.