Polypharmacy and medicines optimisation

It would seem that polypharmacy is on the increase and that is no surprise to me. I am occasionally asked to review medication as part of a team providing direct care and I often hold my head in my hands.

We may call this process medicines optimisation, but it is half a job and the medicines optimisation specialist pharmacist within General Practice are making a mistake when they review individual patients and make recommendations about their medicines. This does not change prescribing behaviours and we should consider a new approach.

Having reviewed some elderly patients on multiple medication the key question is not what we should do now – that is usually simple – but how and why have we arrived here. So with a group of prescribers I have asked those questions using case examples in a non-judgemental way.

The discussion is always interesting and often I have to agree that it might have seemed a good idea at the time; often it fitted with a guideline or a protocol. But the discussion generates further questions:

  • So what were you hoping to achieve with that prescription (what was the goal)?
  • Was it something that was important for the patient? Would it make a difference to their quality of life?
  • What were the chances of that medicine achieving that goal, bearing in mind the patient’s condition and the evidence supporting the medicine in that patient?
  • Was there an intention to review and what criteria were you going to use to define success?
  • Was there any other way of achieving the desired result without medicines?
  • What support was necessary as an adjunct to the medicine to achieve the desired goal?
  • What was the strategy if that medicine did not achieve the desired effect and had you explained that to the patient/carer?

The discussion was peppered with a variety of phrases including:

  • That medicine is not actually licenced for that indication
  • There is little evidence of benefit in this age group
  • The medicine is unlikely to achieve that goal

There were many obvious comments:

  • no medicine is indicated for loneliness (still waiting for social prescriptions)?
  • A pain killer is only likely to reduce the pain by 50% so how does the patient manage the remainder?
  • What are you hoping to achieve with that medicine (often a statin or aspirin) in an 85 year old?
  • What potential expected side effects are likely to be detrimental (falls, hypos or confusion etc)?

At the end of the session I am happy with the question – should we stop this medicine – and even happier with the recognition – perhaps we shouldn’t have started it in the first place. Sometimes the questions are much more exciting – how are we going to manage a group of patients with these problems in the future – and we might look to involve local voluntary, charitable and housing services along with community pharmacy in solutions.

So if you want to effect polypharmacy and optimise medicines, don’t think about what you do now, but reflect on how you have got here and most importantly how you avoid this situation again.

Advertisements

Medicines optimisation – failure to launch

 

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.

Patient outcomes – it’s a patient thing

I was tempted to write this blog after sitting through a discussion on antibiotics. I know that antibiotic resistance is a huge issue and we desperately need to get a handle on it. But the speaker said that simple antibiotics in urinary tract infections reduce the symptoms by about a day so were not ‘worth it’. A very interesting statement to make to someone who may be feeling unwell, with a pain in their tummy and tell me that they are ‘pissing razor blades’ or ‘their urine is burning them like lava’. I also know how easy it is for someone who is elderly to drift from a slight urine infection to being acutely confused. I rather think that this decision should be made by the patient.

Do we really think about the patient when we prescribe a treatment?

It takes me back to the days when I worked in dermatology. The starting point was ‘we want you to use an emollient regularly’. So with the patient in mind we handed a selection of 5 emollients across and said – “go and tell the GP which one you get on with and ask him/her to prescribe enough”. The most economical emollient is the one that the patient will use to improve and maintain the quality of the skin. I am happy to smile when they say that ‘this one is the best – because the pump works upside down’. Al least it has a chance.

I was also involved in “taste tests” for calcium and vitamin D tablets. Another example where the individual patient’s view is important. How many tablets are sitting in patient’s cupboards and they say “well I don’t really like them”.

Sometimes we are really silly:

  • We prescribe z drugs for insomnia when the problem is daytime functioning
  • We prescribe metformin at a dose which causes indigestion or sulphonylureas which cause ‘minor’ hypos, knowing that the two most common solutions is dose reduction by the patient or snacking. And don’t get caught on the snacking issue – several times I have been thinking two rich tea biscuits at approximately 80 calories – not 9 custard creams at your total daily saturated fat intake and 600 calories or the super latte and a chock chip muffin (because the supersized coffee is a free upgrade) at 800 calories – so nearly half the daily load! Don’t get me started on this one….
  • We prescribe two inhalers when one is what they want

It is not unusual for a patient to get a diagnosis and a prescription within a 8 minute appointment for a completely different problem. The patient arrives at the pharmacy with a totally bemused face.

I could go on, but it is clear that we have to think differently.

As a starter it’s your life, your disease and your treatment – so it’s your responsibility. I am there to inform you, help you, direct you and support you in making the most appropriate decisions. And the community pharmacist will answer a few more when you have thought of them. If you don’t want to then that’s fine. Please don’t absorb valuable NHS resources when you have no intention of using them.  I hate to think how many “nurse equivalents” of money are sitting in the bathroom cabinet as unused medicines.

I will still be there when you change your mind and when you are ready. Also be sure you know why you are stopping a medicine before you do.

Now – let’s discuss your problems and understand what you need to achieve – what will you use the medicines for. I will be honest about the medicines – so we can set some realistic goals. I will never promise ‘complete pain relief’, but discuss with you how you would cope if we could reduce the pain by 2 points on the VAS. I do like to give the medicines a fair chance. So it all becomes a balance between medicines and lifestyle, anchored in reality. They are medicines not magic potions.

You can ask when you feel the effects of the medicine in your body – or when you don’t. You can discuss how long you need to take the medicines for when to start thinking about it. You can explain what you intend to do and I will give you some advice.

It is true that medicines can empower people to take control of their lives and it is also true that medicines can change pathways of care. Medicines can provide you with greater security and help you get back to or stay at work. They may help you to get out a bit more and reduce social isolation. Some medicines can cure you, but most reduce symptoms or are a safety belt that reduces the chances of your life becoming a ‘car-crash’.

I have listened to you; I have discussed treatment options; we have agreed realistic goals; we have designed the treatment package. Please don’t be surprised when I then ask – “what’s your skin in the deal” – “what are you going to do to improve your outcomes?” That is the little section in the care plan that I make you fill in – the bit that you commit to.

Please don’t just rely on a pill to achieve your outcomes.

When is a medicine not a medicine

I know it sounds like the beginning of a joke like:

When is a door not a door – when it’s ajar!

 

This is far from a joke and a very serious question. A medicine, after all, is just a chemical in a pill.

But a medicine is far more than a medicine when it is part of a ‘treatment’. Let’s start at the beginning – it all starts with a human being. You see I don’t want to call them patients or clients or individuals – they are just ‘somebody’ at the beginning – ‘somebody with a problem’.

Showing you care  – as a healthcare professional I care – it says so in the title – so what does that mean? It suggests that I have time and I am interested. There is a saying:

“They don’t care what you know – until they know that you care”

So whether you WWHAM or you RAT it doesn’t matter unless you demonstrate that you care.

Understanding the issue – many people come in ask a question without really stating the issue. I have talked about that re insomnia where people say they can’t get to sleep, but their real problem is that they feel bad the next day. It is a real pity that some would knee jerk to prescribe a benzodiazepine or z drug and make the next day feel worse! So keep asking the question until the person describes their real problem.

Setting goals – this is very important. The goal setting is necessary for adjusting expectation. Someone with chronic pain is unlikely to improve by more than 2 points on a visual analogue scale – it’s not pain free – but it may allow some relief at some time of the day. And for targeting treatment when you decide which symptom is the one that needs action. You may not be able to target everything in one go – so start with the symptom that causes most problem, review and set new goals.

Creating texture – there are usually things that you can do – lifestyle changes – and coping strategies – psychological support – that constitutes the rest of the treatment package. These are the things that may allow the person to take less medicine in due course or even stop. They may allow the medicine to continue to work and arrest some of the factors leading to the symptom expression.

You have always heard the conversation – if you weren’t so fat your knee wouldn’t hurt so much – yes and if my knee didn’t hurt I would move about a bit more and lose weight. Sometimes a short term treatment might create a window of opportunity to change lifestyle enough to get on a path of recovery.

Selecting the medicine – There are many reasons to select specific medicines. Obviously I am going to base this on evidence of safety, efficacy and patient factors/experience. These are the most important, but I will also consider cost. Seldom have I been asked by a patient to treat something that is clearly an end point in a trial. People with diabetes don’t ask for something to bring down their HbA1c. This does require a higher level of investigation and interpretation to find the data that I really want.

Delivering the treatment – so do it. Deliver the treatment package including, if appropriate a medicine. Review what you are doing and make sure it is patient centred and with safety in mind. Check again that the person is engaged and still wants to go ahead. Make sure that there are not barriers that might get in the way of compliance and send them on their way.

Following up – check up on the person and on their progress in line with the expected patient experience. There are times when they will question the treatment and their progress and the future – just be there. But the most important thing here is to learn. My biggest problem here is that I don’t have those symptoms and I haven’t taken the treatment. I have read a book and a paper, but do please remember:

“Talking to people is the only real way to hear – caring is the only way to learn”

I RAT patients

“Is WWHAM out of date” was a question posed by the GPhC and the RPS at their recent workshop. It was an appropriate question to ask when its use might have identified two of the situational research (mystery shopper) situations in the recent Which report.  I think most of us coughed and answered “of course we WWHAM”, while I tried desperately to remember it.

I RAT my patients and as a part of that process WWHAM has its role. I would support the medicines counter assistants (MCA), as long as their WWHAM was part of my overall RAT approach. It is fairly simple and just a switching around of the Advice, Treat, Refer pneumonic that was used within minor ailment and similar schemes.

So here is my approach:

R – means refer. This is the identification of Red Flag situations. The Red Flag situations apply just as well to the medicines counter assistants as to the pharmacists. I have, in the past, taken little red stickers into pharmacies to put by specified P medicines, because I want to speak to all patients before this medicine is sold.

The MCA refers to the pharmacist all patients that have specific symptoms, take other medicines, have co-morbidities, ask for specific medicines and other factors such as age, which takes the patient out of their level of expertise and passes them on to the pharmacist.

The pharmacist will refer to another clinician when the patient presents with specific red flag symptoms or factors in their condition. In this case the red flags might suggest a more serious complaint that requires investigation, or a more severe presentation that requires treatment that I have no access to.

This is important to me – I decide whether the patient is mine – or someone else’s.

A – means advice. I like to offer patients advice first, a leaflet or something that would help them understand their condition. I have often given a leaflet saying “read this, it’s you” – try it – it is great to watch someone’s eyes light up as they flick the paper and answer – “you’re right this is me”. There are often several things to approach first – diet, exercise, smoking, lifestyle are often important. Then things that the patient can do to relieve or reduce the symptoms and this is an important parallel approach.

T – means treatment. I tend to down-play treatment – at least be honest about what can be achieved. I remember teaching – “there is only one thing you know about chronic pain – that it’s chronic” and that medicines seldom do more than reduce pain scores by 2 points. So it’s not so much that treatments cure conditions (although some do), but more about treatments allowing you to get through conditions or cope better with them. The realism here often works better than setting up medicines as a miracle cure

I still have two requests:

I do wish that materials produced by companies to support their products would be structured to help me RAT patients

I do wish that the government would introduce a ‘community pharmacy prescriber’ status or NHS England a series of PGDs that allows me to continue to treat patients who really can’t afford to pay for their medicines.

The waste of medicines in the NHS

It’s not like me to criticise those in power about their solutions to the waste of medicines in the NHS. It is not like me to suggest that they don’t fully understand the reasons. And it’s not like me to suggest that if they came to the coal face and spoke to people then they might know some of the answers. But….

There is no doubt that there is significant waste of medicines in the NHS. £300million, if you believe the York and School of Pharmacy report, but we all know that this is the tip of the iceburg and it is a little more complex than that.

I know that sometimes a prescribed medicine just doesn’t work or it has side effects that lead to discontinuation and this is the acceptable face of waste.

But sometimes medicines are prescribed too quickly before the patient is ready and there is too little support during the early phase of the patient medication experience. See my blogs on the patient medication experience and the art of prescribing (saying no quickly and yes slowly). Some patients don’t even collect their prescriptions; others do with no intention of taking the medicines in the first place. Some instinctively know that the prescriber hasn’t listened and this little pill is not the solution to their real problem.

And then there is the awful prescribing dispensing cycle that leads to the largest component of waste in the NHS. Of course a part of this is stockpiling – or the excess capital investment in medicines. When in hospital we worked to a turnover of 12 – ie we had to turnaround the total stock within the pharmacy twelve times a year. It was a struggle (and we almost reached 12 in the pharmacy), but when we looked to include all medicines throughout the hospital to reduce our capital investment we fought hard to reach 10.

The grandees of the profession say – talk to the patients – encourage them to comply with their medicines. But I have done that and you have missed the point – yet again.

Patients tell me that they are not in charge of their medicines – they are in charge of their prescriptions – and this is not the same. Medicines come altogether, in a group, like busses – did you not know that.

Here is an example of a conversation:

“I tick all the boxes and I get all the medicines”.

“But you don’t have to; you could pick and select the ones that you need”

“It’s not as easy as that, don’t you understand the system – the game we play”

Well here is my lesson that I am sharing. There is a prescription with six items on it. They are all intended to be prescribed for a month. But two are flexible through direction (one upwards and one downwards from the prescribed quantity), two are flexible because the patient says so and two are just right (the patient’s definition because he wants to take them ‘just right’. They all have 6 repeats on the basis that the patient will visit the GP in six months’ time for a formal check-up.

“So some months, when I am less well I have to order the prescription a little early – I can do that without too much hassle”. “If I just order the one that I am short, then it’s a separate triple round trip for me (doctor, doctor, pharmacy) and I am out of sequence and they call me in for my check early”. OK so what happens if you don’t order the one that you don’t need? “That is also OK, but if I forget and don’t order it twice I think that they might cross it off my repeat (actually this did happen about three years ago)”.

“So I tend to order them all about every 20 days”.

So how many boxes do you have in your cupboard at home? “Oh probably thirty to forty or so – for some I am about four or five months ahead, some I am bang on time and there are some that I will never use”. “I have about 10 boxes of stuff that was stopped at my last review that I should bring back to you.”

So I have asked the patient, found the answer and I hold my head in my hands – how can I sort this out with the system that we have? All that I have been told is perfectly reasonable and reflected by the next patient and the next and the next.

So there you are, by my very rough calculations, the NHS has about one billion pounds of capital invested in medicines in the bathroom cupboards around the country. And some of this will be needlessly wasted.

It is so ridiculous that I don’t know whether to laugh or cry. It’s like ordering the same monthly grocery delivery without ever changing it. It’s like a supermarket ordering so much stock in that its shelves are bursting until they put it all in the bin, because nobody is buying it.

We must put the patients in charge of their medicines and not their prescriptions. We must build the system around their needs and change the archaic system that we have. Don’t expect the humble pharmacist to reduce waste when, in the main, it is the system that is to blame.

Why can’t we all sit around a table – GPs, Pharmacists, IT experts, leaders and just talk this through with a whole load of real patients – and sort the thing out the way that they want it.

Will the electronic transfer of prescriptions project be part of the solution – well perhaps – in my opinion it is currently part of the problem, but the solution is there (often over-ridden)  if it develops and pushes through with much greater speed (they do know this – they are clever people – they could save the NHS £1b).

The Pharmacist in General Practice

I am surprised that when the GPs sign their registration with the CQC, they don’t think:’Why don’t we employ a pharmacist in the practice’

And to be honest, I just don’t know why not. I know some enlightened GPs and some fantastic practice pharmacists. So do you need me to explain why?

The CQC requires every GP practice to provide personalised care through the effective use of medicines and your will undoubtedly need to provide evidence of this at some time. You may also be finding the QOF more difficult to achieve. So here is the outline of a job description:

Prescribing policies. To write, train and maintain prescribing policies within the practice To manage risk. Policies on medicines storage (including vaccines), preparation, medicines administration, disposal and prescribing to ensure compliance with the Medicines Act 1968 and the Misuse of Drugs Act 1971.

Prescribing systems. To ensure that the prescriptions are up-to-date, revised and changed according need patient needs or changing condition. That the ordering system is effective and appropriately managed.

Medication review. To ensure that all medicines are reviewed, computer-based reviews and running medication review clinics for those on complex regimens. To be a first source of information for patients about medicines.

Medicines and treatment reconciliation. To ensure appropriate systems in place for medicines reconciliation for all patients transferred out of and back into the practice. To rapidly assess all un-planned admissions and put arrangements in place for review and prevention of further admissions. To audit and feedback on all issues relating to discharge and out-patient letters that fall below contracted standards.

Medicines safety. To ensure compliance with patient safety agency requirements, control of infection reporting, critical incident reporting and to complete routine audits to ensure safety.

Medicines information. To ensure all practice staff have access to up-to-date medicines information in a format that supports patient engagement and education. To provide regular updating on clinical pathways, new medicines and NICE recommendations and guidelines.

Medicines optimisation. To support joint goal setting with patients and appropriate treatment selection. To support better patient medicines experience, reduced waste and improved outcomes within total care packages. To follow up identified patient groups, targeting better compliance with treatment to improve outcomes.

Liaison. To provide link function between the hospital and the local community pharmacy in the use of MUR and NMS services.

Development. To support the development of local services that reduce the workload within the practice. To work with both the CCG and the LA/PH to develop and support the delivery of services that improve the health of the local community.

QOF. To ensure data connectivity and practice organisation to deliver maximum QOF points for the practice. To regularly audit against QOF domains, improve risk stratification of patients and improve service targeting and delivery.

Service Advancement and Delivery. To deliver specific disease management clinics as required, through personal development and progression to Independent Prescriber status.

 

There is no doubt in my mind that a practice pharmacist, working to the practice requirements, can improve the effective use of medicines, provide assurance to the CQC and be a valued member of the practice team.

A vision for community pharmacy

 

The NHS has many issues to manage. An ageing population, an increase in obesity and ill-health at a time when budgets are tight and new ways of working are required. The NHS Alliance in their manifesto for primary care urges the NHS to break boundaries at every level. They present a broader vision of primary care and ask for the community pharmacy contract to be rewritten to support fuller engagement.

 

There is a need for community pharmacy to reorganise under a new contract and to work towards delivering a different range of services, which focus on the patient and concentrates on delivering outcomes. We need to be sure that the new contract is flexible and enables and supports the direction of travel, but we also need to understand the changes in the NHS and a vision of community pharmacy in 5 years time.

 

This article gives one view and describes the service delivery in three sections, which may present an alternative way of looking at the new contract under development. I would consider looking at community pharmacy under four broad headings:

 

Dispensing and procurement

 

There is little doubt that pharmacy procurement, supported by the changes in the drug tariff, has allowed the NHS to reduce the overall drugs bill. This should be congratulated and rewarded in the new system. Community pharmacy dispenses nearly a billion prescription items a year, with accuracy and professional support that should be maintained. Pharmacists should be encouraged, through motivational interview techniques to support the patient medicines experience, the patient goal setting and implementing services that enable patients to reach their goals.

 

Public health and wellbeing

 

The NHS Alliance in their manifesto asks that every patient has a health and wellbeing plan developed in association with a named healthcare professional. 1.8million people access community pharmacy every day, almost twice the number of people who access general practice. It is important to note that many people who access community pharmacy are perceived as well, but stand to gain considerably from lifestyle changes to avert ill health.

 

Community pharmacy needs to adopt a healthy living pharmacy or similar status and begin to support people to stay healthy. They are uniquely able to deliver wrap-around services, including stop smoking, obesity management services and signpost patients to other providers. There are many public health initiatives and local campaigns that community pharmacy can lead, particularly with the elderly.

 

Management of common conditions

 

There is a requirement within the NHS to ‘downshift’ disease management. By this I mean that people managed within hospitals are moved to primary care and people in primary care moved to self-care.  Self-care and supported self-care becomes such an important feature of the NHS that it is able to manage the increase in demands.

 

Community pharmacy must become a real choice for patients wanting to manage their conditions. Patients must have the choice whether they get their common conditions managed at the general practice or within the community pharmacy. There are many examples of conditions such as asthma, dyspepsia, irritable bowel syndrome, eczema where the community pharmacist can deliver total care and provide appropriate feedback to the GP. Co-registration is essential where the patient decides that they will register with a community pharmacy to deliver specific aspects of their care while retaining their continuing registration with a GP practice.

 

Community pharmacy can also be a provider of supported self care. The lives of many patients can be improved if they look after themselves. The NHS and other providers supply a whole range of self-care programmes. The community pharmacy should be seen as a centre for self care support, signposting patients into recognised and supported local programmes and providing encouragement and further support in engaging patients and their carers.

 

Acute Care

 

Community pharmacy should widen their provision of acute care, expanding from minor ailments to a position where they can advise and treat more conditions that might have been referred to A&E. It would seem sensible for the NHS to take advantage of the longer opening hours of some community pharmacies when considering out of hours solutions.

 

If all healthcare professionals and AHPs do not fully engage and take part, the NHS Alliance’s request for a new community pharmacy contract and their encouragement to break down barriers in the NHS will not succeed. This presents a new opportunity for community pharmacy to confirm their position in primary care and take their participation to new heights. The new contract must be flexible and enabling, creating a framework for development where both the local authority / public health and the CCG can support community pharmacy growth. Community pharmacies should be able to progress and develop at their own pace, but without the need to bid at every stage.

 

We must also discuss continuous service progression and the concept of expanding wrap-around services. By knowing the end game then it becomes easier to commission and for pharmacies to develop naturally. I can explain this with a few examples:

 

Asthma management: Community pharmacists should provide total asthma care for appropriate patients. The starting point is to deliver inhaler technique counselling, but there is an understanding that the community pharmacy team will progress through education and supervision to deliver a full service.

 

Sexual health: Community pharmacy may start with the delivery of EHC or STD screening, but it is understood that they will progress through education and supervision to deliver wider sexual health services including HIV testing and ultimately a full oral contraceptive service.

 

Health and wellbeing: All pharmacies should aim to rebrand as healthy living pharmacies or similar. People should be able to obtain a health and wellbeing plan from the pharmacy and the pharmacy should deliver services that wrap around the plan. Services routinely offered should include stop smoking, weight reduction, flu vaccination and signposting to exercise management services.

 

The contract should support such development and progression, allowing pharmacy managers and owners to plan for controlled service development with guaranteed funding.

 

The final question may be what to do with MURs and NMS services. I would suggest that these are initially associated with either dispensing or acute care, but also become elements of care, where community pharmacy can decide with their local Public Health Service and CCG as to how these can be used. The Public Health Service and the CCG can ‘commission’ additional elements of care through the NCB in a planned way to ensure that community pharmacy have the confidence to plan to develop.

 

There is no doubt that the NHS will struggle without the help of pharmacists

Medicines Optimisation Simplified

I have read many things about medicines optimisation that complicates it and adds unnecessary dimensions.

 

Medicines optimisation is goal setting and goal delivery. That is it – nothing more.

Goal setting

For appropriate goal setting we must have knowledge of the disease / condition and an understanding of motivational interview or joint goal setting techniques. We should explore the patient’s understanding and experience of the disease / condition. Through this we can understand which symptom or which complication most worries the individual patient or most interrupts their life and progress to goal setting. The goal must be specific, measurable, achievable, results orientated and time specific, targeting only the goal that is important to the individual patient. Pharmacists have been working SMART for years so this is not a foreign concept, but pay attention to the word achievable.

 

What is perhaps more difficult is keeping the patient goal at the centre, but paying attention to and understanding what might be clinical, system and service goals. In an ideal world all goals would be identical, but the patient goal must be our focus.

 

Goal delivery

We need to create and deliver a care package that delivers the patient goal. Although the care package usually contains a medicine, we need to think about elements of self care and support that would help to deliver the goal. On occaisions additional targeted compliance support will be neccessary, but these are usually easier when the patient is committed to the treatment.

 

Follow up

Please remember that some goals are time dependent and will need to be reviewed. Conditions change and when a treatment helps one symptom another one may appear. Patients may improve their lifestyle and the risk of a complication reduces such that the patient may not consider the absolute risk worth continuing with the treatment. So review and goal checking or goal development is essential.

 

Language

When we follow up and discuss medicines with patients we should support a change to goal orientated language. Patients should feel able to connect a medicine with a goal. For example Ramiplril could be described as an ACE inhibitor or a blood pressure tablet, but we should support the link between reducing and controlling the blood pressure to reducing the chance of a stroke or heart attack. This is particularly important with medicines such as tricyclics antidepressants which might be used to reduce symptoms of pain

 

Formulary and critical appraisal

If we are practising medicines optimisation we need something different from a formulary and the critical appraisal. Rather than looking for medicines that have a population effect, we are looking for medicines which have a specific beneficial effect and a valued place in a pathway. More options for goal targeted treatments, rather than less.

 

So medicines optimisation is simple, putting it into practice is the task.

 

 

Basic prescribing hygiene

 There are many things to think about when prescribing so it is perhaps worth reminding you of a few. All PCTs should have had a prescribing policy and it would be wise to adopt this at practice level with local adaptation. There are plenty of references on the subject and guidance from organisations like the National Prescribing Centre.

Acute vs Repeat. If the treatment is a single short course or you want to review before continuing, use the acute prescription facility in the clinical system.

Always write instructions. Apart from good practice, it allows the system to calculate expected usage and feeds into the calculation of adherence. Make sure the administration staff understand this and can point out when a patient is collecting significantly more or less than intended.

Develop your repeat prescribing policy that includes the following information:

  • Who can re-authorise a repeat prescription and their competences
  • Drugs not suitable and prescribing periods for key drugs
  • How you plan for regular review
  • How you intend to audit process
  • Always prescribe within your comfort zone and take care when prescribing medicines in conditions which you are clinically unfamiliar.
  • Take note of the clinical risk traffic light system.
  • Never prescribe medicines considered ‘red’ and use shared care arrangements where available.

    The majority of medicines on repeat systems are for the elderly and/or for long term conditions. Studies suggest that a breakdown in repeat prescribing accounts for a fifth of drug related preventable admissions and a quarter of adverse drug events. Use the practice medicines optimisation pharmacist to carry out regular prescription review and audit.