Medicines Management – losing its way

I am a great supporter of NICE. It makes reasonable decisions based on a level of uncertainty. When it has been misguided, I have even written a report for the ERG giving them more information and NICE responded.

I was looking at a product recommended by NICE for a common, but high impact on the individual condition. There is some uncertainty about comparable effectiveness to existing medicines, but some certainty about reduced risk of side effects. So NICE says, quite rightly, use it after older medicines unless you are worried about the potential side effects or the patient has experienced the side effects before and then use it first.

Bing, bang, boom – stick it in the formulary – word for word – and translate it into local guidelines – job done – move on. I am not too worried about this as it is actually LESS expensive that the market leader. As I look, it would seem that most of the Pharmacists out there do this – generally we are a very reasonable bunch.

But obviously not all medicines managers follow my lead.

The Medicines Optimisation Pharmacist notices that they use additional medicines to treat the side effects of the older products. So he promotes the product, reduces costs and starts to investigate within a pilot whether the new medicine would improve outcomes. He believes he can reduce cost within this class, reduce the use of additional medicines to deal with side effects, make life simpler for GPs and have a serious look at adherence and longer term outcomes for patients, adding quality to life and perhaps some large savings for the whole system, particularly community and social care. Damn I wish I thought of this!

The ‘not in my budget’ Medicines Manager puts a line in his formulary that says this newer medicine should be initiated by specialists only and they should continue prescribing for three months before transfer to general practice. Good plan, but this area now has three times the level of referrals for that speciality than the regional average and over 60% are single visits. I am sorry; I don’t see the point of paying for a referral to secondary care to get prescribed a cheaper, safer and easier to use medicine than the most commonly prescribed medicine in the area. My GP prescribing lead would have rightly cut my legs of for even suggesting this insult. I can hear his voice boom out ‘are you suggesting that a GP would not be able to prescribe and manage this medicine’. And of course he is right. I doubt that this is in the spirit of NICE, although I am sure they would argue that the recommended medicine was available.

The ‘life’s gone mad’ Medicines Manager puts an incentive scheme for GPs to prescribe the cheapest agent in class first. So GPs accept a payment to use a medicine that, personally, I wouldn’t use in my practice, nor would I want anyone in my family put on and incidentally didn’t have on my formulary. Knowing that more than 4 in 5 people discontinue this drug within 6 months must say something about it and the market leader and medicine that NICE recommends have two to three times this persistence rate. I can’t really get my head around this – life has gone mad. Is it legal? Was there a GP on the board that approved this? So there is a CCG out there that incentivises their GPs to use nasty cheap medicines that patients won’t take to save money in their prescribing budget.

I appreciate that the NHS is strapped for cash and has to make efficiency savings, but these should be made right across the board – the prescribing budget is just one point of expenditure.

Medicines optimisation – the creative use of medicines to improve outcomes for the individual patient is the way forward. There is a need for creative investment of the medicines budget to create savings right across the whole system because patients do better.

Advertisements

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”

A patient called Alice and the Cheshire Pharmacist

The pharmacist grinned when he saw Alice. He looked good-natured, she thought. A white coat and a broad smile, she though he ought to be treated with respect. She held out her prescription.

‘Will it work’ asked Alice.

‘Well that all depends on what you are wanting it to do?’ replied the Cheshire Pharmacist, ‘of course it will work if you take enough of it’

‘But will it make me feel better’ asked a rather frustrated Alice.

‘Feel better? Now that is a totally different question’. ‘You will probably feel something, but I can’t say whether it will make you feel better’

Alice tried a different question ‘what sort of people live about here?

The pharmacist waved his hand round ‘lives a doctor: and in that direction,’ waving the other hand, ‘lives you. Visit either you like: they’re both mad.’

‘Mad’ said Alice, ‘we aren’t mad’. ‘How do you know we are mad?’

‘You must be,’ said the pharmacist, ‘or you wouldn’t be here with a prescription asking me if it will make you feel better’.

In the real world, everybody clearly explains to the prescriber what their condition means to them and the dominant symptom that they want help with to enable them to feel better. And every prescriber co-produces a treatment plan with the patient that tackles the specific symptom, possibly including a medicine within a support programme to support the patient to feel better.

Which one is reality and which one is fiction – sometimes it’s hard to tell.

Speaking to Ministers

I was happy to be invited to the NHS Alliance AGM and policy day. It gave me two 30 second opportunities to speak to ministers – not a conversation, but two single bullet point opportunities. It is not that easy to blurt out two points, but here are my attempts:

To the Shadow Health Minister: “Please look at the legal framework for prescribing and get community pharmacists simple prescribing status, similar to district nurses so they can prescribe medicines to those who can’t afford to buy their medicines and are directed to general practice.”

I am not sure that she fully understood what I asked, but she duly looked interested and wrote it down. There is a level of ambiguity in what I am asking for and a level of confusion created by pharmacists themselves. Pharmacists often talk about ‘counter-prescribing’ which is a confusing term, much better translated into ‘we sell medicines to those who can afford to buy them’ – and probably to some that can’t, but are desperate. People understand this and those who don’t want to buy go to their GP and contribute to the bulging waiting rooms. It is a situation that is unfair to those on low incomes, unemployed, on benefits, retired – anyone who feels that they can’t afford the price. It is inequitable – if you are wealthy you go to the convenient community pharmacy – if you are poor, you go to the GP practice – simple! It doesn’t help those living in tough communities (I was told not to use deprived any more). I would agree that several localities have identified this issue and have minor ailment systems in place like ‘Pharmacy First’, but there needs to be over 200 systems throughout England, administered through 28 area teams, all with PGDs. And the two options are to commission minor ailment schemes nationally with huge bureaucracy or simply change the law/regulations. Give a community pharmacist a prescription pad and a limited list formulary and they will use it wisely to the benefit of their communities.

I do not understand how, post the Crown Reports, a system where community pharmacists were allowed to prescribe a selection of medicines from a limited list in line with the common conditions that they manage under minor ailment schemes at the NHS expense was not included. Just admit it – it was an error, an oversight – just sort it out please – preferably before general practice implodes.

When introduced to Lord Howe, he smiled and said that he was the minister responsible for Pharmacy: “There are over 800 community pharmacies with 100 hour contracts; many more that are open for 80+ hours a week and none of them have a specific contract for the provision of out of hours care.”

Well that’s another one that hit a quizzical face. No honestly, the regulations were altered to allow community pharmacies a contract if they were open to the public for at least 100 hours a week. And with the additional 600 that were granted last year, I have grossly underestimated the numbers – probably closer to 2,000 now. I thought that I understood the logic of forcing community pharmacies to open longer and provide a much increased service to the population for the same cost to the NHS. Access was the driver and it all made sense. But now I have to ask – “was the Department of Health creating a valuable asset for the NHS to waste?” – “Having a laugh” – “have they lost their way”.

I have read so many documents on urgent care that I now play community pharmacy bingo. ‘Commissioning the whole system (urgent care): why the big picture matters’ – not a single mention – hardly a big picture then. No one has twigged that some community pharmacies are open 100 hours a week with a pharmacist on duty. If the pharmacy had an out of hours addition to their contract; if they employed a pharmacist independent prescriber; if they co-located a nurse; if they co-located a GP – well you have a walk in centre, a minor injury unit, something that will make a difference.

I do agree with commentators that it is important to match supply to demand – the higher the attendances at hospital – the higher the admission rate. But to leave community pharmacy out of the mix – amazing!

Well, they were my two 30 second opportunities to ministers – what would you have said?

Medicines safety – everyone’s business

A recent conversation through @wepharmacists on twitter has me thinking about medicines safety.  I can almost hear leaders across the board saying – it’s everyone’s business. The usual management rubbish when they can’t think of anything better to say.

i don’t really want to comment on hospital pharmacy – the chief pharmacist is responsible and through the board, has oversight of the whole process from admission and prescribing, through procurement and supply to administration and discharge. The whole 9 yards! Post Francis, I am sure that every Chief Pharmacist will fill any of the gaps in their organisations process.

But what about primary care?

I remember a day working in community pharmacy when a grateful patient thanked me for spotting an error and saving their life. I was going to mention that I have several beacons:

the there must be something wrong, because I can’t dispense it beacon – which incidentally came into action for the patient just mentioned – nobody takes 20 pills a day without me checking.

The this is a tricky drug beacon – you know warfarin, methotrexate and the like.

the hey I’ve never seen it before beacon – better have a quick look.

and the something has flashed up on the computer beacon – which I immediately think about my answer in court – so you bypassed the warning without at least a simple check?

But my other beacons are very weak. The – this probably isn’t a good idea in this patient – the renal function or hepatic function means a dose reduction and a whole host of others that require a level of insight currently beyond the boundaries of community pharmacy.

The reliance on community pharmacy as a ‘backstop’ to prescribing errors is a problem. There are actually a limited number of errors that you can reasonably expect a community pharmacist to spot. And this reliance might actually be a barrier to improvement. Why worry the community pharmacist will spot it syndrome. I have heard a doctor say with confidence – I didn’t think the dose was right, but I knew the pharmacy would sort it out!

i also worry about the system that is in place to link up safety so that errors can feed through into system improvement and education to actually prevent errors or simple poor prescribing getting through. Where is the primary care equivalent of a hospital system? Where is the NPSA?

So who is responsible?

This responsibility must fall to NHS England. By definition they hold the contracts with both general practice and community pharmacy. Surely this then falls under Domain 5 as it is all about patient safety amongst a group of contractors that the NHS England commission.

So perhaps it is not everyone’s responsibility – the responsibility falls to Jane Cummings or perhaps Dr Mike Durkin? Well someone there in the NHS England domain 5 group.

On reflection, perhaps it is a good job that they have David Cousens in their midst, but the job is to joining medical education, to prescribing, to dispensing, to feedback and back into safer systems and better education at both a local and national level.

Where should they start and whose help should they employ? Well the answer is not community pharmacy! The CQC have already commented on the lack of medicines reconciliation in general practice, the low level of face to face medication review and the poor systems and completion of critical incident analysis in general practice. I might also add questionable levels of educational support, local prescribing audit capability and general feedback mechanisms.

I assume that the CQC will pay particular attention to outcome 9, Management of Medicines within their provider compliance assessment visits and supportive CCGs will take a positive interest.

It is such a pity that practice pharmacists, employed by the old PCTs have not been employed by practices wishing to get ahead of the game with regard to fulfilling their registration requirements, nor been supported in that function by CCGs. Their real ability to create an improved link between general practice and community pharmacy will become very important.

So lets stop pretending that the system is safe – it is really not – and let’s see the Domain 5 team at NHS England come out and sort it with the support of the CQC and the CCGs.

 

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.

Medicines Reconciliation

All interfaces in care represent risk to the patient. Hospitals have made significant progress in targeting pharmacists to check medicines as soon after admission as possible. GPs have made some progress in supporting this process with green bag and yellow folder schemes, but these are not always used. There is also some issues with the referral letters, particularly discussing medicines that are to be discontinued before discharge.

PCTs have driven hospitals to improve the quality of discharge letters. The timeliness and quality of these still need work to improve care and reduce the chance of read mission. In particular clarity about discontinued medicines and the indication and duration of initiated medicines including information about titration if required.

Looking at medicines reconciliation in primary care, this needs urgent attention. In the recent CQC report less than 8% of GPs were aware of a PCT policy. Less than half of the PCTs had a policy and less than half of the GP practices had their own. None of the PCTs visited by the CQC were able to demonstrate that medicines reconciliation in general practice was either timely or accurate.

An average GP practice would have up to 6 discharges a day and several letters from out-patients. It is important for these to be reviewed, tests ordered, clinical system updated, medicines changed and patients risk stratified and sent invitations to see the GP/nurse/practice pharmacist if required. Automatic contact with patients post discharge may improve outcomes and facilitate better medicines experience. In my own research within an acute cardiac ward, over 60% of medicines were discontinued on admission. 40% of initiated medicines were discontinued before discharge and 30% of discharge medicines were changed within 30 days.

Medicines reconciliation in general practice to too important to ignore. A systematic approach would support the use of practice based medicines optimisation specialists to drive reconciliation as part of their work to improve outcomes, reduce referrals, reduce admissions and reduce waste.
 

Medication review

Medication reviews broadly fall into three types:

  1. A prescription review
  2. A concordance and compliance review
  3. A medication review

The first simply checks whether the prescriptions are correct. The second involves the patient and checks the pattern of medicine use, understanding and technical ability to comply. The third represents a full clinical review of medical conditions and adjustment of treatment.

I am sure that where the NHS believes they are paying for a full medication review, they are merely getting a prescription review. This was evident in some of the findings within an early report from the CQC.

Every patient prescribed a medicine should receive a full clinical medication review every year. This should be risk stratified so the GPs deal with the patients at highest risk and with the most co-morbidities. The remaining reviews can be completed by practice pharmacists, practice nurses and for certain conditions community pharmacists.
High risk patients, including those discharged from hospital for an un-planned admission or those admitted to a care home should be prioritised and receive earlier and more frequent reviews.
The NPC and other organisations have produced excellent guides on this issue.
The review should be systematic and fit within the control of repeat prescribing in the practice.

Every patient on a regular medicine should be offered a concordance and compliance review. These can be completed by the practice pharmacist or in a planned or opportunistic manner by the community pharmacist under MUR or directly commissioned services. Particular attention should be paid to devices such as inhalers for asthma and COPD.

Every patient should receive a prescription review completed by practice staff every time they put out a repeat prescription to be signed and as part of structured audit carried out by the practice pharmacist.

Many PCTs have worked hard to improve medicines safety and governance, but it is time that this responsibility was embedded into general practice and commissioned in a structured manner with community pharmacy.

The art of prescribing

There are two very important lessons to learn with prescribing and the interaction with patients:

Say no quickly and yes slowly”

Think of the answer and then think about the question”

 

If you have no intention of prescribing a medicine, where there is no suitable, endorsed or recommended treatment, then say ‘no’ quickly. This offers little room for discussion, but opens up the question ‘so what can I do’. You can then fill the gap with things that the patient can do to relieve symptoms, including the purchase of medicines and remedies over the counter, self-help or self-care. Don’t be tempted to offer a reason why you are not going to prescribe – just try not to open this line of conversation or you may lose and be persuaded to prescribe something that is not appropriate.

 

If you have the intention of prescribing a medicine, then say ‘yes’ slowly. This is the first stage of the medication experience, and is very important in getting things off to a good start. You need to open up a dialogue to enable you to deal with issues important to the patient’s medication experience at the earliest opportunity.

 

I appreciate that the system is set up to make a diagnosis and give a medicine, but a patient’s mind may not work this way.

 

Have you considered the question ‘would you like me to prescribe something that might help?’ In my experience many patients would prefer not to take a medicine and this is often followed by a reply such as ‘so what options do I have’ that allows you to explore alternatives. It may be an open door to explore life-style changes that may either help the condition and/or reduce the need for a medicine in the first place.

 

Obviously this opens up further opportunities for discussion:

  • What will the medicine mean for me? Some medicines may reduce or release specific symptoms and others may reduce the likelihood of a further complication. There are outcome charts with smiley and sad faces that may help.

 

  • What will it do to me? It is very important to explain what a patient might feel when the medicine is in their body – how will they know when it is working.

 

  • How long will I need to be taking it for? Medicines that are quickly curative or deal with specific symptoms may be easier to accept than medicines that have to be taken long term (see previous blog).

 

  • What flexibility do I have? Remember that patients will take control and you may want to discuss flexibilities and in this way they drive their own compliance. I know that dexterity, vision and memory can cause problems, but they can be overcome by the community pharmacist.

 

You cannot achieve perfect compliance in a patient that doesn’t want to take the medicine the way that you advise.

 

This may represent a great start at the point where the medicine is introduced, but note the stages of medication experience and make sure that your wider team, including the community pharmacist are available when the patient asks further questions.

 

Where there are significant life-style or self-management issues, consider which patient support programs might be available. Ask the CCG to explore self-management programs delivered by charities and supervised through community pharmacy.