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How Pharmaceutical Advisers Can Ensure Quality and Effectiveness at the Interfaces


What are the medicines and pharmacy issues? ... (ref: Bandolier Extra, June 2002, Adverse Drug Reactions in Hospital Patients: A ... – PowerPoint PPT presentation

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Title: How Pharmaceutical Advisers Can Ensure Quality and Effectiveness at the Interfaces

How Pharmaceutical Advisers Can Ensure Quality
and Effectiveness at the Interfaces
  • Sue Carter MRPharmS
  • Head of Prescribing Pharmacy,
  • Adur, Arun Worthing tPCT
  • And Co-Founder,
  • Primary Care Pharmacists Association

  • Interfaces where are they?
  • How are the interfaces shifting?
  • What are the medicines and pharmacy issues?
  • How can those issues be addressed by primary care
  • Some points to ponder

Interfaces Where (and What) Are They?
  • Classical description when a patient goes into
    or comes out of NHS hospital elective and
  • . But also out-patient activity and out-reach
  • . And also social care, intermediate care,
  • . And also out-of-hours services
  • . And also private providers
  • Communication
  • Pharmacists ? GPs ? patients ? secondary care ?
    social care ? community healthcare ? health
    service managers

  • Discharge admission
  • Communication
  • Local guidelines
  • Integrated medicines review as part of seamless
    patient care
  • GP medical records
  • Ensuring quality of care and managing risk
  • Shared care
  • Shared care guidelines
  • Prescribing responsibility
  • Monitoring
  • Service redesign
  • Policies DTC, APC,
  • Formulary
  • Service level agreements

Policy Changes the Road Ahead
  • Patient choice plurality
  • Chronic disease management managed care
  • Primary care contracting innovation
  • Payment by results tariffs foundation trusts
  • Service modernisation secondary to community
    shift, tier 2 services,
  • Non-medical prescribing
  • Practice based commissioning
  • Demand management resource management

Intermediate care
Social care
Home Self Care
GP Surgery
Admission Discharge
Tertiary care
Secondary care
Primary Care pharmacy
Hospital Pharmacy
Community Pharmacy
Intermediate care
Social care
Home Self Care
GP Surgery
Admission Discharge
Tertiary care
Secondary care
Primary Care pharmacy
Hospital Pharmacy
Community Pharmacy
(No Transcript)
Intermediate care
Social care
Home Self Care
GP Surgery
Admission Discharge
Primary care pharmacy
Hospital Pharmacy
Community Pharmacy
Where Do Medicines Pharmacy Fit?
  • 4 in 5 over 75s take at least one medicine and
    36 of them take 4 or more
  • Half of people with long term conditions fail to
    take medicines properly
  • 5 to 17 of hospital admissions may be due to
    older peoples problems with medicines
  • . And while in hospital 6 to 17 will experience
    an adverse drug reaction

Where Do Medicines Pharmacy Fit?
  • USA evidence
  • Estimated 44k to 98k deaths per year due to
    medication errors (including adverse drug events)
  • 6th most common cause of death in the USA (higher
    than RTAs, suicide, homicide and AIDS)
  • Costs estimated at 76.6 billion dollars per annum
    in the USA
  • (Ref JAMA 2002 9479-490)
  • USA long term condition managed care outcomes
  • Decreased use of medicines with benefits to
  • Reduced medicines-related adverse events
  • 39 of patients incr. compliance with medication

Where Do Medicines Pharmacy Fit?
  • UK - Importance of ADRs
  • Estimated to take up 4 out of 100 hospital bed
  • Estimated 15 to 20 x 400 bed hospital equivalents
  • Annual UK cost 380 million per year
  • One in 10 of all NHS bed days are taken up by
    consequences of ADR or hospital-acquired
  • (ref Bandolier Extra, June 2002, Adverse Drug
    Reactions in Hospital Patients A systematic
    review of the prospective and retrospective
    studies. Whiffen P, Gill M, Edwards J, Moore A.
  • Has led to UK focus on managed care, community
    matrons, transforming long term care programmes,
  • Medicines management has huge, as yet largely
    undeveloped, potential to ensure quality and
    effectiveness at new and existing interfaces
  • Pharmacists are the experts in all aspects of
    medicines use

Medicines Management
  • Medicines management is a broad term which
    encompasses every aspect of use of medicines at
    both organisational and individual patient level

Medicines Management
  • Service improvement demand management
  • Policy, strategy and performance management
  • Budgets, incentives monitoring
  • Statutory responsibilities legal framework
  • Workforce planning skillmix
  • Rational prescribing
  • Clinical governance
  • Dispensing
  • Access to medicines
  • Patient-centred medication review
  • Concordance, compliance patient partnership /

Evolved Approach to Medicines
  • Proactive, patient-centred and systematic
    approach to medicines
  • Patient partnership for improved self-care
  • Stratifying patient population to identify high
  • Individualised care plan to prevent adverse event
    improve outcomes, based on need, preference
  • Pharmaceutical care
  • Service redesign
  • Opportunities in new contracts

Medicines Management Ensuring Quality and
  • Make sure it is -
  • Safe
  • Effective
  • Efficient
  • Systematic
  • Needs based
  • Patient centred
  • Accessible
  • Multidisciplinary
  • Integrated
  • Sustainable
  • Supported with clinical leadership

Safe Guidelines Protocols
  • Joint formularies
  • Practice formularies
  • Reviews and advice
  • Formal local guidelines
  • Development
  • Consultation
  • Implementation
  • Monitoring
  • Audit
  • Shared care guidelines
  • Prescribing by new groups of professionals
  • NHS increasingly protocol / guideline driven
  • NICE guidance and guidelines
  • NSF standards
  • Prodigy
  • NHS direct
  • Local health economies
  • Performance management - healthcare commission

  • Evidence based practice
  • Only part of decision making
  • Monitor outcomes
  • Admissions
  • Quality and outcome framework
  • Spend or prescribing patterns
  • Interventions
  • Pharmaceutical care record outcomes!

  • Target the right service to those that need it
  • Avoid unnecessary duplication
  • Integrate complementary services across a health
    economy for maximum effect
  • Develop IT systems
  • Take a patient focussed approach
  • Elderly diabetic asthmatics develop CHD!

Targeted Medicines Management
  • Practitioner
  • Assess, plan, evaluate
  • Ongoing not just a single point review
  • Identify problems, implement plan to avoid or
    monitor for problems
  • Set therapeutic goals for each drug
  • Pharmacist (or practitioner) takes
    responsibility for outcomes
  • Commissioner
  • Strategy
  • Equity of access
  • Monitoring
  • Clinical governance
  • Resources
  • Workforce development

Needs Based
  • Medicines are unique as a clinical intervention
  • Vast majority are self (or carer) administered
  • .And so factors other than disease prevalence
    dictate the need for care
  • Prioritisation should be based on agreed values
  • Stratified approach
  • Patient and public involvement
  • Equity, fairness, effectiveness, cost
  • Health needs assessments
  • Health equity audit
  • Systematic prioritisation

Patient Partnership in Medicine Taking
  • Empowering patients to take an active role in
    managing their own care.
  • Prescribing needs to be based on an agreement
    between the patient and the health care
  • Pharmacists can help in this process
  • educating about treatments and options
  • interpreting and explaining risks and benefits
  • Proactive support resource to patients

Accessible - Services
  • Pharmaceutical services distribution
  • Contract regulation reform
  • Competition choice
  • Workforce
  • Commercial pressure
  • Professional pressure
  • Local pharmaceutical services
  • Resources
  • Out of hours
  • Pharmacists and NHS direct
  • Dispensing out-of-hours
  • Access to pharmaceutical care
  • Supporting self-care
  • Minor ailments

Accessible - Medicines
  • Patient group directions
  • POM to P
  • P to GSL?
  • Walk-in centres
  • One-stop primary care centres
  • Health centre pharmacies v. High street
  • Electronic prescribing e-pharmacy
  • Non-medical prescribing
  • Supporting self-care

  • Not just about pharmacists
  • The agenda is huge
  • And so are opportunities for those who are
  • Other staff are better placed to provide many
    aspects of medicines management
  • And are trying to do it at the moment!
  • And are less expensive!
  • But maybe have different skill sets

  • Consistent approach driven by policy, protocol,
    standards etc
  • Responsibilities clearly defined
  • And accountability (duty of care?)
  • Communication should be effective, efficient and
    responsive but not as easy as it seems!
  • Single assessment develop national SAP for

  • Longer term finances avoid pilot syndrome
  • Demonstrate benefits
  • Dont overload already hard-pressed professionals
  • Identify champions
  • Define roles and build relationships

Clinical Leadership
  • From all professions involved including
  • Leaders provide knowledge and expertise for
    service / protocol development
  • Leaders educate
  • Mentoring or shadowing (accompanied visits)
  • Leaders could take on difficult bits
  • Provide ad-hoc advice
  • General encouragement

How Are Primary Care Pharmacists Dealing With the
  • Practice, locality commissioning board, (new) PCT
  • All have operational and strategic need for
    primary care pharmacists
  • Additional statutory roles at PCT level

Primary Care Trust
  • Fewer, larger PCTs
  • PCT-wide cross-health economy engagement
  • Co-ordination of local health economy
    medicine-related policies
  • Performance Management
  • Interface medicines management
  • Primary care contracting
  • Procurement initiatives
  • Shared care
  • Influencing clinical practice
  • Workforce development
  • Policy development implementation
  • Statutory roles
  • Local delivery plan / priorities planning /
    horizon scanning

Locality Commissioning Board
  • Audit Support
  • E.g. NSAIDs, Asthma, Statins,
  • Newsletter
  • Local health economy formulary development
  • Proactive and reactive advice
  • Local interface issues
  • Commissioning medicines issues
  • Service redesign secondary to primary care
  • Demand management
  • Performance management
  • Repeat Prescribing Review
  • Practice prescribing analysis

GP Practice
  • nGMS general involvement
  • Input to QOF and assessments
  • Practice visits 3 agreed action points
  • Many medicines issues
  • Repeat Prescribing other practice systems
  • Provision of patient centred medicines services
  • Practice prescribing analysis
  • Audit Support
  • Internal practice formulary development support
  • Proactive and reactive advice
  • Interface issues

Targeted Medicines Management
  • Level 1 population management
  • Supporting self-care
  • Level 2 care management
  • Disease specific interventions for at-risk groups
  • Supporting patients to optimise medicines use
  • Pharmacists with special interest - e.g. as
    disease-specific care managers
  • Level 3 case management
  • E.g. Targeted medicines support at discharge
  • Proactive pharmaceutical care

The New Pharmacy Contract Major Themes
  1. Support for self-care
  2. Management of long-term conditions (CDM)
  3. Public Health health promotion plus

Strategic Direction
  • Investment to help older people keep healthier at
    home for longer
  • Intensive case management - Evercare
  • CDM - better, stratified care for people with
    long term illness care closer to patient
  • Developing services in community primary care
    settings secondary to primary shift
  • New organisational systems, structures and
    processes clinical governance risk management
  • Multidisciplinary focus

Some Points to Ponder ...
  • How will future primary care led self-care,
    disease management and medicines management
    initiatives impact on pharmacy workforce and
  • Can better use of skillmix make enough
  • Will the forthcoming white paper take some of
    these issues on?
  • Can quality and effectiveness at interfaces be
    ensured in an NHS with constantly shifting
    structures, rules and personnel?