How Pharmaceutical Advisers Can Ensure Quality and Effectiveness at the Interfaces

1. 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

2. Overview • 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 pharmacists? • Some points to ponder Sue Carter BPC 2005

3. Interfaces – Where (and What) Are They? • Classical description – when a patient goes into or comes out of NHS hospital – elective and non-elective • …. But also out-patient activity and out-reach • …. And also social care, intermediate care, self-care • …. And also out-of-hours services • …. And also private providers • Communication • Pharmacists  GPs  patients  secondary care  social care  community healthcare  health service managers Sue Carter BPC 2005

4. 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 – D&TC, APC, Formulary Service level agreements Interface Sue Carter BPC 2005

5. 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 Sue Carter BPC 2005

6. Intermediate care Social care Home & Self Care GP Surgery Admission & Discharge Tertiary care Secondary care Primary Care pharmacy Hospital Pharmacy Community Pharmacy

7. Intermediate care Social care INDEPENDENT SECTOR Home & Self Care PLURALITY GP Surgery Admission & Discharge Tertiary care CHOICE Secondary care Primary Care pharmacy Hospital Pharmacy Community Pharmacy

9. Intermediate care Social care Home & Self Care GP Surgery Admission & Discharge Primary care pharmacy Hospital Pharmacy Community Pharmacy

10. 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 people’s problems with medicines • …. And while in hospital 6 to 17% will experience an adverse drug reaction Sue Carter BPC 2005

11. 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; 9:479-490) USA long term condition managed care outcomes: Decreased use of medicines with benefits to health Reduced medicines-related adverse events 39% of patients incr. compliance with medication Where Do Medicines & Pharmacy Fit? Sue Carter BPC 2005

12. UK - Importance of ADRs Estimated to take up 4 out of 100 hospital bed days 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 infection (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. www.ebandolier.com) Has led to UK focus on managed care, community matrons, transforming long term care programmes, etc 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 Where Do Medicines & Pharmacy Fit? Sue Carter BPC 2005

13. Medicines Management Medicines management is a broad term which encompasses every aspect of use of medicines at both organisational and individual patient level Sue Carter BPC 2005

14. 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 / support Medicines Management Sue Carter BPC 2005

15. Evolved Approach to Medicines • Proactive, patient-centred and systematic approach to medicines • Patient partnership for improved self-care • Stratifying patient population to identify high risk • Individualised care plan to prevent adverse event & improve outcomes, based on need, preference & choice • Pharmaceutical care • Service redesign • Opportunities in new contracts Sue Carter BPC 2005

16. Make sure it is - Safe Effective Efficient Systematic Needs based Patient centred Accessible Multidisciplinary Integrated Sustainable Supported with clinical leadership Medicines Management – Ensuring Quality and Effectiveness Sue Carter BPC 2005

17. 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 Joint formularies Practice formularies Reviews and advice Formal local guidelines Development Consultation Implementation Monitoring Audit Shared care guidelines Safe – Guidelines & Protocols Sue Carter BPC 2005

18. Effective • Evidence based practice • Only part of decision making • Monitor outcomes • Admissions • Quality and outcome framework • Spend or prescribing patterns • Interventions • Pharmaceutical care – record outcomes! Sue Carter BPC 2005

19. 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 Systematic Sue Carter BPC 2005

20. 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 Sue Carter BPC 2005

21. 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 professional. • Pharmacists can help in this process • educating about treatments and options • interpreting and explaining risks and benefits • Proactive support & resource to patients Sue Carter BPC 2005

22. 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 - Services Sue Carter BPC 2005

23. 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 Sue Carter BPC 2005

24. Integrated • 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 medicines? Sue Carter BPC 2005

25. How Are Primary Care Pharmacists Dealing With the Agenda? • Practice, locality commissioning board, (new) PCT levels • All have operational and strategic need for primary care pharmacists • Additional statutory roles at PCT level Sue Carter BPC 2005

26. 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 Primary Care Trust Sue Carter BPC 2005

27. Commissioning – medicines issues Service redesign – secondary to primary care shift Demand management Performance management Repeat Prescribing Review Practice prescribing analysis Audit Support E.g. NSAIDs, Asthma, Statins, Newsletter Local health economy formulary development & support Proactive and reactive advice Local interface issues Locality Commissioning Board Sue Carter BPC 2005

28. 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 GP Practice Sue Carter BPC 2005

29. 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 Sue Carter BPC 2005

30. The New Pharmacy Contract – Major Themes • Support for self-care • Management of long-term conditions (CDM) • Public Health – health promotion plus Sue Carter BPC 2005

31. 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 Sue Carter BPC 2005

32. Some Points to Ponder ... • How will future primary care led self-care, disease management and medicines management initiatives impact on pharmacy workforce and workload? • Can better use of skillmix make enough difference? • 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? Sue Carter BPC 2005