@ MarieCurieNI # PharmacyPallCare

1. @MarieCurieNI #PharmacyPallCare

2. Joan McEwan Head of Policy and Public Affairs Marie Curie Northern Ireland @MarieCurieNI #PharmacyPallCare

3. Macmillan Palliative Care Pharmacy Service Improvement Project2017-2019 Peter Armstrong Lead Macmillan Palliative Care Pharmacy Service Improvement Pharmacist, Belfast Health and Social Care Trust peter.armstrong@belfasttrust.hscni.net

4. Pharmacy Services • Importance of pharmacy acknowledged in Living Matters, Dying Matters (2010) • Identified through Transforming your Palliative and End of Life Care • Subsequent multiprofessional Palliative Pharmacy Design Group • In partnership with Macmillan

5. Aim • “Improving existing Pharmacy services and developing ways of working that will make a significant contribution to patients with palliative and end of life care needs.” • 1.0 WTE Lead and covering Belfast area • 4 x 0.4 WTE covering other Trust areas

6. Work Plan Objectives • Improve access to palliative care medicines • Facilitate hospital palliative care discharges • Promote anticipatory prescribing at the end of life • Education/training resources for healthcare professionals and patients/carers

7. Objective 1. Access to medicines • Standardised regional palliative stock list • 26 common palliative medicines • Community Pharmacy Palliative Care Network (CPPCN) • 40 community pharmacies spread across NI • 8 supply service pharmacies http://www.hscbusiness.hscni.net/services/2481.htm

8. Access to medicines • 3. Midazolam 10mg/2ml (and other preferred strengths) • Community prescribing working with GP Practice-based pharmacists • Increased from 57% to 90% • Hospital discharge prescribing working with clinical pharmacists • Trust 1 increased 33% to 83% • Trust 2 increased 70% to 93%

9. Objective 2. Hospital Discharges • Number of days supply on discharge. • Audit of palliative discharges • Variable practice

10. Hospital Discharges • 2. What patients can expect from hospital discharges • Educated on their medicines • Appropriate supply • Transfer of information • 3. Regional SOP for discharging palliative care patients • Standardising procedures across NI

11. Hospital Discharges • 4. Discharging patients on syringe drivers and SC PRN • Standardise procedures across NI • ‘Direction to administer’ to follow patient • Reduce GP/DN time and enable prompt care

12. Objective 3. Anticipatory Prescribing 1. Promote NICE Guideline • Regional guidance for care at end of life and opioid equivalence • Pain • Breathlessness • Nausea & vomiting • Anxiety, delirium, agitation • Noisy respiratory secretions • Embed into practice in all settings 2. Ward stock lists of end of life medicines • To match regional guidance

14. Anticipatory Prescribing • 3. Just in Case Boxes • Evaluation of OOH Centre palliative prescribing • ‘as required’ medicines placed in home before needed • Provide: • Immediate access to medicines • Reassurance to family/carers • Piloting in two areas • Roll out regionally

15. Objective 4. Education & Training • 1. Project ECHO • For community pharmacy palliative care network • Extension for Community Healthcare Outcomes • Video-conferencing to connect clinical experts (Hub) with primary care clinicians (Spokes). • Builds knowledge via teaching sessions, case presentations and discussion. • https://echonorthernireland.co.uk

16. Education & Training • 2. NICPLD End of Life Care Roadshows • 3. Palliative Adult Network Guidelines Book • 4. Patient Information for Common Palliative Medicines • 5. Use of NI Formulary • http://niformulary.hscni.net

17. Pharmacy Resource Folder • Prescribing in Palliative Care • Accessing Medication • Syringe Pumps • Medication Factsheets • Patient Information • Signposting • Useful Contacts

18. Pharmacy and inpatient palliative care Chris Black Palliative Care Pharmacist Marie Curie Hospice Belfast @MarieCurieNI #PharmacyPallCare

19. Medicines reconciliation, Kardex review and rationalisation

20. Information on discharge • Information on how to take • How to measure • Where to order • Who to contact • Information leaflets • Liaison with community teams

21. Specialist advice on the ward • With regards to specialist or unusual medicines – for example Ketamine, clonazepam injection, octreotide. • Send information to community pharmacists and federation pharmacists • Compatibility for syringe drivers • Managing site reactions • Advice on administration routes • Pharmacokinetics • Supply of rarely used medication Conversions between all sorts of medicines Renal and hepatic impairment: co-morbidities

22. Education for non-specialist areas, research and keeping up to date in specialist practice.

23. Gerard GreeneChief ExecutiveCommunity Pharmacy NI

24. Community Pharmacy in NI • 123,00 people per day visit 532 Community Pharmacies • Access to HC professional without appointment, within 2 minutes

25. Community Pharmacy in NI • 55m dispensing episodes last year • Drugs budget of £400m+ managed by community pharmacy, on behalf of the health service

26. Community Pharmacy … the best kept secret • Over 15 million interventions per year across the network • Over 50,000 interventions per day • Almost 100 interventions every day per pharmacy • Over 2.5 million were clinical interventions, with a further 9 million interventions related to prescription supply and over 4 million interventions to improve health and wellbeing. • Almost 30% of survey interventions were judged as “likely to prevent harm”, meaning an estimated 4.4 million interventions preventing patient harm are made by the Northern Ireland community pharmacy network every year. Intervention Survey (Nov 2016)

27. Current Challenges • Funding Difficulties • Current contract outdated • Concessionary prices • Dispensing at a loss • Workforce Pressures • Workload & Rising demand for service • Medicine shortages • Medicine quotas • Increase in violent crime • Brexit

28. Funding • Financial investigations – MS & CoSI • 2019/20 Interim Funding • Transformation Funding • Community Pharmacy Envelope

29. Workforce Pressures Critical level vs increasing workload • 300+ GP practice pharmacists • Numbers of Under-graduate • UK & Republic of Ireland

30. Sourcing Medicines • Medicine shortages – increasing workload • Medicine quotas – restricted supply • Concessionary prices – 100 lines • Dispensing at a loss

31. Regional Contractor Survey (2018) • 99% of contractors are either “very” (19%) or “extremely”(80%) concerned about current funding • 87% are either “very”(25%) or “extremely” worried about their own business • 60% are currently having difficulty meeting their financial obligations, with staff wages (49%), supplier bills (56%), and bank commitments (45%) • 81% state the situation is having an impact on their health and wellbeing

32. Contract Preparation • MoU and Vision Agreed December 2016 • Ministerial Announcement 13th January 2017 • Health & Well-being – Delivering Together • Collapse of NI Assembly 2017….. ….WORK CONTINUES • Service Framework agreed • Priority services identified • Service Development work ongoing

33. Service Framework

34. Pharmacy Services

35. The Future of Community Pharmacy in NI • Department of Health policy - H&W 2026 • All-party political and public support • Community pharmacy should be frontline • enhanced public health and preventative services • targeted screening and health checks • community pharmacists as prescribers • The unique access point of community pharmacy should be maximised • early intervention with referral pathways to GPs and other HCPs • signposting to other sources of community support • The potential to shift a significant volume of work from GP practice into community pharmacy needs to be a priority, not only for minor ailments.

36. Paula’s Story … “Paula, a 53 year old lady was diagnosed with pancreatic cancer, she was understandably devastated by the diagnosis and had very little family or community support. She had attended one community pharmacy all of her life and had built up a good relationship with the pharmacist. The pharmacist knew her very well, in part due to Paula’s history of drug and alcohol addiction which meant they dispensed her medicines on a weekly basis. On discharge from hospital the first place Paula visited was her community pharmacy. She was completely confused and bewildered with the complex new medicine regime she had been given. The pharmacist spent two hours talking with Paula, explaining all her new medicines and contacted the hospital in an attempt to have the regime simplified. Eventually a final regime was agreed with Paula’s hospital team, this simplified regime involved Paula taking 69 doses of medication every single day……. From Living Matters, Dying Matters (DHSSPS, 2010 pg. 71)

37. Paula’s Story … ….The pharmacist offered to prepare the medicines for Paula in a pill box and she delivered the pill box weekly to Paula’s home. During the pharmacist’s visits as Paula’s condition deteriorated, she checked that Paula seemed physically and mentally fit to manage the administration of her medicines. As her condition progressed the pharmacist contacted the nursing team to express her concerns and the team managed to organise a carer to help Paula with the administration of her medicines, the pharmacist counselled the carer on Paula’s medicines to ensure she understood the regime. The pharmacist continued to visit Paula weekly providing advice and support as needed until sadly she passed away two months later”. From Living Matters, Dying Matters (DHSSPS, 2010 pg. 71)

38. Paula’s Story … the gaps • 30+ years of alcohol and prescription drug dependency • Repeated OD attempts • Community pharmacy main or only point of contact with HSC – weekly medicines • Challenging personality – changing moods • Little or no family/community/social support • Trusting relationship with CP built over 5yrs - encouraged Paula to seek community support (AA, bereavement counselling) gradually moved into a better place, coping better, fewer relapses • Presented at CPh with abdominal pain and referred to GP • Prescribed mebeverine – continued pain – severe – CP contacted GP to request immediate appointment • Admitted to hospital – pancreatic cancer diagnosis – discharged in frail, confused condition on 69 doses of meds with no social support • CP staff remained main source of support as condition worsened • Died at home alone 8wks later, found by member of pharmacy staff

39. Thank you

40. Community Pharmacy & Palliative Care Philip Boyle Community Pharmacist, Crossgar Pharmacy Plus ICP Pharmacy lead, Down

41. Who is your Community Pharmacist?

42. A flavour of what we actually do…. • Dispense prescriptions and advice • Give advice and support for self care • Over the counter medicines for common conditions/ailments • Signposting to other services • Minor ailment services • Health Promotion • Medicine Use Reviews • Other services e.g. smoking cessation programmes • BCPP projects • Integrated Care partnerships

43. A typical day in a Community Pharmacy?

44. Pharmacy in YOUR community We are often the first point of access to health services We have good relationships with our communities We have regular contact with patients, families and their carers Regular contact with other healthcare professionals We are a valuable frontline resource in the health service

45. Community pharmacy and Palliative Care

46. Moving to Palliative Care • All pharmacies offer general palliative care services. • Patients/carers are advised to use their regular Community Pharmacy in the first instance for medication & advice. • As palliative care evolves, medication intensity increases. • Creates an increasing burden on patients, families and carers. • Situations can develop rapidly e.g. supply of new medicines , emergency O2 supply. • Conversations develop > sharing of problems with staff. • Support for patients, families or carers becomes more apparent.

47. Hidden Carer Support Service Started in SET 2016 Other Trusts now engaging. Promotes Carer health & wellbeing Highlights support available to Carers locally Non-medical but offers crucial support for carers to continue in their caring role

48. Community Pharmacy Palliative Care Network (CPPCN) • All pharmacies can access and provide medication for palliative care. • Use regular pharmacy in the first instance. • When palliative care intensifies, you may need to use a pharmacy listed in the CPPCN. • 40 Community Pharmacies distributed throughout NI, and an additional 8 supply service pharmacies.

49. Why have CPPCN pharmacies? • To facilitate access to palliative care medicines by patients and their representatives. • These pharmacists are trained in the use of palliative care medicines and can provide advice to carers and other healthcare professionals. • For patients who are receiving palliative care at home and who are prescribed medicines included in the local formulary.

50. CPPCN pharmacies (cont’d) • All Community Pharmacy Palliative Care Network (CPPCN) pharmacists stock an agreed list of drugs. • Pharmacists should be available to provide the service during working hours. Out-of-hours providers may contact the pharmacist nearest to the patient in the first instance. There is no obligation on the pharmacist to provide an on-call service. • All CPPCN pharmacists provide oxygen.