The New Medicine Service (NMS) & Targeted MUR

1. Wolverhampton & Walsall LMCs & LPCs The New Medicine Service (NMS) & Targeted MUR Dr Satya Sharma Dr Ajit Desai Narinder Gogna Jeff Blankley

2. The New Medicine Service (NMS) & Targets MUR Programme • 7.00pm Buffer • 7.30pm Welcome Dr S V Sharma – Chair Wolverhampton LMC • 7.40pm Non-adherence: The scale and detrimental impact on the Management of Long Term Conditions and the NHS Dr A Desai – Chair Walsall LMC • 8.20pm Solving the Dilemma: “New Medicine Service” and ‘Targeted ‘Medication usage Review’ services Narinder Gogna – LPC Secretary • 9.00pm Summary and Closing Remarks – Chairman Dr S V Sharma • 9.15pm Close Kindly Sponsored by: Ravi Kaur – Eli Lilly & Co Ltd , Anthony Lowe – Pfizer, Ashraf Kanwar - Astra Zeneca, Graham Rogers – GSk, Pamela McGowen – MSD, Bally Kumar – Sanofi, Neena Nahar – Novartis, Kal Patel - Boehringer

3. NMS & Targeted MUR Steering Committee

4. Context – the importance on the role of medicines 1: Wolverhampton JSNA 2008 2: Wolverhampton PCT Prescribing Team • Around 15m people with one LTC, half of over 60s have one or more Long Term Conditions (LTC). For Wolverhampton the LTC prevalence is1: • Approximately 50,100 have a LTC , equates to 21% of the population • Approximately 4.7% of the population suffer from diabetes • Approximately 15.4% of the population suffer from hypertension • Approximately 3.9% of the population suffer from CHD • Approximately 6.0% of the population suffer from Asthma • Treatment and Care for LTC patients accounts for over 70% of the primary and acute budget. In primary care the mainstay of treatment is prescribing2: • Total number of items dispensed in primary care is 4.5m • Total cost of items is £40m • Prescribing costs for Cardiovascular is £7.5m • Prescribing costs for Endocrine is £6.0m • Prescribing costs for Respiratory is £5.0m

5. The Goal – maintaining vital signs ≈ Source: Department of Health – • QOF Clinical Indicators rewards interventions, mainly prescribing, that control vital signs with a range, examples include: • The percentage of patients in whom the last blood pressure reading is 150/90 or less (CHD6, STROKE6 & BP5) • The percentage of patients whose last measured total cholesterol is 5mmol/l or less (CHD8) • The percentage of patients whose the last HbA1c is 7.5% or less (DM26) • A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed 4 or more repeat medicine (MEDICINES11) • Enabling patients to commit themselves to get the benefits from their medications is a journey: • understand the rationale, benefits and possible side-effects, • work in partnership with their health providers, • improve confidence in their medicines, • to take some responsibility for repeat prescription requests.

6. How well are we (the NHS) performing now? • Despite the serious investment in investigations and treatment the variation for the HbAIc is still far below our target range for the patients

7. The scale of non-adherence for all medicines • 5-8% of hospital admissions are attributed to preventable adverse effects of medicines and 30%-50% of admissions are related to poor adherence with treatment • Non-adherence starts early, within days of starting treatment. • Estimates vary on the scale of non-adherence: • Between 30 - 50% of medicines for LTCs are not used as recommended • 20-30% don’t adhere to regimens that are curative or relieve symptoms • 30-40% fail to follow regimens designed to prevent health problems • Non-adherence problem is of ‘striking magnitude’, leading to: • Unnecessary ill health; • Avoidable additional treatment, investigations etc; • Significant waste of resources • Increased complexity of medication regime; • Factors are classed as intentional/Unintentional

8. Reality for patients…… • Research published in 2004 showed that 10 days after starting a new medicine: • 7% of patients had completely stopped taking the medicine (completely non-adherent) • 30% of patients still taking the medicine were non-adherent • 45% of non-adherence was intentional (the remainder was unintentional) • 61% of patients expressed a substantial and sustained need for further information • 66% of patients still taking their medicine reported at least one problem with it: • Side effects (50%) • Concerns about the medication (43%) • Difficulties with the practical aspects of taking the medication (7%) Patients’ problems with new medication for chronic conditions. Barber N et al. Qual Saf Health Care 2004;13:172-175

9. Group Work – Share your experiences Having gone through the ‘trouble’ to get a GP appointment, share their problem, agree to the medication & advice, fill the prescription…… • What are the reasons for non-adherence (intentional / unintentional)? • What is the impact to patients, and the wider NHS? • What level of support do patients need to progress on the journey to commit to get the most from their medicines? • What measures would you assign to assess success of the services?

10. New Medicine Service & Targeted MURs • Increasing adherence is likely to have a far greater impact on health than any improvement in medical treatments • Support patients to get the most from their medicines • Both services based on proof of concept research • NMS for targeted groups - Early support on the newly prescribed medication • Asthma & COPD • Type 2 diabetes • Anti-platelet / anti-coagulation therapy • hypertension • MUR for targeted groups - support on all medication (includes OTC etc) • ‘High risk’ medications (diuretics, NSAIDs, anti-platelet or anti-coagulation therapy) • Recently discharged from hospital with amended medicines; • Respiratory disease • New services started on 1 October 2011. NMS will only be re-commissioned after March 2013 if the benefits can be demonstrated

11. Evidence and benefits for the interventions…. • Evidence • At 4-week follow-up, non-adherence was significantly lower in the intervention group compared to control (9% versus 16%, P = 0.032); • The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control (23% vs. 34%, P = 0.021). • Patient Benefits: • Gives patients knowledge to make informed decisions about their care; • Improves patient adherence, leading to better health outcomes; • Increases patient engagement with their LTC and medicines. • GP Benefits: • Improved control of vital signs and performance of some QOF clinical indicators; • Reduced wastage of medicines, thereby reducing medication costs; • Potential to reduce workload as improved outcomes and knowledgeable patients can access support from community pharmacist. • Community Pharmacy Benefits • Evolution of services and relationship with patients to better utilise pharmacy skillset; • Promotes better local working between healthcare providers; • Opportunity to extend services across other key disease areas, such as epilepsy etc.

12. NMS – outline service spec Make sure you read the service spec before providing NMS! • Three stage process • Patient engagement (day 0) • Intervention (approx. day 14) • Follow up (approx. day 28) • Opportunity to provide healthy living advice at each stage

13. NMS Service Specification • Problems with medication, compliance etc can be flagged to the GP in any of the interventions • Patient engagement (prior to drug administration) • Recruit patient by prescriber referral or opportunistically by the community pharmacy; • Dispense the prescription and provide initial advice; • Schedule appointment to perform intervention (f2f or call). • Intervention (shortly after starting drug – 7 to 14 days) • Assess the patient’s concordance - adherence, identify problems and the patient’s need for further information and support • Provide necessary support • Follow up (Intermediately after starting drug 14 to 21 days) • Check the patient’s concordance • Provide necessary advice

14. Full NMS and MUR Services Joint Working Delivery of NMS & MUR Services Joint Working Advertise Services Communicate Outcomes to GP Practice Identify Patients Recruit Patients Deliver Interventions Report Activity to PCT On-going Support to Patient Refer Patients

15. Implementation Principles, Assumptions & Constraints • Principles: • The NMS service delivery is not onerous for both professions; • Where required, communication between GP practices and Community Pharmacies should be timely and actioned accordingly; • The NMS service to be started as close to the initial prescription, for example hospital prescribing, as possible; • Patients will need help to understand ‘why’ and ‘what’ of the NMS and MUR services; • Utilise nationally agreed tools, by BMA, PSNC and NHS Employers, • Joint working needs to be built into the implementation to achieve objectives. • Assumptions: • Where patients have issues relating to all of their medicines this will be a trigger for a targeted MUR. • Constraints; • The GP IT systems can not be altered to highlight prescribing of NMS due to EPS Release 2 requirements to have only drug name and dosage; • There is no electronic way to communicate across the professions – will need to continue to use paper.

16. Getting patients to understand the ‘why’ and the ‘what’ • Advertise Services • Display posters in GP Surgeries, hospitals, community pharmacies etc; • Communicate key messages to GP Practice and Pharmacy staff; • Identify Patients • Various mechanisms to identify patient, stickers, stamps etc; • Refer Patients • Referral cards, verbal signposting etc • Joint working to identify and refer patients will assist the patient on the journey to ‘commit’ to get the most from their medicines – consistent messages from different professions.

17. Example of poster

18. Example of referral card Respiratory – Diabetes – High Blood Pressure – Anti-Coagulants Providing NHS Services Respiratory – Diabetes - High Blood Pressure High Blood Pressure – Anti-Coagulants – Respiratory – Diabetes You have been prescribed a new medicine. Your new medicine _________________________ is for_____________________________________ Hand this card to your regular community pharmacist when you collect your first prescription. Your community pharmacist is working with your doctor and practice team to help you to get the most from your new medicine by supporting you to understand how to take it at the right time and in the right way. Talk to your community pharmacist, who is here to help. High Blood Pressure – Anti-Coagulants – Respiratory – Diabetes - High Blood Pressure

19. For Community Pharmacy Use Example of referral card High Blood Pressure – Anti-Coagulants – Respiratory – Diabetes Respiratory – Diabetes – High Blood Pressure – Anti-Coagulants Providing NHS Services Respiratory – Diabetes - High Blood Pressure Initial pharmacist appointment: ___________________________ Follow up appointment: ____________________________________________________________________________________________________________ Respiratory – Diabetes – High Blood Pressure – Anti-Coagulants – Respiratory – Diabetes

20. Different Scenarios • Problems with medication, compliance etc can be flagged to the GP in any of the interventions • NMS & MUR Triggers - Primary Care • GP practice prescriber initiates 'NMS medicine' for the first; • GP Practice prescribes new drug that has been initiated by hospital for the first time; • GP Practice staff believe the patient may need support to understand all of their medications, includes recently discharged from hospital. • NMS & MUR Triggers – Secondary Care • Hospital prescriber (outpatient) initiate 'NMS medicine' for the first time on FP10 prescription; • Hospital prescriber (inpatient) initiate 'NMS medicine' in hospital. Medicine provided to patient on discharge. The GP prescribes 'NMS drug' for the first time after request for repeat. Also, could be new drugs on discharge as trigger for MUR.

21. The NMS Intervention ‘Template' • Initial Engagement • Explain the purpose of the NMS or MUR service; • Obtain consent to share information with GP Practice. • Deliver intervention using ‘Intervention Worksheet’ • Provide opportunistic lifestyle advice

22. Communicating Outcomes to GP Practice on issues • Pharmacists will need to refer patients to their GP, where an issue has arisen that cannot be solved by the pharmacist and patient • NMS Feedback form to communicate with the GP practice

23. Targeted MURS • patients taking high risk medicines; • NSAIDs • Anticoagulants (including low molecular weight heparin) • Antiplatelet • Diuretics • patients recently discharged from hospital who had changes made to their medicines while they were in hospital. Ideally patients discharged from hospital with receive an MUR within four weeks of discharge but in certain circumstances the MUR can take place within eight weeks of discharge; and • patients with respiratory disease • Follows current approach and format

24. Data capture and reporting to the PCT PharmaBase will collate your NMS data and produce the quarterly PCT report A standard dataset has been developed for NMS This supports data capture in a standardised manner, to support evaluation of the service A standard report can be requested by the PCT on a quarterly basis

25. New Medicine Service & Targeted MUR Questions

26. Thank you

27. NMS & Targeted MUR Steering Committee