NHS Community Pharmacy Contractual Framework

1. NHS Community Pharmacy Contractual Framework Targeted MURs

2. Changes to the MUR service • Changes are intended to help demonstrate the benefits of the service to patients and the NHS • Introduction of national target groups • patients taking high risk medicines • diuretics • NSAIDS • anticoagulants • antiplatelets

3. Changes to the MUR service • patients recently discharged from hospital who had changes made to their medicines while they were in hospital • patients with respiratory disease • At least 50% of MURs conducted from Oct 2011 must be within these target groups

4. Changes to the MUR service • Further target groups will be identified and added to the list in due course • MURs should be conducted on patients who are on more than one prescribed medicine (except high risk medicines)

5. Changes to the MUR service • Outcome / output data will be collected for all MURs • Total number of MURs delivered to patients in each group • Number of patients where a medication issue was identified by the pharmacist and action was taken • Number of patients referred back to the GP practice or another primary health care provider • Number of patients where as a result of the MUR the pharmacist believes there will be an improvement in the patient’s adherence to the medicines and type of benefit (more than one may apply): • Better understanding of why they are using the medicine/what is it for • Better understanding of when/ how to take the medicines • Better understanding of side effects and how to manage them • Better understanding of the condition being treated

6. Changes to the MUR service • Consent arrangements for MURs will be updated • Written consent for all patients • Consent to share data with GP / PCT / BSA • Next steps for PSNC and NHS Employers • Review approach to MUR data capture and paperwork

7. NHS Community Pharmacy Contractual Framework The New Medicine Service (NMS)

8. Background – non-adherence • Estimates vary on the frequency of non-adherence: • Between 33% and 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 • It has been suggested that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments Haynes R, McDonald H, Garg A, Montague P. (2002). Interventions for helping patients to follow prescriptions for medications. The Cochrane Database of Systematic Reviews, 2, CD000011.

9. Non-adherence to newly prescribed medicines • 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. QualSaf Health Care 2004;13:172-175

10. The ‘NMS’ research • Research was published in 2006 reporting on a randomised controlled trial (n=500) on which the NMS is based • 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) • Intervention group patients also had more positive beliefs about their new medicine, as shown by their higher score on the ‘‘necessity-concerns differential’’ (5.0 vs. 3.5, P = 0.007) Patient-centred advice is effective in improving adherence to medicines.  Clifford S et al. Pharm World Sci 2006;28:165-170 The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines. Elliott R A et al. Pharm World Sci 2008;30:17-23

11. New Medicine Service • It’s all about helpingpatients to get the most from their newly prescribed medicine • Based on proof of concept research • Advanced service (time limited to March 2013) • Service will continue if it has demonstrated value to the NHS • Provision can commence 1st October 2011

12. Benefits • PSNC and NHS Employers envisage that the successful implementation of NMS will: • improve patient adherence • increase patient engagement with their condition and medicines • reduce medicines wastage • reduce hospital admissions due to adverse events from medicines • lead to increased Yellow Card reporting • receive positive assessment from patients • improve the evidence base on the effectiveness of the service • support the development of outcome and/or quality measures for community pharmacy

13. Funding • Up to £55m in both 2011/12 and 2012/13 • 2011/12 – implementation payment (£750) and target payments • 2012/13 – target payments • Target payments will depend on the achievement of activity thresholds which will be related to the prescription volume

14. Funding – target payments 2011/12

15. NMS – outline service spec • 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 Make sure you read the service spec before providing NMS!

16. NMS – Patient engagement • Follows the prescribing of a new medicine for: • Asthma or COPD • Diabetes (Type 2) • Antiplatelet / Anticoagulant therapy • Hypertension (but not where it is only a dosage or formulation change) • Recruitment by pharmacy or via referral • Dispense script and provide advice (as part of Dispensing service) List of medicines at www.psnc.org.uk/nms

17. NMS – Patient engagement • Provide patient with information on the service • Patient leaflet text – use of this text is not mandatory • Collect written patient consent • Agree a method and time for the intervention (in 7-14 days)

18. NMS – Intervention • Intervention typically day 7 – 14 • Face to face in a consultation area or over the phone • Semi-structured interview technique to: • assess adherence • identify problems • identify the patient’s need for further information and support Make sure you are aware of the limitations of telephone consultations

19. NMS – Intervention • Pharmacist provides advice and support • agrees follow up • agrees solution(s) • refers to GP (only where absolutely necessary) • Make a record of the discussion using the standard dataset • An NMS worksheet has been published to help you make notes during the discussion You can use PharmaBase to make your records of the discussion

20. NMS – Follow up • Follow up typically between 14 and 21 days after the Intervention • Face to face in a consultation area or over the phone • Semi-structured interview technique to: • assess adherence • identify problems • identify the patient’s need for further information and support The Interview Schedule has been developed to prompt a thorough conversation with the patient

21. NMS – Follow up • Pharmacist provides advice and support • Patient adherent • Patient non-adherent • refer to GP (using nationally agreed NMS Feedback form) • provide more advice and support • Make a record of the discussion using the standard dataset • An NMS worksheet has been published to help you make notes during the discussion Only refer to the GP where absolutely necessary

22. Premises requirements • Pharmacies must have a consultation area that meets the requirements for the MUR service in order to provide the NMS

23. MURs and NMS • Patients are not usually eligible for an MUR within 6 months of receiving the NMS, unless in the pharmacist’s professional opinion the patient will benefit from an MUR • A note of the reason for carrying out an MUR within 6 months should be made on the patient’s record • There is no limit on the number of NMS a patient can receive in a year

24. DNAs and completed NMS • If a patient • does not attend the intervention or follow up • cannot be contacted on the phone at the agreed time The pharmacy must attempt to contact them to rearrange the appointment • The NMS is only ‘completed’ in certain circumstances • Only competed NMS can be claimed for

25. DNAs and completed NMS

26. DNAs and completed NMS

27. Knowledge & skills for NMS • Pharmacists must complete and sign the NMS – self-assessment of readiness for community pharmacists • There is no absolute requirement for training before providing NMS… • …but pharmacists must ensure they have the requisite knowledge Make sure you record your NMS related learning in your GPhC CPD record

28. CPPE learning materials Comprehensive review of the service Practise the skills for the service See what the service looks like www.cppe.ac.uk/nms Other training resources are listed on the PSNC website

29. Communicating with GP practices • Pharmacy contractors or their representative must communicate with local GP Practices before providing NMS • LPCs may support contractors with this task and may work with the Local Medical Committee • A briefing document for GP Practice teams is available from the PSNC website Don’t forget to talk to Practice Nurses as well as GPs!

30. Communicating with GP practices Available at www.cppe.ac.uk

31. Data capture and reporting to the PCT • 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 PharmaBase will collate your NMS data and produce the quarterly PCT report

32. Claiming NMS payments • You must notify your PCT prior to providing the NMS • The £750 implementation payment can be claimed once you have completed 6 NMS • The target payments will be made by NHS Prescription Services. The number of completed NMS will be recorded on the FP34(C) at the end of each month PCT notification form and Implementation Payment claim form - links on the PSNC website

33. PharmaBase support • The NMS module in PharmaBase will support contractors to provide the NMS service, including the following functionality: • patient registration • printing consent forms • scheduling interventions and follow ups using a pharmacy calendar (which can also be used to manage appointments for other pharmacy services) • printing a patient information leaflet and appointment reminder • creating a task list of patient reminders to be provided prior to appointments • recording the mandatory dataset for the intervention and follow up • creating NMS Feedback forms to refer patients back to their GP practice • an ‘NMS dashboard’ to allow the pharmacy team to keep track of their NMS activity during the month • creating the quarterly reports for PCTs

34. Evaluation of NMS • NMS will only be re-commissioned after March 2013 if the benefits of the service can be demonstrated • The data collected via the NMS module in PharmaBase will support the evaluation of the service • The Department of Health are currently selecting an academic team to evaluate NMS

35. What do you need to do now? • Read the outline service specification and the Directions / final service spec • Read the PSNC/NHS Employers guidance • Read the CPPE open learning programme • Use the other CPPE and alternative learning resources as needed • Attend a local workshop on NMS (where available) The final version of the service spec will be published soon

36. What do you need to do now? • Complete the pharmacist self-assessment form and a CPD record or two… • Develop an SOP (templates are available) • Train your pharmacy team on the service • With your support team, plan how the service will operate in your pharmacy • Familiarise yourself with the data recording requirements and paperwork

37. What do you need to do now? • Discuss the service with your local GP practice teams (working with your LPC where appropriate) • Familiarise yourself with the PharmaBase module • Notify your PCT when you are ready to start providing the NMS (a form to do this will be published soon) • Claim your £750 Implementation payment once you have completed 6 NMS (a form to do this will be published soon) The PharmaBase module will be launched before the end of September

38. Questions & comments www.psnc.org.uk/nms