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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. Overview. Interfaces – where are they?

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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

overview
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

interfaces where and what are they
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

interface
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

policy changes the road ahead
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

slide6

Intermediate care

Social care

Home & Self Care

GP Surgery

Admission & Discharge

Tertiary care

Secondary care

Primary Care pharmacy

Hospital Pharmacy

Community Pharmacy

slide7

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

slide9

Intermediate care

Social care

Home & Self Care

GP Surgery

Admission & Discharge

Primary care pharmacy

Hospital Pharmacy

Community Pharmacy

where do medicines pharmacy fit
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

where do medicines pharmacy fit1
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

where do medicines pharmacy fit2
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

medicines management
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

medicines management1
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

evolved approach to medicines
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

medicines management ensuring quality and effectiveness
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

safe guidelines protocols
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

effective
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

systematic
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

needs based
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

patient partnership in medicine taking
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

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 - Services

Sue Carter BPC 2005

accessible medicines
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

integrated
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

how are primary care pharmacists dealing with the agenda
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

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

Primary Care Trust

Sue Carter BPC 2005

locality commissioning board
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

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

GP Practice

Sue Carter BPC 2005

targeted medicines management
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

the new pharmacy contract major themes
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

strategic direction
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

some points to ponder
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