Making prudent healthcare happen

Maximising fresh opportunities through prudent pharmaceutical care

  • Bethan Tranter, Chief Pharmacist, Velindre Cancer Centre
  • Mair Davies, Chair, Royal Pharmaceutical Society Wales

Summary

This article highlights ways the pharmacy team across the whole of the NHS can contribute to the prudent healthcare agenda. It recognises the delivery of healthcare services are changing and shows how clinical pharmacy roles can offer fresh opportunities for changing the dynamics of patient care in both community and acute care environments.

Pharmacy

Introduction

Pharmacists are ideally placed to implement the principles of prudent healthcare. As the third largest professional group in the NHS, the pharmacy profession has a significant and valuable contribution to make to the healthcare of people in Wales.

The Welsh Health Survey of 2013 found that 70 per cent of adults reported using a pharmacy in the last 12 months and 36 per cent reported buying a medicine in the previous four weeks [1].

The pharmacy team is not only made up of highly-skilled pharmacists with expert clinical knowledge of medicines, but also features qualified pharmacy technicians who are also registered with the General Pharmaceutical Council and support staff spanning both the community and hospital sectors.

Every hospital in NHS Wales has a team of pharmacists which provides advice and guidance to patients about their medicines as well as actively undertaking a variety of roles in managing the safe and effective use of medicines.

The network of more than 700 community pharmacies throughout Wales offers expert advice on medication and pharmacy-led services that are available at a local level for the people of Wales.

As experts in medicines, pharmacists and their teams want to make sure, as NHS Wales moves to deliver prudent healthcare, it makes the most of their skills. The pharmacy team operates at all stages of the processes relating to medicines – from clinical and patient-facing to technical and financial roles. Pharmacists have the knowledge and skills to support patients with long-term medical conditions, through intensive medicines management and coaching. They are the first port of call for minor ailments and they make sure people feel reassured and supported with all aspects of their use of medicines. It is paramount, that these medicine and pharmaceutical needs are well coordinated through all healthcare journeys, with the full input and support of the pharmacy team at all levels.

Prudent pharmaceutical care

Prudent healthcare depends on a coordinated and collaborative approach between health professionals and people in Wales. Medicines are a common denominator in most episodes of healthcare. It’s critical that decisions about medicines and advice about pharmaceutical care are guided by the expertise of the pharmacy team. Services which fully integrate the pharmacy team into multidisciplinary models of care are urgently needed to ensure the principles of prudent healthcare can be applied in practise.

Pharmacists have been practicing many of the principles of prudent healthcare for many years and they are well established in the daily roles and functions of pharmacy teams in all healthcare settings.

Keeping patients safe with medicines support

Medicines can be life-prolonging and life-saving but they can also cause harm if used incorrectly. To minimize harm and maximise benefit, pharmacists are essential members of the multidisciplinary team.

Automated dispensing

Wales was the first UK country to implement a comprehensive programme of automated dispensing systems – “robots” – across hospital pharmacies. These robots have underpinned improvements in the skill mix between pharmacists, pharmacy technicians and support staff, improving dispensing times for outpatients, discharge medicines and most importantly, reducing dispensing errors. These benefits have freed pharmacists to have time to develop more clinical roles with greater patient contact in hospitals.

The opportunities to incorporate automated dispensing systems in community pharmacy are developing. Automation is now streamlining the dispensing processes in community pharmacies across Wales and releasing time and resources to support the development of clinical roles for pharmacists working in the community.

Empowering patients

The pharmacy team, in all settings, aims to ensure that patients have the right medicines at the right time. Pharmacists use evidence to help educate patients about their medicines, and listen to their beliefs and concerns, ensuring that they feel supported and informed. The pharmacy team builds relationships with patients, ensuring they are only prescribed evidence based medicines that they need and are prepared to take. Through interaction with the pharmacy team patients are also supported to self manage chronic conditions and self care for minor acute conditions.

Governance

Sound medicines governance arrangements are also a critical component in delivering safe and effective pharmaceutical care. Governance protects patients but is largely unseen, under-recognised and under-valued. Good governance arrangements provide the means by which systems and processes are designed, implemented and monitored to provide protection for patients from medicine related harm. Pharmacists also deliver medicines leadership and are responsible for the development of local medicines formularies, taking account of clinical and safety evidence as well as cost.

Disease state management

Pharmacists are key team members in the development of evidence-based policies and procedures to support disease state management. These policies guide medical and nursing staff in the safe prescribing and administration of medicines. They act as an important safety tool for NHS Wales which also ensure that all patients with similar conditions are treated equally as per clinical need.

Protection against harm

Patients can be protected from future harm by making sure health professionals learn from incidents and errors and implementing necessary changes in systems and practice. Pharmacists working in health boards and NHS trusts are the medication safety officers. This formalises a long-standing role of driving the improvement of medication incident reporting and the implementation of authoritative advice and direction. The role of pharmacists as Yellow Card Champions has been shown to reverse the decline in the reporting of adverse drug reactions. The Yellow Card scheme provides data on adverse medication events, which when collated at the UK level, are used to inform future medicines licensing and use to minimise the risk of adverse reactions [2].

Crossing care settings

Harm can arise from failures of communication when patients’ care crosses the boundaries between care settings. Internal research in Cwm Taf University Health Board has shown that 22 out of 60 prescribing changes on discharge advice letters (DAL) were not followed through into prescribing in primary care. The implementation of the e-DAL (electronic transfer of DAL information) will address many of the issues identified in the research.

Giving everyone access to health care support

The community pharmacy network in Wales offers people the opportunity to access health promotion and self-care advice without a referral or an appointment and in a location that is convenient for them – for example, on high streets and in supermarkets. The pharmacy team can treat common ailments, provide healthy lifestyle information, medicines advice and deliver opportunistic health related interventions at the point of medicines supply.

Relationships

Through regular interaction with the pharmacy team, patients and their carers can build very positive relationships.  Pharmacists often pick up on changes in a patient’s health, general wellbeing and social situation as a result of such regular contact, which provides opportunities for addressing the holistic needs of individuals.

Current services

Pharmacists currently offer a number of services to support patients’ health and wellbeing, such as smoking cessation services. Others include medicine use review services, which put the patient at the heart of the consultation, empowering patients to work with pharmacists to ensure they understand what medicines they take and if they are working well for the patient.

Pharmacists in both hospital and community settings often work together when a patient is discharged from care, making sure any changes to medicines are followed up in community. This is done through the discharge medicines review service. There is scope to extend this important service and further exploit advances in technology to maximise benefits for patients as part of the prudent healthcare agenda.

The right skill mix in the pharmacy team

In every pharmacy team and setting, there are a number of different roles and responsibilities. Individuals will be qualified to different levels with varying levels of expertise and clinical knowledge. For many years the pharmacy profession has recognised the benefits to patient care by ensuring that appropriately-trained members of staff undertake roles that only they can do. Examples of new roles which have developed in the pharmacy team include:

Pharmacist non-medical prescribers – as the experts in medicines, pharmacists are well placed to take on the natural progressive role of prescribing. Since non-medical prescribing was first introduced in Wales, there has been a steady increase in the number of pharmacists who are qualified independent prescribers.  Pharmacist independent prescribers are now well established in a number of clinical specialities across Wales and provide valuable additional skills to help support patients.

Accredited checking pharmacy technicians – qualified to undertake final technical accuracy checks on all dispensed prescriptions. This means that once a clinical check has been undertaken on a prescription by a pharmacist, a pharmacist does not have to review that prescription again before it is handed out to the patient. This reduces the requirement for a pharmacist to work within the confines of a dispensary, thus releasing pharmacists to spend more time directly with patients.

Medicine management pharmacy technicians – work alongside pharmacists on hospital wards and help to ensure that patients have accurate medication histories recorded and correctly dispensed and labelled medication in the patient’s bedside lockers. This process allows patients’ own medicines to be used while in hospital, helping to reduce waste and ensuring patients can maintain ownership and understanding of their medicines while in hospital.  This also makes sure nursing staff have direct access to medicines labelled for individual patients and so improves the efficiency and safety of medicine rounds. It can also help to facilitate quicker discharges for patients as medicines are available on the ward at the point that the prescription is written. Having medicines management technicians on wards allows pharmacists more time to concentrate on complex clinical queries.

Ambitions for prudent pharmaceutical services

The pharmacy profession in Wales has recently come together to produce a visionary document for the future of pharmacy. ‘Your Care, Your Medicines’[3] which sets out the ambition for pharmacy to be fully integrated into the healthcare team so it can further contribute its unique skills and knowledge, for the benefit of the people of Wales.

1. Further using the skills of the pharmacy team

The people of Wales can have more convenient access to appropriate healthcare if the clinical knowledge of pharmacists is used to its fullest potential.  More pharmacy-led clinics in both hospital and community settings can have a positive impact on clinical capacity and this will both help support doctors while helping  take pressure off them. This ultimately helps make sure patients are seen quickly in locations that are more convenient for them.

Pharmacist independent prescribers are now well established in a number of clinical specialities across Wales and provide valuable additional skills, especially in clinical specialities where medical recruitment difficulties lie, eg oncology, renal and respiratory medicine.

Current good practice with pharmacists in Wales includes:

Emergency Hormonal Contraception – Many community pharmacies across Wales offer a service where women can access emergency hormonal contraception and be given sexual health advice directly from the pharmacy, increasing access and choice for patients. Patients will be given non-judgemental, confidential, professional advice and can be referred to another healthcare professional for further support or treatment if necessary. “During 2011-12 the provision of emergency hormonal contraception (EHC) replaced the supervised administration of prescribed medicines as the enhanced service provided by the largest number of community pharmacies.” [4]

Pharmacist prescribers – pharmacists in this role have demonstrated a positive impact on several hospital wards and in clinic settings [5] Prescribing pharmacists have been able to manage and prescribe further supply of medication for long-term conditions. An example of this can be seen in Cwm Taf where a prescribing pharmacist has been working on the surgical ward in the Royal Glamorgan hospital, benefits have included excellent compliance with prescribing guidelines, easing the prescribing burden for doctors, prompt prescribing of medicines on admission and a timely discharge process. More details can be read here.

Community pharmacy smoking cessation services – these established services have demonstrated improvements in patient access to support and treatment at a local level [6]. This enhanced pharmacy service has been extremely successful in the Cwm Taf University Health Board, both in the numbers of smokers accessing the service and the quit rates achieved. An evaluation report – Merthyr Tydfil pilot of a local enhanced community pharmacy smoking cessation service (Year 1) states that “56.7% (55/97) of treated clients self reported that they had successfully quit at the 4-week follow up.”

Flu vaccination – during 2012-13, 1,537 people across Wales received their influenza vaccinations at a community pharmacy. The results of the patient questionnaire showed a94% of patients that were vaccinated through community pharmacy were very happy with the service [7].

2. Unscheduled care

The ambition of pharmacists in Wales, as set out in ‘Your Care, Your Medicine’[4],  is to ensure people in Wales will benefit from early detection and treatment of health conditions when engaging with the pharmacy team. There is an opportunity for symptoms of common ailments and non-life threatening emergencies to be treated by the pharmacy team and to be referred to other health services when symptoms require further and more specialised investigation and treatment.

We envisage a triage service in A&E departments with nurses and pharmacists working together to treat less serious cases, allowing patients with more serious injuries and illnesses to be seen more quickly by doctors. We also anticipate that the pharmacist will be able to deal with medication-related issues when a patient is admitted to hospital and work with the patient to ensure any problems are resolved, avoiding subsequent admissions. Betsi Cadwaladr University Health Board has already started looking at Facilitating Avoidance of Medication-Related Admissions, material available here [8].

Current good practice with pharmacists in Wales includes:

Choose Pharmacy – a common ailments service – has been piloted in two areas of Betsi Cadwaladr and Cwm Taf University Health Boards since May 2013. It allows people to receive free treatment from their local pharmacy for a range of common illnesses without a prescription and is designed to take pressure off local GP surgeries [9] The service effectively supports the management of unscheduled care and helps keep patients out of hospitals and GP surgeries.

3. Manage Medicines for Chronic Conditions

Patients with chronic conditions should have access to regular contact with a pharmacist who has the expertise to provide medication advice and coaching, this would ideally take place in a setting that is most suitable for the patient. Patients should feel empowered and supported to have an active role in decision making about their medication and health needs.

In order for this ambition for the management of chronic conditions to be achieved, it is vital that the pharmacy team can access the same medical information as the GPs, sharing data in this way also improves patient safety, particularly as they transfer from one care setting to another or back to community.

Examples of good practice in continuation of care include:

The All Wales Medicines Strategy Group supported the development of guidance to address some of the issues regarding polypharmacy and particularly focusing on prescribing for the frail and elderly [10].

The Discharge Medicine Review service aims to improve the management of medicines following the discharge of a patient from a care setting [11].

Optimising medicines treatment in heart failure – a Community pharmacist pilot project in Hywel Dda, aimed at providing specialist advice to patients as part of the integrated referral pathway for heart failure patients in rural areas. The pilot evaluation demonstrated that “42% of all the patients referred to the pharmacist required changes to their drug treatment, which is a measure of the importance and value within the community team”.  The full evaluation document can be accessed here [12].

4. Supported living needs for people in Wales

People with supported living needs, whether they are living independently in their own homes or in a care home setting, need the same access to the pharmacy team to help manage their medicines effectively and to maintain their health and wellbeing.

Examples of current good practice include:

Domiciliary medicines use review services in the Cwm Taf and Betsi Cadwaladr university health board areas deliver pharmacy services in elderly housebound patients’ homes, offering advice and support about medicine use and addressing patient’s ongoing pharmaceutical needs [13].

5. Improving patient experience at end of life

Patients with palliative and end-of-life care needs can be empowered to shape their own clinical pathways with support from the pharmacy team, ensuring they are treated with dignity and respect, to address medication needs and social needs, including language choice. One example of good practice is ‘Just in case boxes’.

Just in case boxes – these are sealed boxes which contain specific medicines that can be use during the end-of-life stages for a terminally ill patient. These boxes are prescribed by the GP and can be supplied by registered pharmacies in order to ensure that the care team have timely access to important medicines. These boxes have been used in several health Boards in Wales, more information about the service provided in Aneurin Bevan can be accessed here.

Next Steps towards more prudent pharmaceutical services
1. Minimising Harm

Concerted action is needed across NHS Wales to optimise the benefits of pharmaceuticals, minimise their harm and to release the time of pharmacists to deliver clinical services. Using automated dispensing systems to reduce dispensing errors, harnessing the clinical skills of the pharmacy team to benefit patients and ensuring medicines information is shared appropriately as patients move through the NHS are key steps to make sure patients get the best from their medicines.

2. Skill mix

A review of the pharmacy team’s skill mix is needed to inform NHS workforce and service planning. Steps are needed across Wales to ensure patients can benefit from the integration of the skills of the pharmacy team into service models.

3. Promoting services

The wealth of resources available from pharmacists both in the community and through services like Choose Pharmacy, needs to be vigorously promoted to people in Wales so they see pharmacists as an integral part of health services available to them. Encouraging the public to seek early advice from their local community pharmacy and ensuring the pharmacy team can support A&E department’s triage about medicines-specific issues are both examples of how the pharmacy team can collaborate across settings to prevent unscheduled care and reduce unplanned and emergency admissions to hospital.

4. Pharmaceutical care plans

Patients with chronic conditions, complex medication regimens and those with supported living needs should have the opportunity to have a personalised pharmaceutical care plan.  A pharmaceutical care plan is a way of ‘working in partnership with the patients to agree a plan regarding the medicines they are taking and the health goals they expect to achieve from taking their medicines correctly and making positive lifestyle changes. These plans can be jointly produced between the patient and the pharmacist and should offer opportunities for regular review to ensure all medicines prescribed are appropriate, effective and safe.

5. Decision making

The pharmacy team can be actively brought into medicines decisions at all stages of the care pathway to ensure expert advice on medicines is available to patients, their families and carers and other healthcare professionals. Bringing the pharmacy team in to support care in the end stages of life is particularly important when difficult decisions about treatment and medicine are needed.

Conclusion

There is great potential for pharmacy services in Wales to support the delivery of prudent healthcare. Managing and supporting the safe use of medicines – from advice on self care through to assisting self management of complex drug regimens in patients with life threatening illnesses – as well as extending existing clinical care and health promotion opportunities alongside advice and support on medicines, present an opportunity for value, efficiency and improving patient experience the NHS in Wales can capitalise on. The profession is ready, willing and able.


References

  1. Welsh Government, The Welsh Health Survey of 2013
  2. Yellow Card Scheme, MHRA https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/ [Accessed 5th January 2015]
  3. Royal Pharmaceutical Society and the Welsh Pharmacy Committee Your Care, Your Medicines: Pharmacy at the heart of patient-centred care. (2014). Available at http://www.rpharms.com/wales-pdfs/YourCareYourMedicines.pdf Accessed 5th January 2015
  4. http://wales.gov.uk/docs/statistics/2014/141112-community-pharmacy-services-2013-14-en.pdf
  5. Kailey Sassi-Jones (2010) Benefits of implementing pharmacist prescribing on a surgical ward, British Journal of Clinical Pharmacy Vol.2 Dec 2010. Available at: http://www.clinicalpharmacy.org.uk/volume1_2/2010/december/p338_sharprac_web.pdf [Accessed 5th January 2015]
  6. NPHS and Merthyr Tydfil LHB (2009) Evaluation report: Merthyr Tydfil pilot of a local enhanced community pharmacy smoking cessation service (Year 1). Available at: https://www2.nphs.wales.nhs.uk/PharmaceuticalPHTDocs.nsf/61c1e930f9121fd080256f2a004937ed/df39478c60e603e0802575e80053ae5f/$FILE/Final%20Eval%20MT%20Pharm%20Stop%20Smoking%2024%204%2009.pdf [Accessed 5th January 2015]
  1. Welsh Government (2013) Community Pharmacy Influenza vaccination 2012-13, Welsh Government Available at: http://wales.gov.uk/docs/dhss/publications/131009pharmacyflureporten.pdf [Accessed 5th January 2015]
  2. Thomas, J (2011) Facilitating Avoidance of medication –related admissions, Patient Safety Congress May 2011. Available at: http://yhhiec.org.uk/wp-content/uploads/2012/05/PSC2011-Facilitating-Avoidance-of-medication-related-admissions-pdf.pdf [Accessed 5th January 2015]
  3. All Wales Medicines Strategy Group (2013) All Wales Common Ailments Service Formulary, May 2013. Available at: http://www.awmsg.org/docs/awmsg/medman/All%20Wales%20Common%20Ailments%20Service%20Formulary.pdf [Accessed 5th January 2015]
  4. All Wales Medicines Strategy Group (2014) Polypharmacy: Guidance for Prescribing in Frail Adults. July 2014. Available at: http://www.awmsg.org/docs/awmsg/medman/Polypharmacy%20-%20Guidance%20for%20Prescribing%20in%20Frail%20Adults.pdf [Accessed 5th January 2015]
  5. Welsh Institute for Health and Social Care (2014) Evaluation of the Discharge Medicines Review Service, March 2014. Available at: http://www.cpwales.org.uk/Contractors-Area/Pharmacy-Contact—Services/DMR/DMR-Evaluation_Final-Report_13082014.aspx [Accessed 5th January 2015]
  6. Hywel Dda Heath Board, Evaluation of the Hywel Dda Community Pharmacist pilot optimising medicines treatment in heart failure. Available at:http://www2.nphs.wales.nhs.uk:8080/pharmaceuticalphtdocs.nsf/61c1e930f9121fd080256f2a004937ed/a68535c450a8b431802578e7004eaf8c/$FILE/RuralHealthPharmacyEvaluationHywelDda%20v1.pdf [Accessed 5th January 2015]
  7. The Pharmaceutical Journal, 15 February 2014, Vol 292, No 7797, p181 | URI: 11134249. Available at: http://www.pharmaceutical-journal.com/news-and-analysis/news/medicines-care-for-those-most-in-need/11134249.article [Accessed 5th January 2015]

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Watch Bethan Tranter and Mair Davies talk more about this article, click the video.

Prudent pharmaceutical care

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