How Pharmaceutical Advisers Can Ensure Quality and

Effectiveness at the Interfaces

Sue Carter MRPharmSSue Carter MRPharmSHead of Prescribing & Pharmacy,Head of Prescribing & Pharmacy,

Adur, Arun & Worthing tPCTAdur, Arun & Worthing tPCT

And Co-Founder, And Co-Founder,

Primary Care Pharmacists’ AssociationPrimary Care Pharmacists’ Association

Sue Carter BPC 2005

Overview

Interfaces – where are they?Interfaces – where are they? How are the interfaces shifting? How are the interfaces shifting? What are the medicines and What are the medicines and

pharmacy issues?pharmacy issues? How can those issues be addressed How can those issues be addressed

by primary care pharmacists? by primary care pharmacists? Some points to ponderSome points to ponder

Sue Carter BPC 2005

Interfaces – Where (and What) Are They? Classical description – when a patient goes into or Classical description – when a patient goes into or

comes out of NHS hospital – elective and non-comes out of NHS hospital – elective and non-electiveelective

……. But also out-patient activity and out-reach. But also out-patient activity and out-reach ……. And also social care, intermediate care, self-. And also social care, intermediate care, self-

carecare ……. And also out-of-hours services. And also out-of-hours services ……. And also private providers. And also private providers CommunicationCommunication

Pharmacists Pharmacists GPs GPs patients patients secondary secondary care care social care social care community healthcare community healthcare health service managershealth service managers

Sue Carter BPC 2005

Interface

Discharge & admissionDischarge & admission CommunicationCommunication Local guidelinesLocal guidelines Integrated medicines Integrated medicines

review as part of review as part of seamless patient seamless patient care care

GP medical recordsGP medical records Ensuring quality of care Ensuring quality of care

and managing riskand managing risk

Shared care Shared care Shared care Shared care

guidelinesguidelines Prescribing Prescribing

responsibilityresponsibility MonitoringMonitoring Service redesignService redesign

Policies – D&TC, APC, Policies – D&TC, APC, FormularyFormulary Service level Service level

agreementsagreements

Sue Carter BPC 2005

Policy Changes: the Road AheadPolicy Changes: the Road Ahead

Patient choice = pluralityPatient choice = plurality Chronic disease management & managed careChronic disease management & managed care Primary care contracting & innovationPrimary care contracting & innovation Payment by results & tariffs – foundation trustsPayment by results & tariffs – foundation trusts Service modernisation – secondary to Service modernisation – secondary to

community shift, tier 2 services,community shift, tier 2 services, Non-medical prescribingNon-medical prescribing Practice based commissioningPractice based commissioning Demand management & resource Demand management & resource

managementmanagement

Sue Carter BPC 2005

Intermediate care

Primary Care pharmacy

Social care

Hospital Pharmacy

GP Surgery

Community Pharmacy

Admission & Discharge

Home & Self Care

Secondary care

Tertiary care

Sue Carter BPC 2005

Intermediate care

Primary Care pharmacy

Social care

Hospital Pharmacy

GP Surgery

Community Pharmacy

Admission & Discharge

Home & Self Care

Secondary care

Tertiary care PLURALITY

CHOICE

INDEPENDENT SECTOR

Sue Carter BPC 2005

Sue Carter BPC 2005

Intermediate care

Primary care pharmacy

Social care

Hospital Pharmacy

GP Surgery

Community Pharmacy

Admission & Discharge

Home & Self Care

Sue Carter BPC 2005

Where Do Medicines & Pharmacy Fit? 4 in 5 over 75s take at least one medicine 4 in 5 over 75s take at least one medicine

and 36% of them take 4 or moreand 36% of them take 4 or more Half of people with long term conditions Half of people with long term conditions

fail to take medicines properlyfail to take medicines properly 5 to 17% of hospital admissions may be 5 to 17% of hospital admissions may be

due to older people’s problems with due to older people’s problems with medicines medicines

……. And while in hospital 6 to 17% will . And while in hospital 6 to 17% will experience an adverse drug reactionexperience an adverse drug reaction

Sue Carter BPC 2005

Where Do Medicines & Pharmacy Fit?USA evidenceUSA evidence Estimated 44k to 98k Estimated 44k to 98k

deaths per year due to deaths per year due to medication errors medication errors (including adverse drug (including adverse drug events)events)

66thth most common cause of most common cause of death in the USA (higher death in the USA (higher than RTAs, suicide, than RTAs, suicide, homicide and AIDS) homicide and AIDS)

Costs estimated at 76.6 Costs estimated at 76.6 billion dollars per annum billion dollars per annum in the USAin the USA

(Ref: JAMA 2002; 9:479-490)(Ref: JAMA 2002; 9:479-490)

USA long term condition USA long term condition managed care outcomes:managed care outcomes: Decreased use of Decreased use of

medicines with medicines with benefits to healthbenefits to health

Reduced medicines-Reduced medicines-related adverse related adverse events events

39% of patients incr. 39% of patients incr. compliance with compliance with medicationmedication

Sue Carter BPC 2005

Where Do Medicines & Pharmacy Fit?UK - Importance of ADRs UK - Importance of ADRs Estimated to take up 4 out Estimated to take up 4 out

of 100 hospital bed daysof 100 hospital bed days Estimated 15 to 20 x 400 Estimated 15 to 20 x 400

bed hospital equivalentsbed hospital equivalents Annual UK cost £380 Annual UK cost £380

million per yearmillion per year One in 10 of all NHS bed One in 10 of all NHS bed

days are taken up by days are taken up by consequences of ADR or consequences of ADR or hospital-acquired infectionhospital-acquired infection

(ref: Bandolier Extra, June 2002, Adverse (ref: Bandolier Extra, June 2002, Adverse Drug Reactions in Hospital Patients: A Drug Reactions in Hospital Patients: A systematic review of the prospective systematic review of the prospective and retrospective studies. Whiffen P, and retrospective studies. Whiffen P, Gill M, Edwards J, Moore A. Gill M, Edwards J, Moore A. www.ebandolier.com)www.ebandolier.com)

Has led to UK focus on Has led to UK focus on managed care, managed care, community matrons, community matrons, transforming long term transforming long term care programmes, etccare programmes, etc

Medicines management has Medicines management has huge, as yet largely huge, as yet largely undeveloped, potential to undeveloped, potential to ensure quality and ensure quality and effectiveness at new and effectiveness at new and existing interfacesexisting interfaces

Pharmacists are the Pharmacists are the experts in all experts in all aspects of aspects of medicines usemedicines use

Sue Carter BPC 2005

Medicines Management

Medicines managementMedicines management is a is a broad term which encompasses broad term which encompasses every aspect of use of medicines every aspect of use of medicines at both organisational and at both organisational and individual patient level individual patient level

Sue Carter BPC 2005

Medicines Management

Service improvement & Service improvement & demand management demand management

Policy, strategy and Policy, strategy and performance performance management management

Budgets, incentives & Budgets, incentives & monitoringmonitoring

Statutory Statutory responsibilities & legal responsibilities & legal framework framework

Workforce planning & Workforce planning & skillmixskillmix

Rational prescribing Rational prescribing Clinical governanceClinical governance Dispensing Dispensing Access to medicinesAccess to medicines Patient-centred Patient-centred

medication reviewmedication review Concordance, Concordance,

compliance & patient compliance & patient partnership / supportpartnership / support

Sue Carter BPC 2005

Evolved Approach to Medicines

Proactive, patient-centred and systematic Proactive, patient-centred and systematic approach to medicines approach to medicines Patient partnership for improved self-carePatient partnership for improved self-care

Stratifying patient population to identify high Stratifying patient population to identify high riskrisk

Individualised care plan to prevent adverse Individualised care plan to prevent adverse event & improve outcomes, based on need, event & improve outcomes, based on need, preference & choicepreference & choice Pharmaceutical carePharmaceutical care

Service redesignService redesign Opportunities in new contractsOpportunities in new contracts

Sue Carter BPC 2005

Medicines Management – Ensuring Quality and Effectiveness

Make sure it is -Make sure it is - SafeSafe EffectiveEffective EfficientEfficient SystematicSystematic Needs basedNeeds based Patient centredPatient centred

AccessibleAccessible MultidisciplinaryMultidisciplinary IntegratedIntegrated SustainableSustainable Supported with Supported with

clinical leadershipclinical leadership

Sue Carter BPC 2005

Safe – Guidelines & Protocols

Prescribing by new groups Prescribing by new groups of professionalsof professionals

NHS increasingly protocol / NHS increasingly protocol / guideline drivenguideline driven NICE guidance and NICE guidance and

guidelinesguidelines NSF standardsNSF standards ProdigyProdigy NHS directNHS direct Local health economiesLocal health economies

Performance management Performance management - healthcare commission- healthcare commission

Joint formulariesJoint formularies Practice formulariesPractice formularies Reviews and adviceReviews and advice Formal local guidelinesFormal local guidelines

DevelopmentDevelopment ConsultationConsultation ImplementationImplementation MonitoringMonitoring AuditAudit

Shared care guidelinesShared care guidelines

Sue Carter BPC 2005

Effective

Evidence based practiceEvidence based practice Only part of decision makingOnly part of decision making

Monitor outcomesMonitor outcomes AdmissionsAdmissions Quality and outcome frameworkQuality and outcome framework Spend or prescribing patternsSpend or prescribing patterns InterventionsInterventions Pharmaceutical care – record outcomes!Pharmaceutical care – record outcomes!

Sue Carter BPC 2005

Systematic

PractitionerPractitioner Assess, plan, evaluateAssess, plan, evaluate Ongoing – not just a Ongoing – not just a

single point reviewsingle point review Identify problems, Identify problems,

implement plan to avoid implement plan to avoid or monitor for problemsor monitor for problems

Set therapeutic goals for Set therapeutic goals for each drugeach drug

Pharmacist (or Pharmacist (or ‘practitioner’) takes ‘practitioner’) takes responsibility for responsibility for outcomesoutcomes

CommissionerCommissioner StrategyStrategy Equity of accessEquity of access MonitoringMonitoring Clinical governanceClinical governance ResourcesResources Workforce Workforce

developmentdevelopment

Sue Carter BPC 2005

Medicines are unique as a clinical interventionMedicines are unique as a clinical intervention Vast majority are self (or carer) administeredVast majority are self (or carer) administered …….And so factors other than disease .And so factors other than disease

prevalence dictate the need for careprevalence dictate the need for care Prioritisation should be based on agreed valuesPrioritisation should be based on agreed values Stratified approachStratified approach Patient and public involvement Patient and public involvement Equity, fairness, effectiveness, cost – Equity, fairness, effectiveness, cost –

Health needs assessmentsHealth needs assessments Health equity auditHealth equity audit Systematic prioritisationSystematic prioritisation

Needs Based

Sue Carter BPC 2005

Patient Partnership in Medicine Taking Empowering patients to take an active role in Empowering patients to take an active role in

managing their own care.managing their own care. Prescribing needs to be based on an Prescribing needs to be based on an

agreement between the patient and the health agreement between the patient and the health care professional.care professional.

Pharmacists can help in this processPharmacists can help in this process educating about treatments and options educating about treatments and options interpreting and explaining risks and interpreting and explaining risks and

benefitsbenefits Proactive support & resource to patientsProactive support & resource to patients

Sue Carter BPC 2005

Accessible - Services

Pharmaceutical services Pharmaceutical services distribution distribution Contract regulation Contract regulation

reformreform Competition & choiceCompetition & choice WorkforceWorkforce Commercial pressureCommercial pressure Professional pressureProfessional pressure Local pharmaceutical Local pharmaceutical

servicesservices ResourcesResources

Out of hoursOut of hours Pharmacists and Pharmacists and

NHS directNHS direct Dispensing out-of-Dispensing out-of-

hourshours Access to Access to

pharmaceutical pharmaceutical carecare

Supporting self-careSupporting self-care Minor ailmentsMinor ailments

Sue Carter BPC 2005

Accessible - Medicines

Patient group directionsPatient group directions POM to PPOM to P P to GSL?P to GSL? Walk-in centresWalk-in centres One-stop primary care One-stop primary care

centrescentres Health centre Health centre

pharmacies v. High pharmacies v. High streetstreet

Electronic prescribing &Electronic prescribing & e-pharmacy e-pharmacy

Non-medical prescribingNon-medical prescribing Supporting self-careSupporting self-care

Sue Carter BPC 2005

Integrated

Consistent approach – driven by policy, Consistent approach – driven by policy, protocol, standards etcprotocol, standards etc

Responsibilities clearly definedResponsibilities clearly defined ……And accountability (duty of care?)And accountability (duty of care?) Communication should be effective, Communication should be effective,

efficient and responsive – but not as easy efficient and responsive – but not as easy as it seems!as it seems!

Single assessment – develop national SAP Single assessment – develop national SAP for medicines?for medicines?

Sue Carter BPC 2005

How Are Primary Care Pharmacists Dealing With the Agenda? Practice, locality commissioning Practice, locality commissioning

board, (new) PCT levelsboard, (new) PCT levels All have operational and strategic All have operational and strategic

need for primary care pharmacistsneed for primary care pharmacists Additional statutory roles at PCT Additional statutory roles at PCT

levellevel

Sue Carter BPC 2005

Primary Care TrustFewer, larger PCTsFewer, larger PCTs PCT-wide cross-health PCT-wide cross-health

economy engagementeconomy engagement Co-ordination of local Co-ordination of local

health economy health economy medicine-related medicine-related policiespolicies

Performance Performance ManagementManagement

Interface medicines Interface medicines managementmanagement

Primary care Primary care contractingcontracting

Procurement initiativesProcurement initiatives Shared care Shared care Influencing clinical Influencing clinical

practicepractice Workforce Workforce

developmentdevelopment Policy development & Policy development &

implementationimplementation Statutory rolesStatutory roles Local delivery plan / Local delivery plan /

priorities planning / priorities planning / horizon scanninghorizon scanning

Sue Carter BPC 2005

Locality Commissioning Board Commissioning – Commissioning –

medicines issuesmedicines issues Service redesign – Service redesign –

secondary to primary secondary to primary care shiftcare shift

Demand managementDemand management Performance Performance

managementmanagement Repeat Prescribing Repeat Prescribing

Review Review Practice prescribing Practice prescribing

analysis analysis

Audit SupportAudit Support E.g. NSAIDs, E.g. NSAIDs,

Asthma, Statins, Asthma, Statins, NewsletterNewsletter Local health economy Local health economy

formulary formulary development & development & supportsupport

Proactive and reactive Proactive and reactive adviceadvice

Local interface issuesLocal interface issues

Sue Carter BPC 2005

GP Practice nGMS general nGMS general

involvementinvolvement Input to QOF and Input to QOF and

assessmentsassessments Practice visits & 3 Practice visits & 3

agreed action points agreed action points Many medicines issuesMany medicines issues

Repeat Prescribing & Repeat Prescribing & other practice other practice systemssystems

Provision of patient Provision of patient centred medicines centred medicines services services

Practice prescribing Practice prescribing analysis analysis

Audit SupportAudit Support Internal practice Internal practice

formulary formulary development & development & supportsupport

Proactive and Proactive and reactive advicereactive advice

Interface issuesInterface issues

Sue Carter BPC 2005

Targeted Medicines Management

POPULATION APPROACH - HEALTH PROMOTION AND SELF-CARE

ONE - MAJORITY OF PATIENTS TAKING MEDICINES FOR LONG TERM CONDITIONS

TWO - HIGH RISK PATIENTS

THREE - HIGHLY COMPLEX

PATIENTS

Level 1 – population managementLevel 1 – population management Supporting self-careSupporting self-careLevel 2 – care managementLevel 2 – care management Disease specific interventions Disease specific interventions

for at-risk groupsfor at-risk groups Supporting patients to optimise Supporting patients to optimise

medicines usemedicines use Pharmacists with special Pharmacists with special

interest interest - e.g. as disease-specific care - e.g. as disease-specific care managersmanagers

Level 3 – case management Level 3 – case management E.g. Targeted medicines E.g. Targeted medicines

support at dischargesupport at discharge Proactive pharmaceutical careProactive pharmaceutical care

Sue Carter BPC 2005

The New Pharmacy Contract – Major Themes

1.1. Support for self-careSupport for self-care

2.2. Management of long-term Management of long-term conditions (CDM)conditions (CDM)

3.3. Public Health – health Public Health – health promotion pluspromotion plus

Sue Carter BPC 2005

Strategic DirectionStrategic Direction Investment to help older people keep Investment to help older people keep

healthier at home for longerhealthier at home for longer Intensive case management - “Evercare”Intensive case management - “Evercare” CDM - better, stratified care for people with CDM - better, stratified care for people with

long term illness – ‘care closer to patient’long term illness – ‘care closer to patient’ Developing services in community & Developing services in community &

primary care settings – secondary to primary care settings – secondary to primary shiftprimary shift

New organisational systems, structures New organisational systems, structures and processes – clinical governance & risk and processes – clinical governance & risk managementmanagement

Multidisciplinary focusMultidisciplinary focus

Sue Carter BPC 2005

Some Points to Ponder ... How will future primary care led self-care, How will future primary care led self-care,

disease management and medicines disease management and medicines management initiatives impact on pharmacy management initiatives impact on pharmacy workforce and workload?workforce and workload?

Can better use of skillmix make enough Can better use of skillmix make enough difference?difference?

Will the forthcoming white paper take some of Will the forthcoming white paper take some of these issues on?these issues on?

Can quality and effectiveness at interfaces be Can quality and effectiveness at interfaces be ensured in an NHS with constantly shifting ensured in an NHS with constantly shifting structures, ‘rules’ and personnel?structures, ‘rules’ and personnel?