Locality Clinical Pharmacy Pilot in the West New Forest Vanguard Ginny Ward, Helen Plumb, Sally Johnston 2nd November 2016

West New Forest Vanguard 7 practices included

Aims of the Pilot Supplement and complement the current services to provide Fully-integrated, primary-care-embedded medicines optimisation service, where Clinical medication review particularly for the frail elderly is a priority and With a move to being a much more patient-facing role Supplement and complement the current pharmacy services to develop a fully integrated service across the South West New Forest area which is embedded in primary care Focus on undertaking clinical medication review of high risk patients e.g. frailty, patients with multiple LTCs, care home residents and patients at high risk of admission to hospital and becoming an integral part of the discharge process for vulnerable patients with medicines issues Work with local community pharmacists to support effective use of medicines, along with the provision of integrated pharmaceutical input into the seven practices

Traditional role of Medicines Management in primary care WHCCG Workplan 16/17 (Meds Optimisation Incentive Scheme) cost and quality initiatives including deprescribing problematic polypharmacy Other Financial Recovery Plan savings Other quality and safety issues (e.g. MHRA alerts) Medicines queries from practices and prescribers As 0.67wte pharmacist and 0.5wte technician across 8 practices

Team working across the 7 Vanguard practices Increased to allow approx. 2-3 days a week of clinically-focussed pharmacist input to each practice and doubled technician input We see the “extended roles” as an important and natural development (e.g. in 2014/16 approx 2,500 problematic medicines for elderly patients were de-prescribed in conjunction with prctices and prescribers across the whole CCG area)

3 interlinked and important aspects to balance BLC outcome priorities GP workload priorities CCG sustainability priorities

Working in practices identify areas for improvement repeat prescribing-including problem-solving for individual patients and increasing use of e-prescribing to reduce workload contribute to medicines integrated care team work provide clinic sessions and domiciliary visits (special interest/independent prescribers) resolve queries, provide general medication reviews WHCCG MO Workplan 16/17 cost /quality & safety interventions other FRP-related savings / quality and safety issues (e.g. MHRA, SIRIs)

Working with Hospital Trusts seamless care on admission and discharge liaison with Interface Pharmacist and follow-up outpatient ‘red/amber’-status medication queries medicines reconciliation on admission & discharge working with hospital pharmacy (medication reviews pre-admission and post-discharge)

Working with local Community Pharmacies liaise around supply (problems and alternatives) and discharge issues particularly e.g. MDS for individuals review managed repeat over-ordering especially PRNs, inhalers and skin products reduce waste from unnecessary repeats requested encourage practices to highlight patients for New Medicines Service and MURs

Working with Nursing Homes focus on clinical medication reviews and appropriate de-prescribing of problematic medicines develop ability to perform basic clinical assessment – e.g. BP, pulse etc. advice on appropriate sip feeds (nutrition) and dressings use forms advice on practical aspects of medicines use e.g. PEG tubes or swallowing difficulties review ordering processes and prevent unnecessary ordering e.g. PRNs ordered regularly

The 7 Practices individualised “Top 5” focus nursing homes: med reviews on admission, and relating to falls, annual reviews, sip feeds, ordering and reducing waste other med reviews: polypharmacy in frail elderly, post discharge, from virtual ward/ICT monitoring high risk drugs up-titrating/ follow-up of meds changes meds reconciliation admission/ discharge domiciliary visits for housebound if needed repeat prescribing: dealing with queries, reviewing processes and systems and managed repeats to reduce waste liaising with community pharmacies about out-of-stocks, ordering and problems

Where are we now? “Go-live dates” First month joint induction One practice 19th September 2016 Two practices 26th September 2016 Two practices 17th October 2016 One practice 31st October 2016 First month joint induction

FAQs How will these roles be recruited and what say will practices have? Joint interviews with two of the BLC GPs Discussed priorities with practices prior interview Who is setting their objectives? Jointly between CCG Meds Optimisation team and the lead GP/Practice Manager in the practice Won’t it increase GP workload and queries? Aim is to reduce not increase workload but inevitably there may be an embedding process during induction phase

FAQs Insurance liability Does not fall on the practice – CCG vicarious liability for activities in Job Description and most have own professional indemnity as well Are there advantages in being hosted by CCG team? Yes. Back up from wider team includes formulary support, DPC, commissioning of high cost drugs, provides professional support and leadership, avoids duplication, promotes networking etc.

The Pharmacist Perspective : 6 weeks in Mrs Helen Plumb Medicines Optimisation Pharmacist Wistaria and Milford Surgery West Hampshire CCG

The GP Perspective : 6 weeks in Dr Sally Johnston GP Chawton House Surgery, Lymington Clinical Lead, West Hants MCP (BLC)