1. Private and confidential Community Pharmacy Future Four-or-more medicines support service Update on progress and next steps Approved18 th June 2012 This version6 th July 2012 For amendments, please contact Jonathan Buisson, Alliance Boots

2. Private and confidential NHS commissioners are changing focus and looking to providers (including community pharmacies) to demonstrate that they are making real improvements to patient outcomes. Evidence of better outcomes will influence future commissioning and funding. The Community Pharmacy Future project, which is being funded by the four largest pharmacy multiples, is aiming to demonstrate how community pharmacies can make a difference to patients using medicines for long-term conditions, in ways that are complementary to other NHS services. The results from the planned pharmacy implementation phase will be evaluated by health economists to show the benefits that can be derived. The new NHS Commissioning Board will control the community pharmacy contract for England from April 2013. Our objective is to gather powerful evidence that will convince the Board to commission new national services through community pharmacies. Our work will also inform the development of pharmacy services outside England. Community pharmacy future – why are we doing this? 1

3. Private and confidential Four-or-more: why we selected this pathway Persons aged over 65 years old taking four-or-more medicines (Four-or-more) Patients in this group may have more than one long-term condition They make extensive use of NHS resources but may not be getting optimal use from the medicines they have been prescribed Care of people with long-term conditions accounts for 70% of health and social care budget The Department of Health is developing its strategy for long-term conditions There are large opportunities for reducing medicines waste in this group We have developed STOPP START criteria that focus on prescribing for older persons These patients already extensive users of pharmacies, but the pharmaceutical care they receive may not be optimal for delivering the best outcomes 2 Private and confidential

4. STOPP START criteria STOPP – Screening Tool of Older Persons’ potentially inappropriate Prescriptions 65 indicators relating to drug interactions and therapeutic duplication START – Screening Tool to Alert to Right (appropriate, indicated) Treatment 22 indicators of common prescribing omissions Clinically-validated, evidence-based indicators for appropriate prescribing in over-65s Developed and trialled by Cork University Hospital and University College Cork 1 Produces significant and sustained improvements in prescribing appropriateness The four-or-more service uses 31 STOPP criteria and 2 START criteria This selected sub-set of STOPP START indicators is appropriate for interventions made by community pharmacists using the clinical data from their own patient records 1. Gallagher, PF et al. Prevention of potentially inappropriate prescribing for elderly patients: a randomised controlled trial using STOPP/START criteria. Clin Pharmacol Ther 2011; 89: 845-54. 3 Private and confidential

5. Patient recruitment and initial assessment Patient enrols onto the service – this can be via the pharmacy or by healthcare professional referral. Baseline information is collected and the patient is issued with a ‘patient personal record’ which details the patients repeat medication and due dates. The baseline information also allows the pharmacist to decide whether the patient would benefit from any public health services including smoking cessation and weight management. Pharmacist reviews the patients medication in line with the STOPP START rules and discusses potential issues with the patient’s GP. Pharmacist also identifies whether the patient requires any specific support in relation to their medicines, eg, falls risk or pain management, and schedules a follow up where required. Regular assessment Patient collects their prescription regularly. The pharmacist carries out a quick review checking for any signs of compliance issues. Any changes to medication are reviewed in line with the STOPP START rules. Annual medicines use review Each year the pharmacist will schedule an appointment with the patient to carry out a medicines use review. This will incorporate a more detailed conversation around the use of medicines and will identify any medicines use issues. Where appropriate further support will be provided to help achieve compliance. An action plan will be agreed and where considerable medicines issues arise regular follow-up will be scheduled. If appropriate a MUR with the patient’s carer will take place to help aid medicines administration. Annual assessment 12 months post recruitment an annual assessment is carried out with the patient. Outcomes measures will be recorded and certain measures such as smoking status will be retaken. If appropriate to the time of year, seasonal issues will be discussed including vaccination. 4 Four-or-more: the patient’s journey through the year

6. Private and confidential Four-or-more – Wigan Borough area (c30 pharmacies) Area chosen after analysis of demographic data Implementation to start from 17 th September 2012 for an initial six months The service has been presented to the Local Pharmaceutical Committee Local NHS organisations, local authorities and clinical groups are being engaged There will be full training for our pharmacy teams prior to launch Further details will be shared as they are available Pharmacy implementation – next steps 5

7. Private and confidential For Boots: Kath Gulson (T: 07834 497427; E: kath.gulson@boots.co.uk For the Co-operative Pharmacy Catherine Cox (T: 07713 315065; E: catherine.cox@co-operative.coop) For Lloydspharmacy Shaun Fernandes (T: 07795 335581; E: shaun.fernandes@lloydspharmacy.co.uk) For Rowlands Pharmacy Nicky Grundy (T: 07717 580889; E: ngrundy@rowlandspharmacy.co.uk) Contact details 6