1. Integrating the Chronic Medication Service in primary care
Professor Alison Strath
Principal Pharmaceutical Officer
Scottish Government

2. Objectives Brief outline of service
Benefits for patients & healthcare professionals
Progress to date
Putting it into context
Summary
I will cover five objectives in this short presentation on the Chronic Medication Service which is one of four core services within the Scottish community pharmacy contract.
I will provide:
A brief outline of the service
Describe the benefits of the service for patients and GP practices
Outline the progress to date i
Share the proposed next steps
Finish with a short summary.

3. Building on the Evidence
Prescribing
At least 5.2% of items are never cashed in
Compliance / concordance
non-adherence 30-50%
3%-7% of hospital admission due to ADR & can be as high as 30%
Pharmaceutical care model schemes
Paper based repeat dispensing
The Ritchie report

4. Most importantly….. Not duplicating effort
Playing to the strengths of each profession
Paying attention to lessons learnt from elsewhere

5. Chronic Medication Service
Description
A system of personalised pharmaceutical care to patients with long term medical conditions.
Purpose
To ensure patients obtain optimal therapeutic benefit from their medicines and minimise any predictable undesirable effects.

6. Brief outline of service
Stage 1 Patient registration Community pharmacy
Prioritise by assessment
Stage 2 Pharmaceutical Identifying pharmaceutical care planning problems
Agreeing outcomes
Documenting practice
Communication with practices
Stage 3 Therapeutic Serial prescribing & partnership dispensing
Generic protocol
Electronic feedback
The Chronic Medication Service formalises the role of community pharmacists in helping patients with long term conditions achieve the best outcomes from their medicines and minimise the risk of adverse reactions. There are three stages to CMS.
The first stage is patient registration which is voluntary, occurs at the community pharmacy and is underpinned by informed patient consent. To be eligible to register for the service a patient must have a long term condition and be registered with a Scottish GP practice. Patients in Care Homes and Temporary Residents are not eligible at this time.
Registering a patient for CMS in the pharmacy automatically sends a CMS patient registration notification message to the patient’s GP practice informing the practice that the patient has registered for the service and providing the details of the pharmacy where they have registered. This message is flagged in the patient record and acts as a trigger to let the GP know that they can generate a serial prescription – if appropriate – for the patient. Registration for the service does not guarantee a patient will receive a serial prescription – that is for the GP to decide. There may be some patients who are not suitable for a serial prescription and others where the GP thinks yes – but just not at this time. The CMS registration notification messages are currently disabled and I will come back to the reason for this later.
As part of the registration process a community pharmacist undertakes a pharmaceutical assessment of the patient and their medicines in order to help identify and prioritise those patients who would benefit from stage 2 of the service – the pharmaceutical care planning element.
The second stage of CMS introduces pharmaceutical care planning where the pharmacist works with the patient to identify and prioritise any problems or issues they are experiencing with their medicines, agree desired outcomes and decide the action/s required to deliver the outcomes. These are documented in a pharmaceutical care plan which is then monitored and reviewed. A patient is given their own personal copy of their pharmaceutical care plan. However not every patient who registers for CMS will receive a care plan.
The third stage of CMS establishes the therapeutic partnership or shared care element which allows the GP to produce a 24 or 48 week serial prescription for a patient which is dispensed at appropriate time intervals determined by the GP. Initially the only patients eligible for serial prescriptions are those who are exempt on the basis of age or medical exemption status – however the GP IT system will only flag eligible patients. Information detailing the date of a dispensing event for a CMS serial prescription item is automatically sent back to the GP practice electronically after each serial dispensing episode. Stage 3 is supported by a generic CMS protocol which outlines any specific reporting or referral criteria. Once the last instalment from the serial prescription has been dispensed the pharmacist electronically sends an end-of-care treatment summary to the practice – which can include a serial prescription renewal request.

7. Stage 1: Patient Registration (CP)
Patient registers with pharmacy of their choice
Register via the Patient Registration System (PRS)
Underpinned by explicit patient consent
Eligibility:
Patient must be registered with a Scottish GP practice
Patient must have a long term condition/s
Not resident in a Care Home
Patient can withdraw at any point 7

8. Stage 1: Patient Registration (GP)
Electronic CMS registration notification message is picked up by the GP IT system
Patient record is flagged
registered for CMS
pharmacy details
GP IT system can be used to flag suitable patients for CMS serial prescriptions
Patient registration withdrawal notified to GP practice 8

9. Stage 1: Pharmaceutical Assessment (CP)
Completed within 3 months of registration
Supported by a web based care planning tool
Pharmacy Care Record
Assists in determining the necessity for a personalised pharmaceutical care plan to complement wider care plan

10. Stage 2: Pharmaceutical Care Plan (CP)
The patient and pharmacist
identify any issues / problems with medicines
establish desired outcomes
agree any actions to address them
The pharmacist
documents the issues, desired outcomes and actions in the Pharmacy Care Record
monitors, reviews and updates progress 10

11. PCR Individual Care Issue

12. Stage 3: Serial prescribing & dispensing
Eligibility based on age or medical exemption initially
The patient’s GP
decides on their suitability for a serial prescription
selects the medication term (24- or 48- weeks)
selects dispensing intervals (e.g. every 8- weeks)
The pharmacist
retains the serial prescription
dispenses the prescription according to defined intervals
Feedback
dispensing information with each dispensing episode
end of care treatment summary information
dispensing information and any specific relevant care information
can include a request for new serial prescription 12

13. Benefits Patients Improved continuity of care
Increased focus on pharmaceutical interventions, outcomes & concordance
Promotion of self care
Easier patient journey
Healthcare professionals
Patient safety
Prescription administration decreased & improved audit trail
Appropriate utilisation of the workforce
Improved multi-professional working & communications
There are a number of benefits for patients and GP practices as a result of introducing CMS.
For patients they include:
Improved continuity of care through the documentation of pharmacy practice
An increased focus on pharmaceutical interventions, outcomes and concordance rather than purely a focus on the dispensing and supply of medicines – a more proactive rather than reactive role for pharmacists
The promotion of self care by encouraging a holistic approach
An easier patient journey in terms of accessing medication through serial prescribing and dispensing
For GP practices they include:
A focus on patient safety – for example a practice will know which pharmacy a patient has registered with
Prescription administration workload is decreased with an improved audit trail including feedback to the practice on what has been dispensed for a patient as opposed to only prescribed
Appropriate utilisation of the practice team workforce
Improved multi-professional working and communications.

14. Progress to date GP CMS software installed
and in some cases enabled
CP software installed and enabled
Pharmacy Care Record available
Nationally GP CMS registration notification messages disabled
Implementation phase
National CMS Reference Group
Turning now to local progress on CMS:
CMS software for both Vision and EMIS has already been installed in GP practices across Tayside. Vision requires an additional step to enable it in the practice and the facilitation team will support this activity across GP practices.
I mentioned earlier that the GP CMS registration notification messages are currently disabled on a national basis. There are two reasons for this:
Firstly to give Boards time to roll out and enable CMS software to practices; and
Secondly to support the majority of NHS Boards who are currently embarking on GP IT replacement programmes. The ePharmacy Team want to be able to assure practices that CMS data will migrate like any other data. To this end, they are currently working with EMIS and Vision to test this. Once proven a decision will be made about enabling the registration messages to flow to all GP practices.
In Tayside we have worked with patients, GPs and their practice staff and community pharmacists to undertake a benefits realisation exercise which has helped us to develop an implementation plan for rolling out CMS. One key element of this is the establishment of some early adopter sites to support the successful implementation of the service
We have also undertaken a number of presentations to key stakeholder groups such as the GP Sub-committee of the LMC and the Area Pharmaceutical Committee and provided a number of community pharmacy local awareness events.

15. Next steps
Establish a number of serial prescribing & dispensing early adopter sites to:
establish training requirements
consider working processes
resolve any exception scenarios
document and share best practice
establish local champions
feedback to key stakeholders
Board-wide implementation plan
appropriate training and roll out
facilitate communications between GP practices and community pharmacies
In terms of next steps:
We will be offering individual practices further communications on CMS either through presentation by either the local practice pharmacist or myself
We will also be establishing a number of early adopter sites in Tayside and we will be working with them to:
Test our training plans in order to establish a robust training programme for rolling out CMS to all GP practices in Tayside
Establish the working processes that underpin successful delivery of CMS
Resolve any exception scenarios that we come across such as dealing with hospital discharges and changes to medication on a serial prescription
Document and share best practice related to providing CMS
Establish local champions to provide peer support as part of local implementation plans and to
Develop feedback to key stakeholders
This work with the Early Adopter sites will assist us in finalising a Tayside-wide implementation plan and ensure that we can roll the service out to all practices with appropriate training and identified working processes.
We will also facilitate communications between GP practices and community pharmacies as they start to embark on stage 3 of CMS.

16. Putting it into context
For patients with COPD:
symptom control
side effects
inhaler technique
oxygen
smoking status (link to smoking cessation)
vaccinations

17. Summary CMS is a model which: is patient centred
promotes patient safety
is focused on promoting self care
enhances multi-professional working
provides the opportunity to enhance QOF and patient outcomes
formalises the role of community pharmacists within the primary care team
Summarising - CMS is a model which:
is patient centred and promotes patient safety in line with the core objectives in the Quality Strategy
is focused on promoting self care with pharmacists providing a holistic approach to patient care as part of the extended healthcare team
enhances multi-professional working by introducing the concept of therapeutic partnerships between a patient, their GP and their community pharmacist and electronic communications between practices and pharmacies
And provides the opportunity to enhance QOF and patient outcomes.
Thank you.