1. How Pharmaceutical Advisers Can Ensure Quality and Effectiveness at the Interfaces Sue Carter MRPharmS Head of Prescribing & Pharmacy, Adur, Arun & Worthing tPCT And Co-Founder, Primary Care Pharmacists’ Association

2. 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 pharmacy issues? What are the medicines and pharmacy issues? How can those issues be addressed by primary care pharmacists? How can those issues be addressed by primary care pharmacists? Some points to ponder Some points to ponder

3. Sue Carter BPC 2005 Interfaces – Where (and What) Are They? Classical description – when a patient goes into or comes out of NHS hospital – elective and non- elective Classical description – when a patient goes into or comes out of NHS hospital – elective and non- elective …. But also out-patient activity and out-reach …. But also out-patient activity and out-reach …. And also social care, intermediate care, self-care …. And also social care, intermediate care, self-care …. And also out-of-hours services …. And also out-of-hours services …. And also private providers …. And also private providers Communication Communication  Pharmacists  GPs  patients  secondary care  social care  community healthcare  health service managers

4. Sue Carter BPC 2005 Interface Discharge & admission Discharge & admission  Communication  Local guidelines  Integrated medicines review as part of seamless patient care  GP medical records Ensuring quality of care and managing risk Ensuring quality of care and managing risk Shared care Shared care  Shared care guidelines  Prescribing responsibility  Monitoring  Service redesign Policies – D&TC, APC, Policies – D&TC, APC, Formulary Formulary Service level agreements Service level agreements

5. Sue Carter BPC 2005 Policy Changes: the Road Ahead Patient choice = plurality Patient choice = plurality Chronic disease management & managed care Chronic disease management & managed care Primary care contracting & innovation Primary care contracting & innovation Payment by results & tariffs – foundation trusts Payment by results & tariffs – foundation trusts Service modernisation – secondary to community shift, tier 2 services, Service modernisation – secondary to community shift, tier 2 services, Non-medical prescribing Non-medical prescribing Practice based commissioning Practice based commissioning Demand management & resource management Demand management & resource management

6. Intermediate care Primary Care pharmacy Social care Hospital Pharmacy GP Surgery Community Pharmacy Admission & Discharge Home & Self Care Secondary care Tertiary care

7. 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

9. Intermediate care Primary care pharmacy Social care Hospital Pharmacy GP Surgery Community Pharmacy Admission & Discharge Home & Self Care

10. Sue Carter BPC 2005 Where Do Medicines & Pharmacy Fit? 4 in 5 over 75s take at least one medicine and 36% of them take 4 or more 4 in 5 over 75s take at least one medicine and 36% of them take 4 or more Half of people with long term conditions fail to take medicines properly Half of people with long term conditions fail to take medicines properly 5 to 17% of hospital admissions may be due to older people’s problems with medicines 5 to 17% of hospital admissions may be due to older people’s problems with medicines …. And while in hospital 6 to 17% will experience an adverse drug reaction …. And while in hospital 6 to 17% will experience an adverse drug reaction

11. Sue Carter BPC 2005 Where Do Medicines & Pharmacy Fit? USA evidence Estimated 44k to 98k deaths per year due to medication errors (including adverse drug events) Estimated 44k to 98k deaths per year due to medication errors (including adverse drug events) 6 th most common cause of death in the USA (higher than RTAs, suicide, homicide and AIDS) 6 th most common cause of death in the USA (higher than RTAs, suicide, homicide and AIDS) Costs estimated at 76.6 billion dollars per annum in the USA Costs estimated at 76.6 billion dollars per annum in the USA (Ref: JAMA 2002; 9:479-490) USA long term condition managed care outcomes:  Decreased use of medicines with benefits to health  Reduced medicines- related adverse events  39% of patients incr. compliance with medication

12. Sue Carter BPC 2005 Where Do Medicines & Pharmacy Fit? UK - Importance of ADRs Estimated to take up 4 out of 100 hospital bed days Estimated to take up 4 out of 100 hospital bed days Estimated 15 to 20 x 400 bed hospital equivalents Estimated 15 to 20 x 400 bed hospital equivalents Annual UK cost £380 million per year Annual UK cost £380 million per year One in 10 of all NHS bed days are taken up by consequences of ADR or hospital-acquired infection One in 10 of all NHS bed days are taken up by consequences of ADR or hospital-acquired infection (ref: Bandolier Extra, June 2002, Adverse Drug Reactions in Hospital Patients: A systematic review of the prospective and retrospective studies. Whiffen P, Gill M, Edwards J, Moore A. www.ebandolier.com) Has led to UK focus on managed care, community matrons, transforming long term care programmes, etc Medicines management has huge, as yet largely undeveloped, potential to ensure quality and effectiveness at new and existing interfaces Pharmacists are the experts in all aspects of medicines use

13. Sue Carter BPC 2005 Medicines Management Medicines management is a broad term which encompasses every aspect of use of medicines at both organisational and individual patient level

14. Sue Carter BPC 2005 Medicines Management Service improvement & demand management Service improvement & demand management Policy, strategy and performance management Policy, strategy and performance management Budgets, incentives & monitoring Budgets, incentives & monitoring Statutory responsibilities & legal framework Statutory responsibilities & legal framework Workforce planning & skillmix Workforce planning & skillmix Rational prescribing Rational prescribing Clinical governance Clinical governance Dispensing Dispensing Access to medicines Access to medicines Patient-centred medication review Patient-centred medication review Concordance, compliance & patient partnership / support Concordance, compliance & patient partnership / support

15. Sue Carter BPC 2005 Evolved Approach to Medicines Proactive, patient-centred and systematic approach to medicines Proactive, patient-centred and systematic approach to medicines  Patient partnership for improved self-care Stratifying patient population to identify high risk Stratifying patient population to identify high risk Individualised care plan to prevent adverse event & improve outcomes, based on need, preference & choice Individualised care plan to prevent adverse event & improve outcomes, based on need, preference & choice  Pharmaceutical care Service redesign Service redesign  Opportunities in new contracts

16. Sue Carter BPC 2005 Medicines Management – Ensuring Quality and Effectiveness Make sure it is - Safe Safe Effective Effective Efficient Efficient Systematic Systematic Needs based Needs based Patient centred Patient centred Accessible Accessible Multidisciplinary Multidisciplinary Integrated Integrated Sustainable Sustainable Supported with clinical leadership Supported with clinical leadership

17. Sue Carter BPC 2005 Safe – Guidelines & Protocols Prescribing by new groups of professionals Prescribing by new groups of professionals NHS increasingly protocol / guideline driven NHS increasingly protocol / guideline driven  NICE guidance and guidelines  NSF standards  Prodigy  NHS direct  Local health economies Performance management - healthcare commission Performance management - healthcare commission Joint formularies Joint formularies Practice formularies Practice formularies Reviews and advice Reviews and advice Formal local guidelines Formal local guidelines  Development  Consultation  Implementation  Monitoring  Audit Shared care guidelines Shared care guidelines

18. Sue Carter BPC 2005 Effective Evidence based practice Evidence based practice  Only part of decision making Monitor outcomes Monitor outcomes  Admissions  Quality and outcome framework  Spend or prescribing patterns  Interventions  Pharmaceutical care – record outcomes!

19. Sue Carter BPC 2005 Efficient Target the right service to those that need it most Target the right service to those that need it most Avoid unnecessary duplication Avoid unnecessary duplication Integrate complementary services across a health economy for maximum effect Integrate complementary services across a health economy for maximum effect Develop IT systems Develop IT systems Take a patient focussed approach – Take a patient focussed approach – Elderly diabetic asthmatics develop CHD!

20. Sue Carter BPC 2005 Targeted Medicines Management

21. Sue Carter BPC 2005 Systematic Practitioner Assess, plan, evaluate Assess, plan, evaluate Ongoing – not just a single point review Ongoing – not just a single point review Identify problems, implement plan to avoid or monitor for problems Identify problems, implement plan to avoid or monitor for problems Set therapeutic goals for each drug Set therapeutic goals for each drug Pharmacist (or ‘practitioner’) takes responsibility for outcomes Pharmacist (or ‘practitioner’) takes responsibility for outcomesCommissioner Strategy Strategy Equity of access Equity of access Monitoring Monitoring Clinical governance Clinical governance Resources Resources Workforce development Workforce development

22. Sue Carter BPC 2005 Medicines are unique as a clinical intervention Medicines are unique as a clinical intervention  Vast majority are self (or carer) administered  ….And so factors other than disease prevalence dictate the need for care Prioritisation should be based on agreed values Prioritisation should be based on agreed values Stratified approach Stratified approach Patient and public involvement Patient and public involvement Equity, fairness, effectiveness, cost – Equity, fairness, effectiveness, cost –  Health needs assessments  Health equity audit  Systematic prioritisation Needs Based

23. Sue Carter BPC 2005 Patient Partnership in Medicine Taking Empowering patients to take an active role in managing their own care. Empowering patients to take an active role in managing their own care. Prescribing needs to be based on an agreement between the patient and the health care professional. Prescribing needs to be based on an agreement between the patient and the health care professional. Pharmacists can help in this process Pharmacists can help in this process  educating about treatments and options  interpreting and explaining risks and benefits  Proactive support & resource to patients

24. Sue Carter BPC 2005 Accessible - Services Pharmaceutical services distribution Pharmaceutical services distribution  Contract regulation reform  Competition & choice  Workforce  Commercial pressure  Professional pressure  Local pharmaceutical services  Resources Out of hours Out of hours  Pharmacists and NHS direct  Dispensing out-of- hours  Access to pharmaceutical care  Supporting self-care  Minor ailments

25. Sue Carter BPC 2005 Accessible - Medicines Patient group directions Patient group directions POM to P POM to P P to GSL? P to GSL? Walk-in centres Walk-in centres One-stop primary care centres One-stop primary care centres Health centre pharmacies v. High street Health centre pharmacies v. High street Electronic prescribing & e-pharmacy Electronic prescribing & e-pharmacy Non-medical prescribing Non-medical prescribing Supporting self-care Supporting self-care

26. Sue Carter BPC 2005 Multidisciplinary Not just about pharmacists Not just about pharmacists The agenda is huge The agenda is huge … And so are opportunities for those who are ready … And so are opportunities for those who are ready Other staff are better placed to provide many aspects of medicines management Other staff are better placed to provide many aspects of medicines management … And are trying to do it at the moment! … And are trying to do it at the moment! … And are less expensive! … And are less expensive! … But maybe have different skill sets … But maybe have different skill sets

27. Sue Carter BPC 2005 Integrated Consistent approach – driven by policy, protocol, standards etc Consistent approach – driven by policy, protocol, standards etc Responsibilities clearly defined Responsibilities clearly defined …And accountability (duty of care?) …And accountability (duty of care?) Communication should be effective, efficient and responsive – but not as easy as it seems! Communication should be effective, efficient and responsive – but not as easy as it seems! Single assessment – develop national SAP for medicines? Single assessment – develop national SAP for medicines?

28. Sue Carter BPC 2005 Sustainable Longer term finances – avoid ‘pilot’ syndrome Longer term finances – avoid ‘pilot’ syndrome Demonstrate benefits Demonstrate benefits Don’t overload already hard-pressed professionals Don’t overload already hard-pressed professionals Identify champions Identify champions Define roles and build relationships Define roles and build relationships

29. Sue Carter BPC 2005 Clinical Leadership From all professions involved including pharmacists From all professions involved including pharmacists Leaders provide knowledge and expertise for service / protocol development Leaders provide knowledge and expertise for service / protocol development Leaders educate Leaders educate Mentoring or shadowing (accompanied visits) Mentoring or shadowing (accompanied visits) Leaders could take on difficult bits Leaders could take on difficult bits Provide ad-hoc advice Provide ad-hoc advice General encouragement General encouragement

30. Sue Carter BPC 2005 How Are Primary Care Pharmacists Dealing With the Agenda? Practice, locality commissioning board, (new) PCT levels Practice, locality commissioning board, (new) PCT levels All have operational and strategic need for primary care pharmacists All have operational and strategic need for primary care pharmacists Additional statutory roles at PCT level Additional statutory roles at PCT level

31. Sue Carter BPC 2005 Primary Care Trust Fewer, larger PCTs PCT-wide cross-health economy engagement PCT-wide cross-health economy engagement Co-ordination of local health economy medicine-related policies Co-ordination of local health economy medicine-related policies Performance Management Performance Management Interface medicines management Interface medicines management Primary care contracting Primary care contracting Procurement initiatives Procurement initiatives Shared care Shared care Influencing clinical practice Influencing clinical practice Workforce development Workforce development Policy development & implementation Policy development & implementation Statutory roles Statutory roles Local delivery plan / priorities planning / horizon scanning Local delivery plan / priorities planning / horizon scanning

32. Sue Carter BPC 2005 Locality Commissioning Board Commissioning – medicines issues Commissioning – medicines issues Service redesign – secondary to primary care shift Service redesign – secondary to primary care shift Demand management Demand management Performance management Performance management Repeat Prescribing Review Repeat Prescribing Review Practice prescribing analysis Practice prescribing analysis Audit Support Audit Support  E.g. NSAIDs, Asthma, Statins, Newsletter Newsletter Local health economy formulary development & support Local health economy formulary development & support Proactive and reactive advice Proactive and reactive advice Local interface issues Local interface issues

33. Sue Carter BPC 2005 GP Practice nGMS general involvement nGMS general involvement  Input to QOF and assessments  Practice visits & 3 agreed action points  Many medicines issues Repeat Prescribing & other practice systems Repeat Prescribing & other practice systems Provision of patient centred medicines services Provision of patient centred medicines services Practice prescribing analysis Practice prescribing analysis Audit Support Audit Support Internal practice formulary development & support Internal practice formulary development & support Proactive and reactive advice Proactive and reactive advice Interface issues Interface issues

34. Sue Carter BPC 2005 Targeted Medicines Management Level 1 – population management Supporting self-care Supporting self-care Level 2 – care management Disease specific interventions for at-risk groups Disease specific interventions for at-risk groups Supporting patients to optimise medicines use Supporting patients to optimise medicines use Pharmacists with special interest - e.g. as disease-specific care managers Pharmacists with special interest - e.g. as disease-specific care managers Level 3 – case management E.g. Targeted medicines support at discharge E.g. Targeted medicines support at discharge Proactive pharmaceutical care Proactive pharmaceutical care

35. Sue Carter BPC 2005 The New Pharmacy Contract – Major Themes 1. Support for self-care 2. Management of long-term conditions (CDM) 3. Public Health – health promotion plus

36. Sue Carter BPC 2005 Strategic Direction Investment to help older people keep healthier at home for longer Investment to help older people keep healthier at home for longer Intensive case management - “Evercare” Intensive case management - “Evercare” CDM - better, stratified care for people with long term illness – ‘care closer to patient’ CDM - better, stratified care for people with long term illness – ‘care closer to patient’ Developing services in community & primary care settings – secondary to primary shift Developing services in community & primary care settings – secondary to primary shift New organisational systems, structures and processes – clinical governance & risk management New organisational systems, structures and processes – clinical governance & risk management Multidisciplinary focus Multidisciplinary focus

37. Sue Carter BPC 2005 Some Points to Ponder... How will future primary care led self-care, disease management and medicines management initiatives impact on pharmacy workforce and workload? How will future primary care led self-care, disease management and medicines management initiatives impact on pharmacy workforce and workload? Can better use of skillmix make enough difference? Can better use of skillmix make enough difference? Will the forthcoming white paper take some of these issues on? Will the forthcoming white paper take some of these issues on? Can quality and effectiveness at interfaces be ensured in an NHS with constantly shifting structures, ‘rules’ and personnel? Can quality and effectiveness at interfaces be ensured in an NHS with constantly shifting structures, ‘rules’ and personnel?