Blueprint for care of older patients highlights roles for pharmacists

The National Service Framework (NSF) for Older People was launched this week and gives a boost for pharmacists. A separate booklet on implementing medicines-related aspects is included with the NSF. “It provides a blueprint for medicines management and recognises the importance of pharmacists,” said Professor Ian Philp (National Director for Older People's services) at the launch of the NSF on March 27. Professor Philp is responsible for overseeing the implementation of the NSF.

The NSF for Older People aims to:

• tackle age discrimination — care will be provided on the basis of need, regardless of age
• provide intermediate care — a new layer of care, between primary care and specialist services, is being developed to prevent unnecessary hospital admission, support early discharge and reduce or delay the need for long-term residential care
• provide evidence-based specialist care
• promote an active, healthy life — emphasis on health promotion activities

The aims of the “Medicines and older people” section are to ensure that older people:

• gain the maximum benefit from their medication to maintain or increase their quality and duration of life
• do not suffer unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicines

The NSF highlights many roles for pharmacists in implementation of the framework. Professor Philp sees pharmacists as “core members of specialist teams for older people” who have an “emerging role as experts in drug management”. This includes paying particular attention to the appropriate use of medicines, covering interactions, compliance and side effects, and in quality assurance. The pharmacist's role is to “work with colleagues to make sure that older people are comfortable in the medicines that they are taking”.

The NSF says that four in five people aged over 75 years take at least one prescribed medicine, with 36 per cent taking four or more.

Some of the problems with use of medicine in older people it highlights are:

• occurrence of preventable adverse drug reactions
• wastage and under-use of prescribed medicines
• inadequate dosing instructions on medicines labels (for example, “take as directed” or “take as required”)
• poor repeat prescribing systems

Ways to tackle these problems are proposed in the booklet on implementing medicines-related aspects of the NSF. Two main themes of the document are medication reviews and repeat prescribing.

Medication reviews

Appropriate medicines management systems should be in place so that the medication needs of older people are regularly reviewed, discussed with the patient and their carers, and information and other support provided, it says. The fact that detailed medication review minimises costs is highlighted: “Studies in general practice and nursing homes have shown that every £1 spent on employing pharmacists to review patients' medication resulted in £2 cost saving.”

Medication review should be targeted at patients post-discharge from hospital, in care homes and in cases of polypharmacy, it says. A review should cover all medicines being taken (including non-prescribed medicines), what medicines are actually being used, the patient's and carer's understanding of the purpose of the medicines and any side effects being experienced.

Practical aspects to cover include problems with ordering and receiving repeat prescriptions, removing medicines from containers, swallowing tablets, difficulty in reading labels, and forgetting to take medicines. The NSF includes a list of suggested questions a pharmacist could use during a review (see panel below).

Suggested questions for medication reviews*

• How long have you been taking/using this medicine?
• Is the medicine in its original container?
• What is the purpose of this medicine?
• Do you know how to take the medicine, when and how often?
• Do you have a routine for taking this medicine?
• Do you have any side effects from this medicine?
• Do you have any medicine allergies?
• Do you buy (or has anyone else bought for you) any non-prescription medicines from the chemist or any other shop such as a supermarket?
• Has anyone (such as a friend or neighbour) given or “lent” you any medicines, vitamins, herbal or homoeopathic products to use?
• Do you use/take any other form of medication or home remedies or products prescribed by any other source of advice?

*Source: quoted in the NSF for Older People, adapted from Hull medication review clinics

It notes that although pharmacist-conducted medication reviews are generally well received by patients, “a gradual culture change needs to occur for some older people to more readily accept advice from pharmacists and nurses”.

Repeat prescribing

Repeat medication presents key problems including unnecessary therapy, ineffective therapy, lack of or inadequate routine monitoring, inappropriate choice of therapy/dosing schedule and non-compliance, the NSF says.

It adds that health authorities should explore commissioning of community pharmacist monitoring of repeat medication. “Repeat dispensing is one means of achieving this [repeat medication monitoring], and its benefits to patients and GP practices have been demonstrated.” The NHS plan contains a target that repeat dispensing schemes will be in place nationally by 2004.

Opportunities

The NSF highlights opportunities for pharmacists working in all areas of the profession.

Prescribing advice/support is described as an effective intervention. The NSF notes that prescribing support provided by pharmacists is now purchased by many Primary Care Groups (PCGs), GP practices and Primary Care Trusts (PCTs). It says that reviews of prescribing of long-term continuous or intermittent medicines has a place for patients of all ages. PCGs and PCTs should implement medicines management strategies “so that people get more help from pharmacists in using their medicines,” it says. Health authorities should explore local pharmaceutical service contracts to improve prescribing and use of medicines and should secure pharmaceutical advice for residential and nursing homes.

The NSF also highlights issues in the specific disease areas of stroke, mental health and falls, and sets out aims for improving prescribing habits in each area. One aim to prevent falls is to reduce the prescribing of hypnotics.

A specific role for community pharmacists is to use screening questions to detect adverse drug reactions and compliance issues when patients are starting new medications. Community pharmacists and GPs should work together to ensure that no older person's medicine is labelled “as directed” except in the case of some complex dosing schedules where other instructions, accompanied by oral explanation, is acceptable.

There are also roles highlighted specifically for hospital pharmacists. They should be involved in specialist old age multidisciplinary teams, which should be set up in all general hospitals, the NSF says.

Hospitals should put in place systems for medication review on admission. It describes successful schemes in which pharmacists have produced discharge prescriptions, a problem area for changes in medication, and also worked on admissions wards to make sure patients' medicines are right early in their stay. It suggests that copying the discharge prescription to community pharmacists can reduce the number of unintended changes to medication once the patient goes home.

Medicine-related milestones

• By 2002, all people over 75 years should normally have their medicines reviewed at least annually and those taking four or more medicines should have a review every six months
• By 2004, every PCG/PCT will have schemes in place so that older people get more help from pharmacists in using their medicines

Concerns

At the launch of the NSF, concerns were made by representatives from professional bodies over the mechanics of how the NSF will be delivered. These concerns included funding issues, the availablity of health care professions and how assessments would be targeted at specific populations. The Department of Health (DoH) says that assessments will be targeted at the vulnerable, at-risk older population, ie, frail older people rather than fit and healthy older people.

In terms of funding, the DoH says: “The NHS plan commits an extra £1.4bn specifically for older people to be provided annually by 2004.”

The NSF for Older People can be found on the Department's website.

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