Opportunities for pharmacists created by the NSF for Older People

The National Service Framework for Older People suggests many roles for pharmacists. Clare Bellingham investigates

One of the milestones of the National Service Framework (NSF) for Older People published last week (PJ, March 31, p415) is that by 2004, “every primary care group or trust [PCG or PCT] will have schemes in place so that older people get more help from pharmacists in using their medicines”. Many pharmacists are developing their roles so that they can provide a better service for patients. This article examines a few projects that are currently under way in areas highlighted by the NSF for Older People.

Repeat dispensing

The NSF says that repeat dispensing is a means of achieving monitoring of repeat medication. A pilot repeat dispensing project has been running in Ashford since January. Judi Cross (prescribing adviser, Ashford PCG) explains that under the scheme, community pharmacists undertake to manage repeat dispensing for patients with a chronic disease requiring regular repeat medication. The project involves 100 patients attending one community pharmacy in Ashford. All the patients were regularly using this pharmacy before the project began.

Once a patient has agreed to take part in the pilot, the surgery issues six one-month prescriptions that the patient takes to the pharmacy. A record card of repeat medication is provided for the patient and patients use the card to request repeat medication directly from the pharmacy.

The scheme also involves pharmacists undertaking other activities in medicines management. These are to:

• identify any drugs not being requested
• identify overuse or over-ordering of any drugs, particularly with reference to drugs used on a “when required” basis
• discuss with the patient, at least once during the six-month period, the purpose of each drug and to identify non/poor compliance and side effects
• give advice on drug therapy monitoring (eg, blood pressure), length of treatment, over-the-counter (OTC) medicine use
• give additional advice for specific disease areas, eg, lifestyle advice for dyspepsia, importance of blood pressure and blood glucose control in diabetes, and the roles of different inhalers in asthma

Pharmacists in the scheme also offer a service to housebound patients. Patients are visited in their own homes where a medication review is conducted. Advice is given on the best use of their medicines and drug therapy monitoring.

Mrs Cross says that there are benefits for all involved in the scheme. Patients have a one-stop request service and also receive intensive support to aid compliance. Surgeries have a reduced workload of requests for repeat prescriptions. Pharmacists and surgeries have a better working relationship, and pharmacists are able to highlight compliance problems and reduce drug wastage. Pharmacists involved in the scheme are paid £10 per patient.

Results from the first month of the scheme are positive. Many items that were not required were identified, including Diprobase cream, Betnovate cream, paracetamol tablets, Gaviscon liquid and lactulose. One patient was identified who had built up a large stock of bisacodyl, gliclazide and warfarin.

Admission and discharge schemes

In hospitals, the NSF advises that medication reviews should be conducted on admission to identify medicines-related problems. Hospitals should consider systems to enhance older people's use of medicines while in hospital and following discharge, and review arrangements for prescribing at discharge, it says.

One hospital that has introduced new systems for use of medicines in hospital is the Countess of Chester NHS Trust, Chester. Alison Ewing (chief pharmacist) says that the hospital has re-engineered the process and that patients now use their own drugs wherever possible. On admission, patients are given 28 days' supply in patient packs, which they keep in cupboards beside their beds.

Pharmacists visit wards and counsel patients about changes to the medication. When the patient is discharged, the pharmacist writes the discharge prescription.

Technicians top up supplies in the patients' cupboards where needed and, if the medicines on the discharge prescription are unchanged from those the patient has been taking in hospital, they are able to dispense the discharge prescription at the bedside. If any changes are necessary, the prescription is dispensed at the pharmacy.

An audit, conducted by Helen Young (clinical pharmacist, Countess of Chester hospital), compared the quality of junior doctors and pharmacist-written discharge prescriptions in three hospital wards. It found that pharmacists were more meticulous at writing prescriptions than doctors and that pharmacists were more likely to reissue patients' own drugs, which avoided duplication and reduced costs.

In the audit, 73.4 per cent of prescriptions were written by pharmacists, 24 per cent by doctors and 2.6 per cent by both. All prescriptions written by pharmacists were legal and legible. However, of the doctor-written prescriptions, 5 per cent had no date, 5 per cent no address, in 5 per cent the drug name was illegible and in 16 per cent the directions were illegible. Discharge prescriptions were queried by the dispensary for omissions of, eg, dose, strength, course length, in 7.5 per cent of doctor-written prescriptions and 0.3 per cent of pharmacist-written prescriptions. Where patients' own medicines were available on the ward, they were not used in 26.3 per cent of cases by doctors and 1.7 per cent of cases by pharmacists.

Preventing falls

One of the standards in the NSF is to prevent falls. It points out that polypharmacy is a risk factor for falls and that hypotension caused by medication is a key contributor. Problem drugs highlighted in the NSF are hypnotics (making patients more liable to fall during the night) and diuretics or laxative medicines (causing dehydration).

Alison Issott (prescribing adviser, Thanet PCG) is involved with a project that aims to reduce such falls. Patients are assessed in their homes for risk of fall by primary care visitors and their medication is assessed by pharmacists based at the PCG. The pharmacist then writes to the patient's general practitioner (GP) to make recommendations about their medication and about their compliance and use of OTC medicines. She said that the project used a “good skill mix”. It was cost effective to use a primary care visitor rather than a pharmacist to make the assessments. It also allowed the pharmacist to concentrate on the clinical aspects by conducting the medication review.

Patients are assessed on living conditions and home environment (eg, carpeting, electrical sockets), standards of personal care and medical assessments (eg, continence and blood pressure). The number of falls the patient has had in the past year is recorded. In addition, primary care visitors record details of patients' medicines. The records are made from the actual medicines the patient has, rather than what is on a repeat prescription card. For each item the primary care visitor records: when it was dispensed, its general condition, whether it is possible to read the label, where the medicine is stored and the approximate quantity of each medicine. The review includes OTC medicines. Any concerns the patient has about their medicine and its purpose is also recorded. This material is taken back to the PCG where a medication review is conducted by a pharmacist.

The project assesses over 100 patients aged over 80 each month. In 50 per cent of cases, some contact with the patient's GP is made, says Mrs Issott. Changes to medication are made in 20 per cent of cases. Audits made in January showed that the scheme was successful and GPs' responses had been positive. The project took about 10 hours a month of pharmacist time.

The NSF highlights hypnotics as a cause of falls in older people. Andrew Bellingham (practice pharmacist, Ashford PCG) has set up a pharmacist-led hypnotic withdrawal/reduction clinic. Patients are encouraged to participate in the clinics by the pharmacist pointing out the positive aspects of stopping hypnotic therapy, ie, a reduction in falls and side effects, rather than just being told to stop taking a long-term tablet that the patients are often physically and emotionally dependent on, he says.

First, the pharmacist identifies patients taking nitrazepam, temazepam and zopiclone from patients' medical records at GP surgeries. Patients are prioritised: the highest priority is given to patients taking other drugs that could contribute to a fall, patients with visual disturbances, joint disorders, Parkinson's disease or dizziness, patients on polypharmacy, and patients with a history of fall. Certain patients are excluded from hypnotic withdrawal, including patients with a history of mental illness, alcohol abuse, severe chronic disease and patients using less than four tablets per week. A final list of all appropriate patients is compiled and is then reviewed by a GP.

The pharmacist then interviews patients and explains that he or she has been identified as being at risk of fall. Advice is given about the benefits, in addition to reduced fall risk, of withdrawing from the drug, eg, loss of hangover effect, loss of dependence on drug, loss of impaired mental alertness.

The method of withdrawal is explained verbally and supplemented by a written protocol of withdrawal over a six-week period for the patient to take away. Possible side effects are explained to the patient and what actions to take to reduce these symptoms. All patients, including those refusing to stop hypnotic treatment, are given a “sleep guide” which is intended to help them sleep at night.

What the NSF says about medicines management and compliance aids

Medicines management strategies should be implemented to help patients get more help from pharmacists in using their medicines, says the NSF. Forgetting to take medicines is common in older patients. It suggests that multi-compartment compliance devices can be useful for some patients and for others simpler measures such as medicines reminder charts are more helpful.

Heather Lucas (prescribing adviser, Channel PCG) conducted a six-month project of pharmacist-filled NOMAD monitored dosage systems. She found that not all patients needed monitored dosage systems and that some medicines problems could be solved in other ways so the NOMAD project became a broader medicines management project. As a result of the project, seven patients who would otherwise have been moved into residential care were able to stay in their own homes, she said.

Patients were referred into the project mainly by social services. Once a patient had been identified, a member of the PCG prescribing team visited the patient at home to assess their medicines management needs. “An important point is that of 50 patients referred, only 10 needed NOMAD devices,” she said. Other methods of solving medicines management problems included counselling and conducting medication reviews. Drug regimens were simplified where possible (eg, making regimens once or twice daily). In addition, liaison with community pharmacists helped to solve some problems such as labelling bottles using larger letters or using different types of packaging for visually impaired people.

The main use of monitored dosage systems was for patients who were confused and who were given medicines by a carer from social services. Community pharmacists dispensed and delivered the NOMAD device, and refilled it on a 28-day basis. They also conducted quarterly reviews of patients. Community pharmacists were paid £150 per patient per year (as two six-monthly instalments) for the service. The PCG paid for the device itself.

Back to Top

Clare Bellingham is on the staff of The Pharmaceutical Journal