The Pharmaceutical Journal Vol 267 No 7160 p206-207
11 August 2001

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Welsh Executive annual lecture

The Royal Pharmaceutical Society’s Welsh Executive annual lecture, given at the annual general meeting in Wales on 17 July consisted of two presentations. One explained the concept of medicines management and discussed research supporting it; the other looked specifically at the development of medicines management in Wales. Christina Lowe reports

What medicines management means
Medicines management: what’s happening in Wales?
Need for clear definitions

What medicines management means

Pharmaceutical care, which has evolved from the original definition of Hepler and Strand (1990), has four main components, according to Professor JAMES C. McELNAY, of the School of Pharmacy, Queen’s University of Belfast, opening his presentation.

The four components are: ensuring optimal drug therapy is prescribed for a patient; agreeing a treatment plan and treatment goals with the patient; patient education (illness, medicines, healthy lifestyle); and monitoring patient outcomes and achievements. This model is outcome-focused and encompasses the concepts of evidence-based medicine, treatment concordance and preventive medicine. The outcomes of pharmaceutical care are cure of disease, elimination or reduction of symptoms, arresting or slowing of a disease process, or prevention of disease or symptoms as appropriate.

Medicines management (MM) comprises the same four main components, but with possibly less emphasis on health promotion.

Medicines management has been defined by the department of medicines management, Keele University, as a practice that “seeks to maximise health through the optimal use of medicines. It encompasses all aspects of medicines use, from the prescribing of medicines through the ways in which medicines are taken or not taken by patients.” Primary care health promotion practice is defined as: “The active and evidence-based promotion of health, patient empowerment and facilitation of lifestyle changes to ensure maintenance of good health, prevention of illness and assurance of disease management.” (PJ, 12 May, p651).

The important issue is not the definition, argued Professor McElnay, but whether increased involvement of pharmacists in patient-centred care improves humanistic, clinical and economic outcomes.

Value of increased pharmacist involvement in patient care

The results from work carried out by Professor McElnay’s research group in Northern Ireland confirm the value of pharmacist interventions, as the following reveal:

• Pharmacist-led protocol development for managing community-acquired lower respiratory tract infection reduced treatment failure from 31.3 to 7.8 per cent and significantly reduced hospital stay and treatment costs (see Panel).
• Pharmaceutical care intervention led to improved cost-effectiveness of Helicobacter pylori eradication treatment. Eradication rate and compliance rate were both significantly increased with counselling enhanced treatment (see Panel).
• Pharmacist-led elderly congestive heart failure care at hospital outpatient clinics led to an improvement in patient care and decreased hospital admissions.
• In asthma patient care research studies indicated that inhaler scores and mean “Living with asthma” questionnaire scores showed improvement in patients receiving education and monitoring intervention compared with controls.
• Community pharmacist involvement in an individualised smoking cessation programme (Pharmacists’ Action on Smoking) significantly increased cessation rates. Sensitivity analysis showed that this programme is more cost-effective than other disease prevention practices such as hyperlipidaemia treatment. A clear case can be made for NHS remuneration of the PAS pharmacy service.

Other studies carried out by the Belfast group have demonstrated the value of patient-centred pharmacy services in the following areas: hormone replacement therapy; elderly patients with four or more prescribed medicines (this study involved seven European countries); domiciliary care to elderly patients; repeat dispensing services; and the role of the community pharmacist in reducing the misuse of over-the-counter drugs. The group is also carrying out research to help target patients in greatest need of pharmaceutical interventions (eg, factors influencing poor disease control in diabetic and hypertension patients; risk modelling of adverse drug events in elderly patients).

New care models in community pharmacy

Comprehensive MM provision will require a re-evaluation of structure, process and outcomes (clinical, humanistic and economic). There is also a need to address issues including environment, staffing (skill mix) and time management.

Different outcome indicators are needed for different “audiences”. Patients are interested in individualised, tangible data, while patient associations are also interested in population effects (eg, percentage reduction in days off work due to diabetes). The third party payers have an economic focus (eg, reduction in admissions to hospital, reductions in diabetic complications).

There is a need for documentation but one can have too much of a good thing, Professor McElnay remarked. From the perspective of a third party payer (or patient association), processes have not taken place, and outcomes have not occurred in the absence of documentation. Comprehensive data collection is preferable from a scientific perspective. However, it will significantly interfere with care provision (and patient participation).

In practice, enough data are needed to demonstrate effectiveness and efficiency but not so much as to make data recording a chore for pharmacists and patients. Paper recording is cheap and easy to put in place, but difficult to manage and manipulate. Electronic data capture is preferable: it requires systems development, but thereafter data are easily managed and manipulated.

Conclusion

Professor McElnay quoted Dr Jim Smith Chief Pharmaceutical Officer for England: “The content of the NHS plan for pharmacy is not negotiable and there will not be another one. This is pharmacists’ last chance to extend their role and they have a short period (probably two years) to demonstrate that they can do it.”

Pharmacists in Wales, as in the other three UK home countries, have a major opportunity for improving health outcomes in a cost-effective manner, through patient centred care provision. They must therefore move quickly to incorporate research findings into practice.

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Medicines management: what’s happening in Wales?

CARWEN WYNNE HOWELLS, Chief Pharmaceutical Adviser to the National Assembly for Wales, gave an overview of the opportunities for implementing medicines management in Wales.

“Improving health in Wales”, the plan for the NHS in Wales, provides a positive and distinctive vision in setting the direction for services for the next 10 years, with a political commitment to developing the pharmacist’s role. “Effective medicines management systems are essential for ensuring that the NHS makes the best use of medicines and the pharmacist has a pivotal role to play in the area,” she said. Last month, “The future of primary care”, which includes a section on pharmacy was published. The future lies in the ability to make best use of the complementary skills of the whole pharmacy family and by adopting a more strategic approach to medicines management.

Five mechanisms for improvement have been identified: advisory services to GPs; direct support to clients and patients; repeat dispensing; development of partnerships between the patient, GP and pharmacist; and risk reduction using patient medical records, including records of OTCs.

It is essential that pharmacists participate in the next stages of the process, including in consultations for the “Action plan for primary care” to be produced by April 2002 and active participation in pilot projects. With the National Assembly pharmacists must develop a strategy for the profession.

One interesting thing to come out of the Task and Finish Group on Prescribing is that patients want regular medication reviews to ensure continued effectiveness and appropriateness with minimum side effects.

Some patients report that once a prescription has been issued professionals have little interest in compliance, effects and effectiveness. “The prescription should be regarded as the first stage of treatment not an end to consultation,” Miss Wynne Howells said.

An exercise to determine what needs to be done and an economic evaluation will contribute to the implementation plan. Pharmacy will be involved the public consultation on the proposed All Wales Medicines Strategy Group as part of this process. The plan will be presented to the Health and Social Services Committee in October.

The proposed new framework for prescribing, supply and administration of medicines outlined in the UK review (Crown) offers opportunities for pharmacists. New groups of professionals would be able to prescribe in specific clinical areas through the use of patient group directions and supplementary and independent prescribing. The Health and Social Care Act makes provision for such supplementary and independent prescribing and for local pharmaceutical services. Current projects exploiting these opportunities include the pilot for PGD supply of EHC in Bridgend.

The implications of the Care Act and Care Commission have probably passed most pharmacists by. These introduce the same standards for all care settings, and pharmacists need to appreciate the implications and recognise the potential opportunities to improve medicines management in the wide range of care settings. All NSFs will include a medicines management section. Pharmacists will start getting actively involved in developing local plans through their constituency, ie, their local health group.

Accessing resources for service developments is essential. Because the NAW allocates money to health authority level, the scope for centrally funded projects is limited. Pharmacists need to engage in “truffle hunting” to access the available funds for small-scale projects. Sources include R&D monies, Innovations in Care awards and Primary Care Development funds.

There are real opportunities to develop more responsive, flexible and integrated pharmacy services and to realise the vision outlined in “Pharmacy in the future” in respect of medicines management.

There is a genuine political desire to use the skills of pharmacists, but they need to bite the bullet and look critically at their services and skill mix and to re-engineer their services to deliver these goals. They can expect positive initiatives over the next 12 months; there are already a lot of small-scale projects at the collating stage, ready for dissemination, Miss Wynne Howells said. Pharmacy is entering a period of rapid change and a consultation document “Structural change in the NHS in Wales”, released on 18 July, provides an opportunity to influence how, and at what level, medicines management develops.

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Need for clear definitions

Opening a discussion session, Professor BRYAN VEITCH referred to the definitions given by Professor McElnay and made a plea for the adoption of a clear definition to reduce confusion and aid communication. He thought that the Scottish approach of keeping the term “pharmaceutical care” had advantages.

Miss Wynne Howells in reply said there was a need to focus on processes to achieve positive patient outcomes rather than be hung up on definitions. Professor McElnay thought that although “pharmaceutical care” was more encompassing, “medicines management” was working politically.

V’IAIN FENTON-MAY said that medicines management does not only include pharmacy and if pharmacists do not use that term they will fall out with the other professions. Pharmaceutical care is that part which can be contributed by pharmacists and this is what we should focus on, with the objective of treating the patient appropriately.

Asked by HAZEL BAKER how her call for PMRs to include OTCs could be achieved, Miss Wynne HowellS acknowledged that it could not be achieved with current systems but with IT developments such as centrally held PMRs it would become possible. Professor McElnay thought that UK pharmacy was badly served by software developers compared with other countries. In the Netherlands, for example, every pharmacy has advanced electronic systems.

MONICA ROSE thought pharmacy was suffering from “pilotitis”. There are already many pilots in West Wales but it was demoralising when the money rsn out, and a way had to be found to take them forward. Miss Wynne Howells responded that this had been recognised by the Task and Finish Group. It was time to look seriously at ways of sustaining such developments and that might involve considering alternatives to the current contract.

ROBERT GARTSIDE said that, with pharmaceutical advisers spending one or two days a week in GP surgeries it was increasingly difficult to attract pharmacists to hospital or community posts. Pharmacists needed to start thinking about how they provided their services: were pharmacists needed in the dispensary when they could be more effective elsewhere?

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