The Pharmaceutical Journal Vol 267 No 7168 p470-481
6 October 2001

BPC 2001 summary

Opportunities for pharmacy in care of older people

Pharmacists are important in the care of older people because more than 80 per cent of people aged over 75 years take one or more medicines, and 36 per cent take four or more, said THERESA RUTTER, pharmacy manager, Parkside Health, London. Up to 50 per cent of medicines are not taken as intended in this age group and adverse drug reactions are the cause of between 5 and 17 per cent of hospital admissions, so there is a need to change the way we provide services, she said.

Mrs Rutter gave three examples of services set up in Parkside Health, which is a community trust in north London.

The first was Brent community rehabilitation team (see PJ, 30 June, p882). The team employs a pharmacist who oversees medicines issues for people moving between care settings. If a patient is taking more than three medicines, the pharmacist undertakes a medication review, usually in the patient’s home, to address problems such as adverse drug reactions and duplicated medicines. The pharmacist also provides training for other members of the team. “All members of the team have learned from the experience and the key benefits have been in communication and joint working,” Mrs Rutter said.

Another area of work had been in intermediate care. Problems were identified at meetings held involving nursing and therapy clinical leads. Medicine-related problems included supply problems if patients were discharged after pharmacy opening hours and the need for patient’s medicine details to be faxed to the hospital before the patient’s admission. “The work brought better shared understanding of what we can do together and brought medicines issues higher up the agenda,” she said.

The final example was a compliance project. An audit had revealed that district nurses spent up to half of their time helping patients with compliance aids (eg, filling them) and that some community pharmacists in the area did not provide monitored dosage system services. Therefore, in the project, community pharmacists filled compliance aids for patients. As a result, district nurses had more time for nursing duties and communication between nurses and pharmacists increased leading to problems being solved as they were identified.

GARY CHOO, development manager, Moss Chemists, described how he had taken a special interest in care of older people when working as a community pharmacist. He had undertaken a project on antibiotic prescribing for urinary tract infection (UTI) in nursing homes. Seven nursing homes and GPs from six surgeries took part. Over a three-month period, 30 UTIs were investigated. It took 4.03 days to receive treatment with a range of one to 12 days. Some patients had to wait for the results of a sample culture before treatment could start. He pointed out the difference between this and patients who walk into a surgery and are given a prescription for an antibiotic along with instructions to leave a urine sample at the reception. “Is there equity in treatment between these two patient groups,” he asked.

The project highlighted the delays in commencing antibiotic treatment in nursing homes. “One way to speed up the initiation of therapy for this group of patients was to bring pharmacy into the prescribing process,” Mr Choo said. A protocol was set up which involved copies of test results being sent to the pharmacy from the pathology laboratories and, under an agreed protocol with local GPs, the pharmacist was able to commence antibiotic treatment.

Mr Choo said that the National Service Framework for Older People and Pharmacy in the Future provided golden opportunities for pharmacy to contribute to the agenda for older people. “It is important that we seize this chance to show what we can do,” he said. It was particularly important that the foundations of robust, deliverable and sustainable services were laid down now because a change in the demographic profile, resulting from the post-war baby boom, would increase the demand for services, he said. “This will only be successful if primary care organisations recognise that these services will produce deliverable outcomes and will need to be resourced appropriately,” he said.

Working together to achieve better outcomes for patients is an obvious goal for all health professionals, said SHARON SIMPSON-PRENTIS, school of health care studies, University of Leeds. However, there are challenges to effective collaboration. She is investigating the roles of health professionals in relation to people’s medicines in a study that is part of her PhD.

The study is based on interviews with community pharmacists, GPs, practice nurses and patients. To date, 42 professionals and 14 patients have been interviewed.

Some community pharmacists had felt frustrated that their skills were not used but GPs responded by saying that they were not aware of pharmacists’ skills or areas of expertise. More effective communication was needed between the professions in an environment based on mutual respect. Things that hindered the collaborative process were a lack of resources (particularly time for meetings and provision of cover for people attending meetings), competing interests, professionals having fixed ideas about their roles and concerns over responsibility and accountability. Doctors, in particular, were reluctant to allow other professionals to take on aspects of medicines management because of accountability, she said.

For pharmacists, one of the key issues identified was that they felt “on the periphery” because they were located in different premises from GPs and practice nurses. Pharmacists also felt that they had occupational limitations, in that they were seen to dispense medicines and little else, and feelings of frustration over the fact that much of the work they had to do was in their own time. One of the issues patients raised about pharmacists was a lack of continuity, ie, different pharmacists working in one pharmacy prevented them from building a relationship with one pharmacist.

Ms Simpson-Prentis said that the implications for practice were a need for:

• Strategies to support good communication are needed, eg, computer systems.
• Negotiating clearly defined roles and responsibilities, ie, getting the team together to discuss roles.
• All parties should pro-actively seek opportunities for collaboration. It is often the pharmacists who go to the GPs to suggest working together, not vice versa, she said.

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