The Pharmaceutical Journal
Vol 269 No 7219 p538
12 October 2002

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British Pharmaceutical Conference 2002 summary

Intermediate care

Getting the partnerships right

Managing discharge is a matter of getting the care pathways right was the message that Andrew Butters, chief executive, Manchester Health and Social Care Partnership, gave to the conference. He discussed the work of the partnership which plans discharge for patients aged 18 to 65 years in an area serving half-a-million people through three primary care trusts. The partnership commissions services which allow specialist assessment of physical and mental health care needs. Such a system gives a managed discharge plan using the expertise of a multidisciplinary placement panel and placement review team. Patients who are ready for discharge are assessed and an appropriate place found to which they can go after discharge.

Mr Butters said that it is important to have primary and secondary interface protocols. The system in place in Manchester has integrated various organisations with a shared philosophy of care, and allowed them to pool budgets.

A tale of two systems

Carmel Hughes, Queen's University, Belfast, talked about pharmacy services and nursing homes. Her discussion, which she described as a tale of two systems, looked at the supply of medicines to nursing homes both in the United Kingdom and the United States.

In the US, there is a system where pharmacists are legally expected to do a monthly review of medicines of patients in nursing homes. "For the Americans, it is a quality of care issue. Antipsychotics, hypnotics and anxiolytics are seen as chemical restraints. Residents of nursing homes have a right to be free of any psychoactive drug administered for the purpose of discipline," said Dr Hughes.

She compared the levels of prescribing of such drugs in countries with this legislation, with those which do not. The level of prescribing in Iceland, for example, was 61 per cent, whereas, in the US, only 14 per cent of nursing home residents were prescribed psychoactive drugs. "This shows that such legislation has a major impact," she said.

Ms Hughes then focused on the prescribing of "good" drugs for the elderly in nursing homes in the US. This group of people are three times more likely to be depressed than those not in such homes, but were more likely to be undertreated. In homes served by a contract pharmacist, the residents were more likely to be treated for depression, but less likely to be treated with a selective serotonin re-uptake inhibitor. "There is an issue of quality versus cost," she said. "Homes are allowed to retain any savings they make and it is possible that to maximise profit, SSRIs are not prescribed."

Turning her attention to practice in the UK, Dr Hughes said that there was a lack of systematically collected data and differences in the organisation of nursing home care. "A consultant pharmacist role is enshrined in US legislation, whereas in the UK, pharmacy services to nursing homes are limited largely to a supply function."

Dr Hughes said that in Northern Ireland, a survey of all nursing and residential homes had been carried out in June 2000. This had shown that there was widespread support for pharmacists getting more involved in areas such as training of staff, systematic collection of data on drug use, monitoring of records and advocacy for older people. In conclusion, Ms Hughes said: "With an increasing elderly population, there is a need for an increased pharmacist involvement for this vulnerable section of the community."

Promoting independence

Hazel Bagshaw, prescribing adviser, Fareham and Gosport Primary Care Trust, told the session that promoting independence in the community was key. After a 1997 Audit Commission Report on intermediate care, the Fareham and Gosport community enabling service (CES) was formed to give patients a holistic approach by involving all the services, for example, social workers, dieticians and community psychiatric nurses. They meet on a monthly basis to ensure that the service is running smoothly. Folders are kept in patients' homes so that all those involved in their care can look at them and add information as necessary.

Pharmacist involvement in CES ensures that the patient gets the maximum benefit from the right medicine at the right dose at the right time. Pharmacists also help to improve patient compliance, produce a medicines management plan, review all medicines and their storage, and remove expired and unwanted medicines.

According to Ms Bagshaw, community pharmacists are ideally placed to be part of the team: they have the necessary counselling skills, regular contact and and knowledge of elderly and susceptible patients, established relationships with local GPs and nurses, and a thorough knowledge of over the counter medicines.

Pharmacists who want to be involved in the scheme have to complete the Centre for Postgraduate Pharmacy Education training package "Visiting patients at home", have a work schedule showing their availability, and have insurance cover.

Be proactive

Paula Wilkinson, deputy chief pharmacist, St John's Hospital, Chelmsford, discussed pharmacists' involvement in the assessment process. She told how her links with intermediary care began with a pilot to develop a medicines management system including an assessment process, that had been introduced in response to the National Service Framework for Older People. She described the levels of assessment:

• Contact Someone decides a health need is required. It is often completed in the accident and emergency department or by the GP, but there is no reason why the pharmacist can not fill in the form.

• Overview One person completes the assessment before referral.

• Specialist The patient can then be referred to the specialist who may decide that the patient may have problems needing an input from others.

Ms Wilkinson believes that pharmacists can be innovators but they have to be proactive to get themselves involved in promoting pharmaceutical care. According to her, pharmacists have a role in also training others to assess the patients' medicines management. For example, social workers, nurses, carers and occupational therapists should all be trained by pharmacists. A third role for pharmacists is as assessors to undertake clinical review.
— Contributed by Diane Langleben, editor, Hospital Pharmacist.