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	The Pharmaceutical Journal Vol 270 No 7243 p470-471 5 April 2003	This article Reprint Photocopy
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News feature

Service improvements continue as the NSF for Older People enters third year

Last week the Department of Health held a conference to mark the second anniversary of the National Service Framework for Older People when it published a progress report. Harriet Adcock (on the staff of The Journal) reports

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Despite a slow start in implementing some of the medicines-related aspects of the National Service Framework for Older People, real progress is being made to ensure older people receive the right kind of care at the right time and in the most appropriate setting. This was one of the messages to come from a conference organised by the Department of Health to mark the second anniversary of the NSF for Older People.

Speaking at the conference, Jacqui Smith, Minister of State for Health, said: "Much good work has taken place locally over the past few years to make older people's services better and many have used their experiences as a basis for looking at the provision of health and social care services across the board."

She added that a single assessment process for older people would ensure information is shared between organisations, reducing replication of effort and ensuring better holistic care for older people.

"This kind of cross-boundary thinking, basing the service development around the older person rather than vice versa, will also help to identify and target those people who are at greatest risk," she said.

Medication reviews

One of the targets set out in the NSF was that all people aged 75 years and above should have their medication reviewed annually by 2002. This seemed a tall order at the time and is still not a reality for many old people.

Professor Ian Philp, national clinical director of older people's services at the Department of Health, acknowledges that there has been a slow start in terms of reaching medication review targets. However, he recognises the huge task that is being faced by primary care organisations. "It is a major system change to have medicines management on a routine basis. But this aspect of the NSF is being taken seriously by most people as part of improving services for older people."

He added that medicines management services would require a joint approach between general practitioners and community pharmacists. "Conversations need to take place and are starting to," he says. Professor Philp estimates that about a fifth of primary care trusts in England and Wales have "cracked" medication reviews. "The rest are on the way," he added.

A report on the progress being made in older people's services was launched at the conference. It highlights work being done by the National Prescribing Centre Medicines Management Collaborative that shows a substantial increase in the number of patients aged over 65 years who have had a documented medication review in the past 12 months.

Richard Seal, national programme director for the collaborative, says that data collected from around 200 practices, located in the 40 PCTs taking part in the second wave of pilots, show that the proportion of older people taking four or more medicines who had a medication review during the past 12 months went up from 27 per cent in June 2002 to 46 per cent in January 2003.

Another aspect of medicines use that has improved since publication of the NSF for older people is the provision of information about how patients should take their medicines. To tackle this, practices taking part in the collaborative are working towards reducing the number of prescriptions being issued without specific dosage instructions. Since October 2001, the proportion of prescriptions without dosage instructions has fallen from 23 per cent to 6 per cent in the first wave pilot.

This work has had an additional benefit, says Mr Seal. "[It] opens doors for community pharmacists to get involved in medicines management in a pragmatic way." He suggests that they can flag prescriptions that include non-specific directions. "This provides an opportunity for community pharmacists to start a dialogue with patients," he says.

Elderly patients taking multiple medicines often request prescriptions that do not include all of their repeat medication. By managing and synchronising repeat prescriptions, pharmacists have helped practices reduce the number of repeats being issued. The latest data collected by the NPC show that the proportion of non-synchronised prescriptions issued by practices in both the first and second wave pilots has fallen from around half to 36 per cent.

"The key thing is that patients are receiving a more convenient service," says Mr Seal. "Older people may be less capable of getting to the surgery so if we can reduce the need for their visits this can be potentially helpful."

Targeting reviews to vulnerable patients

At Newark and Sherwood Primary Care Trust medication review clinics have been set up in sheltered housing and within day care settings. East Kent and Coastal PCT has set up a multidisciplinary referral system for priority medication reviews. Any health or social care worker with a concern that a medicine may be a problem for an older person can refer him or her for a medication review with a pharmacist.

Brendan Prescott, medicines management facilitator, South Sefton PCT, leads a team looking at ways to target the right kind of review to the right patient. With 25,000 people over the age of 75 years on the PCT's books, an annual, face-to-face clinical medication review for all these patients is not realistic.

The PCT is currently working with informal carers and district nurses to identify patients who would benefit most from full medication reviews. "Community care practitioners do a basic review to identify patients with problems," he explains. The team is also looking at different ways patients can be assessed. For example, if a patient has problems reading labels then referral to a community pharmacist is appropriate. "We are looking at the practical implications. Things have to be workable and done year in year out if targets set out in the NSF are to be achieved."

Juanita Westbury, PCT prescribing support pharmacist, Central Cheshire PCT, also targets vulnerable patients for medication review, in particular those who are prescribed 10 or more medicines. Such patients may be taking benzodiazepines, she says, and could be at increased risk of falling, another issue raised by the NSF for Older People.

"By addressing polypharmacy we may be able to reduce the number of falls," says Ms Westbury. To address this further, pharmacists also provide support at a falls clinic that runs as a course over a five-week period. One session of the course is conducted by a pharmacist who talks to older people about their medicines and the risk of falls. Patients are encouraged to seek help from their practice or to talk to their community pharmacist.

Looking ahead

The DoH's progress report also sets out the steps being taken to improve services for older people even more. In particular, it lists ways in which the Medicines Partnership Taskforce is helping to improve medicines management services.

Joanne Shaw, director of the taskforce, says that things are progressing quickly and that the activities and tools listed in the report will have been achieved sooner than the DoH predicts.

In particular, the taskforce, in conjunction with the NPC, plans to survey all PCTs to determine the level of activity on medication reviews for older people by summer 2003. "We want to evaluate 'Room for review' [a guide to medication review produced by the two organisations last year, PJ, 23 November 2002, p737] and track implementation at a local level," says Ms Shaw. The taskforce is keen to find out if pharmacists providing medication review services are using the guide and whether they are providing face-to-face reviews designed to improve concordance.

"We would like to see more patients offered face-to-face reviews in the longer term," she adds.

Another step being taken by the taskforce is to produce a version of the "Room for review" guide for patients and carers. The original guide is aimed at practitioners and managers. Providing patients and carers with information about what they can expect from medication review will be invaluable, says Ms Shaw.

The taskforce has also commissioned pharmacists at Leeds University to produce a number of web-based tools to help practitioners provide medication reviews. Some are already available via the taskforce website but three more are due to be added later this month. These are a medicines compliance assessment tool, a training curriculum for medication review and a guideline for the appropriate use of compliance aids.

Ms Shaw explains that the taskforce is not in a position to provide training nationally. However, the medication review curriculum highlights the issues that need to be covered and is designed to help PCTs set up their own training and to help training providers cover the appropriate topics.

The third tool — a guideline for the appropriate use of compliance aids — came about because pharmacists and GPs are not always aware of the situations where use of monitored dosage systems is appropriate. Ms Shaw suspects that the guideline will reduce use of monitored dosage systems. "These compliance aids have a place in specific situations and the guidance will help people work out when is the right time to use them."

Keep up the momentum

The NSF for Older People represents an enormous challenge. And, with the inclusion of targets for medication reviews in the new GP contract, pharmacists are sure to be in further demand.

The momentum generated over the past two years means that services are set to improve further. Pharmacists have been a vital component of that momentum and their successes should be celebrated.

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