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The model schemes form part of Scotland’s approach to modernising pharmacy services
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Pharmaceutical care model schemes in Scotland are all about
developing new ways of working. This should allow pharmacists to go beyond
the dispensing
process to improve patient care. To some, this has felt like a far-off
concept that was difficult to get to grips with but now, following the
success of the first three schemes, they offer something more tangible.
“The right medicine”, Scotland’s pharmacy strategy,
promised that packages of pharmaceutical care for patients with chronic
diseases,
based on the principles of the pharmaceutical care model schemes, would
be developed and rolled out by 2005. That same year should also see the
start of the new community pharmacy contract in Scotland. But pharmacists
might not have to wait that long to be delivering aspects of the model
schemes.
Annamarie McGregor |
Annamarie McGregor, director of the pharmaceutical care model schemes
development team, says: “We can’t just wait until 2005 to
develop and change practice. The foundations have to be put in place
before then.” She adds: “Aspects of this work will form part
of the new contract. We don’t know exactly what at this stage but
we do know that they will form some of the tools and processes to help
make it happen.”
The new pharmacy contract in Scotland will be divided into four parts:
a pharmaceutical public health service, an acute medication service,
a minor ailments service and a chronic medication service into which
the key components of the pharmaceutical care model schemes will fit.
In order to allow pharmacists to plan for the changes, particularly workload
issues, Ms McGregor suggests that a simple starting point would be to
understand the demographics of the population that their pharmacy serves. “Pharmacists
should think of their pharmacy as a practice in a similar way to GPs
and ask, for example, how many patients with epilepsy or diabetes regularly
visit their pharmacy. Then they can plan how to deliver care to those
people,” she says.
Part of the work is to develop pharmaceutical care screening tools to
identify patients who require more help from their pharmacist and also
assessment tools and pharmaceutical care plans. “Providing services
over time in a targeted manner is a new concept for community pharmacists,” Ms
McGregor says. “Historically, we have defined pharmacies by dispensing
volume, which currently has most pharmacists stretched to the limit.
The thought of additional work seems an impossible dream. If pharmacists
identify the number of people with certain conditions or medication,
it will probably be smaller than they first thought. Within that number,
not everyone will need or want the new services. We have to be aware
of the current capacity issues in community pharmacy and help people
manage change,” she comments.
The steps frameworks
The pharmaceutical care frameworks take a stepped approach:
• Step one: Preparing your practice Pharmacists
examine how patients’ access
to medicines and information can be improved, check patients’ understanding
of their medicines, assess compliance, provide health promotion,
and improve communication and integrated teamwork.
• Step two: Targeted interventions Pharmacists offer targeted pharmaceutical
care interventions and introduce care planning, eg, reduction of
falls and hip fractures in the elderly, and pain management for
palliative care patients.
• Step three: Holistic medication review Pharmacists undertake
an assessment to ensure that all the patients’ drugs are
appropriate in terms of indications, safety,
efficacy and convenience.
The frameworks suggest action points and provide examples of audit,
assessment tools and sources of resources, and outline a baseline
service that could be provided. More information about the model
schemes is available here |
Steps framework
Over the past two years, model schemes in three areas — palliative
care, mental health and the frail elderly — have been developed.
This culminated with the publication, this summer, of a steps framework
for pharmaceutical care for each of the three areas (see Panel). Ms McGregor
explains that the frameworks should help to share learning, standardise
pharmaceutical care and allow all pharmacists to get involved.
A problem in the past has been that there have been pockets of innovation
in some regions that have developed excellent pharmaceutical care but
none in other places. One of the aims of the pharmaceutical care model
scheme development team is to provide national co-ordination in order
to identify and disseminate best practice across Scotland.
All primary care organisations in Scotland now have plans in place to
implement the steps framework. Figures from a survey in May, indicated
that an average of 30 per cent of contractors are involved in model schemes. “As
the steps framework is implemented across Scotland, we have seen a substantial
increase in this figure,” she adds.
To date, eight NHS trusts have implemented all three model schemes. All
trust areas have palliative care networks, seven have developed mental
health schemes and 15 have frail elderly schemes in place. This month
sees the launch of two more model schemes — in mental health and
palliative care — in Fife Primary Care NHS Trust.
“While some areas have struggled to implement the model schemes,
we are learning from each others’ mistakes and successes,” says
Ms McGregor. “Infrastructure, ensuring that you are meeting an
identified need, and teamwork are keys to success.”
Data show the success of the schemes. For example, in Grampian Primary
Care NHS Trust, 49 per cent of community pharmacies are now registered
to provide a medication review service for the frail elderly. Data for
125 patients who have had medication reviews reveal that an average of
two to three pharmaceutical care issues have been identified per patient.
Compliance is the most common issue (45 per cent). Others include identification
of risk of adverse events, inappropriate medicine, untreated conditions
and cost issues. All pharmacists received training before the service
started.
The frameworks for pharmaceutical care are designed for use by trust
chief pharmacists and others working at a strategic level, including
12 local development team co-ordinators, who work with Ms McGregor. The
trusts then adapt or adopt the components of the framework and implement
them locally through the community pharmacists involved in service provision.
“The steps should help to change practice by giving pharmacists the
necessary tools to identify and target the people who need more help,” says
Ms McGregor.
New model schemes
Two new pilot model schemes that are starting this financial year are
in epilepsy and asthma. Where they will take place has been largely
decided on the basis of clinical need. Ms McGregor explains that patient
groups — the National Asthma Campaign and Epilepsy Scotland — were
asked to help identify sites. The Grampian region was picked for the
epilepsy scheme and the
Borders area for the asthma scheme.
The starting point is seeking patients’ views. Ms McGregor explains
that this is because pharmaceutical care is a patient-centred practice.
Work is slightly further ahead on the epilepsy model scheme. Advertisements
were placed in the local press to ask patients with epilepsy to attend
a meeting to discuss how pharmacists could help them, what they knew
about epilepsy and the medication used to treat it. “It was obvious
from the response that patients needed more information and that they
wanted the pharmacist to work closely with GPs,” says Ms McGregor.
The resulting scheme is in two parts. First, pharmacists assess patients
in the pharmacy, find out their individual needs and take appropriate
action. Second, the scheme involves community pharmacists in the development
of an Local Health Care Co-operative wide epilepsy register. All pharmacists
involved will be provided with a pack of information about the type of
advice they will be expected to give and patient information leaflets.
The interventions in this scheme fall into step one and two of the framework
(see Panel, p575). “It will also identify patients who need more
intense help such as those who have regular seizures and need to be referred
to a doctor,” explains Ms McGregor. “At this time we are
not expecting
pharmacists to recommend changes in medication,” she says. Treatment
of epilepsy is considered to be too specialised an area for this to happen
at the moment but this is not the case in the asthma model scheme where
it is hoped that from next year pharmacists will recommend appropriate
drug changes.
Ms McGregor admits that one area requiring work is in communication. “Every
other health professional writes to doctors but pharmacists telephone.
We have to look at this,” she says. “Phone calls are less
likely to be actioned and, in any case, is it appropriate if no other
health professional does it?”. The situation might be improved
in the future with the advent of NHSnet but, until then, a solution is
needed. Ms McGregor suggests that pharmacists should use written referrals
but adds that they should talk to doctors initially so that the doctor
knows to expect they will be sent in writing. A written referral form
is one of the components of the National Compliance Support Initiative,
launched in October 2002.
Pharmacy in Scotland is changing. The next two years are a time of adaptation
before the new contract formalises many of these changes. The first step
is to get involved in the pharmaceutical care model schemes. And more
pharmaceutical care model schemes are just around the corner: new schemes
in diabetes and coronary heart disease will start next year. |
