| The fact that patients have problems with medicines as they move between
primary and secondary care is hardly news. Research in this area dates
back over 10 years and it has been on pharmacy’s agenda for at
least as long. What is remarkable is that the problem has yet to be solved.
Examples of good practice exist but, in general, patients crossing the
interface are not offered seamless care. Perhaps this is why medicines
management across the interface was picked as the theme of this year’s
Primary Care Pharmacists' Association conference, held in London
last week.
Taking medicines will always involve some risks. But it is the fact that
patients are more at risk of things going wrong with medicines when they
move between care settings that is important, explains Catherine Duggan,
director of the academic department of pharmacy, Barts and the London
NHS Trust. This is true even when the medicines are being used correctly.
Speaking at the PCPA conference, Dr Duggan said that the point at which
patients are most vulnerable is straight after discharge from hospital.
Some of the problems that patients encounter are outlined in the Panel
below.
Common problems
The medicines a patient is discharged from hospital on are rarely
the same as those they were taking before admission. What problems
can arise?
· The hospital receives inaccurate information when the patient
is admitted so incorrect medicines are prescribed for the patient
· Patients leave hospital with a week’s supply of new medicines
but it can take longer until the GP is informed of changes: in
the meantime the pre-hospital medicines might have been prescribed
again
· If different brands of the same drug are used, patients might
take both not realising that they are doubling the dose
· Patients think that medicines prescribed in hospital are different
from those prescribed by their GP so take both
· GPs do not receive clear explanations for medication changes
from the hospital so revert to pre-admission drugs
· Clinically unnecessary changes to medicines can be made if a
patient is prescribed a drug that appears on the hospital formulary
but not the primary care formulary (and vice versa) |
What underlies all these difficulties is a lack of communication.
Although the professionals working in each sector are independently
doing their
best for the patient, their ability to offer optimal care is restricted
by their lack of knowledge about what has happened in the other care
setting. What does the research say?
Dr Duggan has been involved in research examining medicines management
at the interface for a number of years. She told the conference that
many changes to prescribed medicines are unintended. At admission to
hospital 11 per cent of medicines had unintended changes and this rose
to 46 per cent at discharge. “These discrepancies are dependent
on either different labelling or supply systems, or breakdown in communication
between secondary and primary care,” she said. “Communication
across the sectors should be routine practice yet only 4 per cent of
those questioned report that they do this.”
Plenty of research has shown that giving discharge information to community
pharmacists improves patient care. For example, in one study, for every
19 pieces of information given to a community pharmacist, one readmission
is prevented. “Pharmacists on both sides of the interface are enthusiastic
to improve communication. The trouble is that they often do not know
how to do this,” said Dr Duggan. “We do have examples of
good practice, but they are neither widespread, nor uniform, nor routine.”
And therein lies the rub. Although the research exists, the problem is
a lack of implementation. Why is this the case? Dr Duggan suggests a
number of problems. There is a gap between research and policy and practice,
she says. The same pilots are being repeated in different localities
rather than moving on to the next level, and people are unsure how to
implement roles. She also thinks that there is a lack of understanding
of roles and responsibilities, a lack of communication between sectors
and a lack of agreement over what should or can be done.
“Discharge planning is not always dealt with at organisational level:
it may not be seen as either a primary care responsibility or a secondary
care responsibility,” Dr Duggan says. But organisations do have
to address this. Last year’s Government document, “Discharge
from hospital: pathway, process and practice”, sets out principles
of good practice and guidance for organisations. Good practice
Possible solutions
Some possible solutions to improving medicines management across
the interface are:
· Discharge information, including an explanation of the discharge
prescription, is faxed from the hospital to the GP, community pharmacist
and primary care pharmacist
· Patients at risk of medication problems after discharge are identified
in hospital and then referred to a named pharmacist or technician
to follow-up at home
· Patients are helped to self-administer medicines in hospital
so they get used to their new medicines before they are discharged
· Discharge planning starts as early as possible in the hospital
stay, even before admission for planned procedures, and should
involve a multidisciplinary approach
· Joint formularies between primary and secondary care are used
to help prevent medicines being changed purely because they are
not on the formulary |
What should be happening? Routine discharge planning should be in place
at all hospitals and standards should be set for information transfer,
suggests Dr Duggan. “Information should be sent out to GPs and
community pharmacists, perhaps using a four-layer copy form. But one
huge issue is ensuring that these forms are legible,” she says. “Having
a plan rather than a TTA [to take away prescription] that can communicate
what changes have occurred and the reasons for these changes might
be better,” she adds. “It all comes down to improved communication.”
In some places, hospitals and primary care trusts have got together
to fund joint posts to improve medicines management over the interface.
In Huntingdonshire, they have gone one step further and appointed a medicines
management team that works across the primary and secondary care settings
(see Vision for Pharmacy, p217).
Another pharmacist in a new interface role is Stuart Richardson. He is
a senior clinical pharmacist employed by Kensington and Chelsea PCT but
he spends his time evenly between the PCT and Chelsea and Westminster
Hospital. “My role is to provide a link between the hospital and
PCT so as to facilitate medicines management across the interface and
to lead on clinical issues relating to older people within each setting,” he
explains. He is in the process of developing a comprehensive GP referral
pathway to improve the information that the hospital gets at admission.
At the other end, he is designing a computerised template to use for
electronic discharge prescriptions. “This will standardise the
information provided and will include concordance issues as well as details
on compliance aids and reasons for changes to medicines,” he explains.
It is hoped that this information will be sent to community pharmacists
as well as GPs.
Similar initiatives are under way at Hull Royal Infirmary, where Paul
Kendrew is a primary/secondary care interface pharmacist. He spends half
his time working on interface issues and the other half as a ward-based
pharmacist. He is involved in introducing an “immediate discharge
letter” which is sent from a short-stay acute admissions ward to
a patient’s GP on discharge. “It provides information about
the diagnosis, medical history and the medicines the patient is taking,
including an explanation of why new medicines have been started,” he
comments. A pilot study of faxing discharge prescriptions from the hospital
pharmacy to patients’ GPs to overcome problems with delays in discharge
letters reaching GPs is also under way.
But even if this type of working is not possible — and there are
difficulties in geographical areas where patients are referred to more
than one hospital and where a hospital provides services for a number
of PCTs —there are still opportunities to improve care at the interface. Community pharmacy roles
Improving care over the interface does not just involve hospital and
primary care pharmacists: there is a role for community pharmacists
too. Claire Jones, assistant head of NHS service development at the
National Pharmaceutical Association, says: “Now is a key time
for community pharmacists to get involved because of the emphasis on
delayed discharge from hospital, implementation of the single assessment
process and a drive to move forward on intermediate care.
“There are various services that community pharmacists can offer, from
monitoring the difference between hospital discharge information and
prescribing by GPs to performing medication reviews in patients’ homes.” Speaking
at the PCPA conference, Ms Jones suggested that if community pharmacists
had a copy of the discharge prescription from the hospital they could
compare it with prescriptions from the patient’s GP and contact
the GP if they identified any discrepancies. A medication review service
could be added to this for patients at high risk of medicines-related
problems.
Examples of good practice do exist. Some hospitals refer patients who
need ongoing support, such as monitored dosage systems, to a specified
community pharmacy. This way the patient knows where to go for help once
discharged from hospital and the community pharmacist is better placed
to provide support because the hospital has provided relevant information.
Similarly, some PCTs fund community pharmacists to review patients that
the hospital has identified as being in need of medicines support. One
system that has been in operation for some time is K-med. The system,
set up at Kettering General Hospital, involves a medication summary (including
explanation for changes) being sent to GPs and community pharmacists.
Similarly, a scheme led by East Riding and Hull LPC involves discharge
information for high risk patients being faxed to community pharmacists.
The pharmacist then reviews the patient’s medication at home, liaises
with the patient’s GP, produces a care plan and provides ongoing
monitoring. The service has just started and a full audit is planned.
It is difficult to see how these systems can work without addressing
one contentious issue: should patients be registered in community pharmacies? “Yes,” says
Dr Duggan. The argument given against registration is that it restricts
patient choice. However, Dr Duggan says: “Patients tend to choose
to go to the same pharmacy. Even in London, research shows that 89 per
cent of patients stick to the same pharmacy.” She adds that patients
do not even think about going to a GP other than their own.
Another real problem that many community pharmacists face is getting
the funding to provide new services. How should they go about this? “The
first thing pharmacists should do is approach the PCT to see what the
local priorities are and make the case that community pharmacist involvement
in the discharge process can make a difference to patient care,” Ms
Jones says. In the future, other opportunities might exist, such as offering
a local pharmaceutical service or a supplementary service under the new
pharmacy contract.
When approaching a PCT for funding, pharmacists need to:
· Carry out the research into the evidence-base for the proposed service
and use this to support the application
· Make sure the service targets local need and the PCT priority areas
· Describe the service, what it aims to achieve and how it will be monitored
· Clearly present the benefits (eg, patient benefits, safety improvements,
meeting PCT targets and cost savings) and costs of the service (eg, resources,
training)
· Start with a small pilot but try to get an advance agreement to roll-out
the service if the pilot is successful
The Royal Pharmaceutical Society is in the process of producing a toolkit
called “Discharge planning and medicines” to help improve
medicines management at the interface. The toolkit will be launched in
the spring. Dr Duggan has played a crucial role in the development of
the toolkit. She explains: “It aims to use research evidence, policy
documents, expert opinion and examples of good practice to develop standards.
We are at the stage of collating examples of good practice from each
sector and each specialty to inform our recommendations for good practice.” When
this has been done, standards can be developed. “Once these standards
have been set, local implementation strategies can be agreed and implemented.
Then good practice can become a baseline for trusts in primary and secondary
care,” she adds. This can only be a good thing for patients.
Which interface?
There is a general assumption that the interface at which problems
arise is that between primary and secondary care. However, it is
worth considering the interface between health and social care,
according to Beth Taylor, principal pharmacist at London Specialist
Pharmacy Services.
Speaking at the PCPA conference, Ms Taylor said that many of the
tasks associated with taking medicines are carried out by people
other than health professionals. She emphasised the importance
of the role of social care. “Prescribing and dispensing medicines
are the only tasks that have to be carried out by health professionals,” she
said. Tasks that could be undertaken by others included requesting
repeat prescriptions, collecting medicines, administering medicines,
monitoring medicine use, disposing of unwanted medicines, encouraging
self-medication and training patients. This raised issues around
the training that social workers have in medicines management,
particularly since social workers might have to assess patients’ ability
to cope with their medicine regimen. “Staff in care homes
and domiciliary care welcome advice on medicines management. They
need some sort of basic guidance about medicines,” Ms Taylor
said.
In April 2004, the single assessment process (SAP) for older people
has to be implemented. “The SAP is a way of providing single,
joined-up assessment for people with complex needs in health and
social care,” she explained. This is so patients do not have
one assessment after another in each area of health and social
care.
“
In the future, more care will be provided through integrated teams.
There will be a greater choice for patients about how they want
to access services,” she added. “Pharmacists need to
think about how they engage with all teams at all levels to support
medicines management services.” |
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The
Pharmaceutical Journal