Organisation statistics
Hinchingbrooke Hospital has 450 beds and serves a population of
150,000. Huntingdonshire Primary Care Trust covers 24 GP practices
and is a rural community with 18 of the surgeries being dispensing
practices. However, no distinction is made and all receive pharmacy
input under the direction of the medicines management team. There
are 22 community pharmacies in the PCT area. |
Over the past year, Huntingdonshire Primary Care Trust and the
local hospital Hinchingbrooke Health Care Trust have radically changed
the
way they work. The restructuring of pharmacy services has been largely
down to the attitude of the chief executives of the primary care and
acute trusts. The opportunity for change was created by the appointment
of a single director of medicines management across both
organisations.
Three new roles were then created. The new team comprises the director
of medicines management Sue Ashwell, and three associate directors. The
three directors are Sati Ubhi, who is responsible for prescribing and
medicines management and is based in the primary care trust, Janet Watkinson,
who is responsible for clinical development of pharmacy in the hospital,
and Darren Leech, who is responsible for pharmacy services delivery in
the hospital.
Discussing prescribing (left to right): Sati
Ubhi, Sue Ashwell and Janet Watkinson
|
The changes in Huntingdonshire started last March when Mrs Ashwell was
appointed. The trigger was partially financial, with the two chief executives
deciding that by working together they could make better use of the drugs
budget, and partially down to a need to address clinical governance.
A review conducted by the Commission for Health Improvement helped identify
what needed to be done in terms of clinical governance. In its review,
CHI said that the hospital trust’s approach to medicines management
needed to be reviewed and for a strategy on medicines management to be
developed. The result of this review is the new cross-sector medicines
management team.
“
It is blinding common sense,” points out Mr Leech. “If my
granny goes into hospital, she cannot understand why the hospital
doesn’t get the right information from her GP and vice versa when
she is discharged. From her point of view it is all one organisation:
the NHS.” Mrs Watkinson adds: “We know that what happens
in the hospital has an impact in primary care and vice versa.” And
the cross-sector approach taken by the medicines management team means
that these issues can be identified and tackled.
The team approach has worked because all those involved follow the same
designated aims. “We came up with a clear set of values: quality,
safety and making the money go
further. Although a number of people are
involved we still work to those core values. This means that patient
care is more effective, safer and more efficient,” Mrs Ashwell
explains.
Mrs Ashwell’s cross-sector role is key to the integrated approach. “As
director of medicines management, I sit on both the professional executive
committee in primary care and the executive committee in the hospital.
This means that I am sitting among the lead clinicians and gives me the
great advantage of free passage in both organisations,” she comments. “We
have spent £0.25m on developing the medicines management team and
we will save £0.5m on prescribing costs this year to be spent elsewhere
in health care.” She emphasises that this is a recurring saving,
not an initial one-off effect, particularly since the team has plans
of new initiatives still to be
introduced.
“One of the important outcomes of this arrangement is that if I
turn up at a surgery, the GPs know who I am,” comments Mrs Watkinson. “And
when Sati walks around the hospital, the consultants know who she is.
We really do have joined up working.”
Prescribing improvement agreement
Underpinning the medicines management team’s work in primary care
is a prescribing improvement agreement. It sets standards around quality
of prescribing with practice pharmacists helping GPs to achieve the standards.
This new agreement replaced the old prescribing incentive scheme.
The prescribing improvement agreement contains 10 quality improvement
standards. Four are compulsory and all GP practices must achieve them.
They tackle repeat prescribing improvements, monitoring high-risk drugs,
ensuring National Institute for Clinical Excellence guidance is followed
and reducing inappropriate prescribing.
“
One size does not fit all practices so which of the other standards apply
depends on what the practice needs to work on,” explains Ms Ubhi.
Examples of the other standards include ensuring monitoring tests are
carried out and that the right services are offered for particular diseases.
Every practice is given a folder outlining the standards that it has
to achieve.
The prescribing improvement agreement might apply to GPs in primary care
but drawing up the agreement took a cross-sector approach. “We
shared the folder with the hospital’s drug and therapeutics committee,” comments
Mrs Ashwell. This meant that what is in the prescribing improvement agreement
fed into the hospital formulary and vice versa: the result is a joint
formulary approach.
How it works: omeprazole
The PCT and hospital have just reached a joint agreement that
omeprazole will be their proton pump inhibitor of choice. This
means that if a patient consults either a GP or hospital consultant,
the message will be consistent. A switch process is about to be
implemented. |
How it works: new drugs
The PCT prescribing subgroup and the hospital drug and therapeutics
committee have reached an agreement over assessing new drugs. A
new drug is considered by the group where the majority of its impact,
in terms of both workload and expenditure, will be felt. Mrs Ashwell
explains that a recent example of this involved the hospital ophthalmologists
wanting to prescribe a new eye drop. The impact of this would have
been greater in primary care so it was the PCT prescribing subgroup
that considered the proposal. |
How it works: tramadol
“We used to spend a lot of money on tramadol,” says
Mrs Ashwell. The team decided that for many patients it was not
the most effective painkiller, not the most cost-effective option
and it had many side effects. “But there was a belief among
GPs that the hospital wanted tramadol to be prescribed,” says
Mrs Ashwell. “We investigated this, spoke to the surgeons
and the pain team and found that actually it is not recommended.
So it was removed from the formulary and we were able to go back
to the GPs and tell them that it is no longer being used in hospital
so let’s review your practice now.” |
Ms Ubhi explains: “It is all about working together. The GPs used
to say that they could not do anything about a medicine that was started
in hospital. Now they are all working together so things can be done.” Examples
of how this works are provided in the panels right. She adds that
each GP practice has both pharmacist and pharmacy technician input. “How
much time each practice requires varies,” she says. The pharmacy
team looks at issues such as repeat prescribing, dose optimisation, high-risk
drugs and appropriate prescribing of drugs such as proton pump
inhibitors.
The team effort is not just about hospital and primary care pharmacists
either. “All the pharmacists working in the practices are practising
community pharmacists,” Ms Ubhi says. This came about after community
pharmacists were invited to an evening meeting to find out if any were
interested in the role. Six pharmacists chose to take on the work in
the GP practices while others felt that they could not leave their pharmacy.
These pharmacists have not been excluded since they are paid to intervene
on errors they find in prescriptions that arrive in the pharmacy. For
each intervention they report to the PCT and the practice they are paid £2. “It
is a closing of the loop,” says Mrs Ashwell.
A lot of the work comes down to good communication, or as the team puts
it “the tea and biscuits approach”. Information is fed both
ways so if a primary care prescribing problem is identified in hospital,
the GPs are informed. And each month GPs are given a newsletter including
information about prescribing decisions made in hospital. The medicines
management team have to ensure they communicate too: they talk on the
phone on a daily basis and meet up weekly so they are all acutely aware
of the overall picture. The hospital roles
The division of work in the hospital between Mr Leech and Mrs Watkinson
is interesting. Mr Leech, who is a pharmacy technician and president
of the Association of Pharmacy Technicians UK, explains that his role
is to run the pharmacy services. “I lift some of the management
burden so that the pharmacists can be more involved in the clinical
side,” he says. His role includes ensuring that all the services
run properly and dealing with issues such as staff management. “One
of the things chief pharmacists say is that they cannot get on with
clinical development because they have to sort out the service delivery
first,” he adds.
Since the arrangement works at Hinchingbrooke so well, they have concluded
that having a chief pharmacist is not the most effective way to deliver
pharmacy services. In law, accountability has to fall to a single person
and that person is Mrs Ashwell. But she points out that she depends on
the associate directors. “It works because we all follow the single
set of core values,” she says.
Within the hospital itself, roles are developing and good use of skill
mix is demonstrated. Greater input of technicians on wards has had an
impact. “Technicians are being used as guardians of pharmacists’ expertise,” explains
Mr Leech. “Half of what wards contact a pharmacist about — inquiries
about supplies, for example — can be dealt with by a technician.
This means that pharmacists are able to react more quickly to clinical
problems. Pharmacists are also on ward rounds where they can influence
prescribing so the dose is right first time, rather than doing a mop-up
several hours later.” He adds: “Nurses should not be leaving
the ward to collect items from pharmacy, instead they bleep the technicians
who deliver it to the wards.”
The pharmacists are able to amend junior doctor’s prescriptions.
If an error is identified, the pharmacist changes it and attaches a note
to the prescription highlighting the alteration to the doctor. “We
started with simple things like correcting amoxicillin that was prescribed
four times a day to three times a day dosing, and ensuring maximum course
lengths for antibiotics of seven or 10 days,” explains Mrs Watkinson.
This not only avoids errors but it also is a form of education for the
doctor. The note system gives the doctors an opportunity to comment on
the changes.
In addition, the pharmacists write many patients’ discharge prescriptions.
Mr Leech attends bed management meetings and can identify potential problem
areas. He then informs the relevant pharmacists so that the discharge
prescriptions can be prepared. By making other people’s lives easier,
pharmacy has gained credibility and support for the development of the
pharmacist’s role as part of ward teams, he adds.
Another concept that the team is keen to introduce is for pharmacists
and technicians to have a “case load” rather than to see
patients according to their location within the hospital. The aim is
to improve continuity of care. For example, on the medical assessment
unit, a pharmacist and technician are employed to liaise with local surgeries
so that a clear picture of patients’ medication histories is gained.
If it is decided to admit a patient, the technician goes to the ward
to check that the patients’ medicines go with them. “It’s
about owning the patient until you hand them over,” says Mrs Ashwell. Future plans
The team has plenty of plans for the future, too. Top of the list is
for the hospital to fax community pharmacists with a summary of medication
changes made in hospital when a patient is discharged. “Community
pharmacists must be included as part of the clinical team,” stresses
Mrs Ashwell.
Another two cross-sector technician positions have been created. They
will spend half their time in hospital on the wards addressing any issues
that patients have about their medicines. The other half will be spent
in primary care following patients up after they have been discharged
from hospital, either doing this themselves or through co-ordinating
community pharmacists to contact the patients, and working on the prescribing
improvement agreement.
Preregistration trainees are also being given cross-sector roles. This
will be operated on a rotational basis so that they spend some time in
primary care, some time in hospital and some time in community pharmacy.
Could Huntingdonshire’s approach to integrated medicines management
be applied elsewhere? “The magic ingredient we started with was
two chief executives who were willing to listen. But what made them listen
was us addressing what mattered to them,” says Mrs Ashwell. However,
she acknowledges that the size of the health system — one acute
trust and one PCT — made the changes easier than would have been
the case if a number of organisations were involved. Whether cross-sector
appointments would work so easily with four or five organisations is
uncertain.
But the experience in Huntingdonshire is positive and much can be learnt
from their approach even if the exact roles cannot be replicated elsewhere. “What
made the difference was that we looked at how pharmacy services and medicines
management could deliver on the wider agenda. This meant that we had
lots of champions, such as the finance directors, consultants and nursing
staff. The team took a step back and worked out what we could offer,
without losing our core value as pharmacy,” says Mrs Ashwell.
Or, as Mr Leech puts it, it is all about revolving the service around
patients rather than around pharmacy. |
The
Pharmaceutical Journal