The Pharmaceutical Journal
Vol 272 No 7291 p350-351
20 March 2004

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Medicines management: opportunities for pharmacists in new GMS contract

In the last article of the series, Sue Carter, head of prescribing and pharmacy, Adur, Arun and Worthing Teaching Primary Care Trust, gives her view on medicines management issues, including medication review and repeat prescribing

Agenda series  |  Pharmacy and the new GMS contract series

Medicines management is a term that covers every aspect of therapeutic use of medicines at both organisational and individual patient level, including prescribing, dispensing, monitoring, policy, clinical governance, education and medication review. The new general medical services contract contains many themes and issues of direct relevance to medicines management, and yet, among the plethora of new GMS guidance, briefings and publications, there is no specific information or documentation on medicines management issues. Some medicines management issues are obvious and set out in the Quality and Outcomes Framework, but for many others, it is necessary to read the detail and look behind the headlines. The medicines management issues fall into four broad categories:

· Medication review
· Repeat prescribing
· Enhanced services medicines management issues
· Contractual and other issues

Medication review

The term “medication review” appears in the contract (see Panel 1), but there is widely varying interpretation of what that medication review should involve in general practice.

The national guidance document “Room for review”1 establishes tiered levels of medication review, and places a great emphasis on involving patients as partners in review, in order to reach informed agreement about their medicines, improve health outcomes and increase satisfaction with care. The number of medicines that a patient is taking will increase as the quality standards in chronic disease management are achieved, and with evidence showing that compliance with long-term medication is far from 100 per cent, it will be more and more important for patients to be involved in medication reviews and partnership in medicines taking.

However, discussions with GPs and their teams show that most GPs are aiming for a far less in-depth approach, mostly without the patient present. It may therefore be necessary for primary care organisation prescribing adviser teams to be pragmatic about agreeing with GPs what should be covered in a medication review, starting with a simple approach such as four or five signposting questions, similar to those used in “Ask about medicines week”. These reviews could act as a filter and signpost to more in-depth reviews provided by pharmacists or others at a higher review level. The more in-depth approach could be used in the two clinical areas of epilepsy and mental health, with all medication reviews gradually being developed into a more thorough service for all patients.

Repeat prescribing

Quality in repeat prescribing systems is emphasised in several indicators including the medication review indicators in Panel 1. Practices are required to have a repeat prescribing policy available to patients, and will be assessed on how well their staff know the policy and how they put it into action. There is therefore a major opportunity for pharmacists to work with practices to help them review their existing repeat prescribing systems, address any gaps or identified problems, and assist with staff training.

Medicines management issues

PCO pharmaceutical teams and practice pharmacists will need to help locally resolve and clarify many medicines management issues, such as those examples in Panel 2.

Contractual and other issues

Part of the new GMS Contractual and Statutory Requirements for practices is a requirement that “the practice adheres to the requirements of the Medicines Act for the storage, prescribing, dispensing, recording and disposal of drugs including controlled drugs”. However, tracking down the exact requirements of the Medicines Act and providing authoritative advice and support to practices on this is a challenge. The first PCO adviser to share his or her practice guidance on this will be very popular! In addition, the requirements for staff involved in administering vaccines to be able to administer appropriate first-line treatment for anaphylaxis require an extensive range of patient group directions to be developed.

The QOF has a standard for practices to check expiry dates of emergency drugs at least annually. However, there is no mention or requirement to check other drugs stocked in the practice or engage in other risk management activity.

Opportunities for pharmacists

There are many opportunities for community pharmacists to engage with their local practices, and to contribute to improvements in medicines management standards across primary care. If pharmacists wish to provide medicines management services direct to practices, it is essential for them to be seen as cost-effective and flexible in meeting individual practice needs. There are obvious parallels with the “Medicines use review” advanced service proposed as part of the new pharmaceutical services contract. However, this is currently specified as a concordance-centred face-to-face review, assessing problems with current medication and administration, and the patient’s knowledge and understanding of their medicines. A medicines use review is therefore more likely to complement a new GMS medication review, rather than replace it, and therefore may not be an avenue for new GMS funding to be used by community pharmacists.

In the case of medication review, this could be achieved by helping practices with the basic new GMS reviews or being remunerated by practice or PCO to carry out more in-depth level 3 reviews for those who need them. Achieving new GMS quality standards in many different areas means that sometimes the patient can be seen as a number of disease areas rather than as a whole person. Medication review can be the ideal time to consider the patient as an individual, looking at the appropriateness of each medicine, side effects and interactions, and assessing whether the patient is able to manage drug regimens that are often complex.

Community pharmacists are ideally placed to demonstrate their expertise in medicines issues, and cement local relationships, by assisting practices in writing repeat prescribing and other protocols, training staff and by helping practices provide information for patients. Hospital pharmacists will need to liaise with primary care colleagues on interface issues, prescribing policies and shared care guidelines. PCO pharmacists have a major work programme ahead to support practices meet the varied issues in enhanced services and QOF, as well as stepping up to the challenge of managing prescribing budgets, which are coming under unprecedented cost pressure.

Working together, pharmacists in all fields of practice have an opportunity through new GMS to engage with GP practices in a better way than ever before to improve patient outcomes, improve professional satisfaction and demonstrate the pharmacist’s role as expert on medicines in community and primary care — all of which bodes well for the future provided this opportunity is not missed.

Reference

1. Room for Review. A guide to medication review: the agenda for patients, practitioners and managers. Available at www.medicines-partnership.org

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