Nicola Roe and Peter Abraham discuss a patient’s medication
history |
It is an area with high levels of chronic
disease, unemployment and crime. Roughly a third of people are living
with a long-term illness so chronic disease management is an important
issue. That is how Nicola Roe, pharmacy service development manager for
Rowlands, describes an area in Salford where a local pharmaceutical service
(LPS) is now being used to tackle some of the chronic diseases.
The LPS is being used to deliver a pharmacist-run medication review service.
But that is only a small part of a much bigger story. What is happening
in this rather run-down urban area is a total redesign of health and
social services — and pharmacy is playing a crucial role.
New Deal for Communities
The trigger for the regeneration of the local
area was a New Deal for Communities (NDC) project. NDC is a programme
that is part
of the Government strategy to regenerate deprived neighbourhoods
in England. Altogether, there are 39 NDC sites. The two neighbourhoods
covered by the Salford NDC are Charlestown and Lower Kersal. A
grant of £53m has been awarded to the area and a 10-year
plan developed. It focuses on health, crime, education and employment,
young people, building communities and the physical environment.
NDC is about more than health so integrating health services within
the wider context of public health was an obvious step. |
The eventual goal is for all the service providers to be relocated together
into one health and social care community centre. The site is being developed
as an NHS Local Improvement Finance Trust (LIFT) initiative with additional
funding through a New Deal for Communities (NDC) project (see Panels).
In the meantime, the different health and social services are being developed,
many from scratch. As the only pharmacy contractor in the NDC area, Rowlands
Pharmacy was the obvious choice for developing the LPS, which started
operating nine months ago.
How the medication reviews work
“The aim of the medication review service is for patients to be
taking the right medicine at the right dose at the right time,” says
Peter Abraham, LPS pharmacist. The first step is for patients to be referred
to the service. This is a prerequisite. If someone walks in off the street
and asks for a review, his or her GP will be contacted and a review only
carried out if the GP consents. The same goes for referral from other
health professionals: reviews are only carried out if the GP gives permission.
In addition to GP consent, the patient has to fulfil certain criteria
and must be:
· Aged over 60 years
· Taking four or more drugs
· Suffering from a chronic disease
· Confused/have a mental illness
Plus one or more of the following:
· Been recently admitted to hospital
· Have poor compliance
· Live alone or have poor home support
· Have restricted access to services because of a disability
“Once patients have has been referred, we send them an information
letter about the service. A couple of days later we telephone them to
arrange an appointment or a domiciliary visit if the patient cannot come
into the centre,” says Mr Abraham. About one-third of patients
require domiciliary visits.
“We ask patients to bring all their medicines with them to the
review; it is a brown-bag review approach,” he says. The review
includes recording a full drug list, assessing problems patients are
having with
their medicines, how medicines are stored, how medicines are supplied
and collected, compliance, adverse drug reactions and lifestyle issues. “During
the review, I develop a care plan with the patient. For example, if they
have poor inhaler technique the care plan would include improving technique
as an action.”
Once the medication review is completed, most patients enter a repeat
dispensing scheme in which ongoing monitoring is provided. Medicines
are dispensed every four weeks. “A week before they are due, I
contact patients to discuss any issues they have with their medicines
and which medicines they need,” says Mr Abraham. He then orders
the prescription from the surgery and dispenses the medicines, which
the patient can collect from the centre or have delivered. This cuts
wastage since only those medicines that are needed are ordered. In fact,
one thing that strikes visitors when they enter the pharmacy is the limited
stock but there is simply no reason to keep more.
Patients are not signed up to the service permanently. “We have
a conveyor belt approach: patients are only with us for the length of
time needed to identify and deal with any issues with their medicines,” explains
Ms Roe. For some patients this could be just a single visit; for others
a longer time on the repeat dispensing scheme is needed to stabilise
their medicine regimen. “Once stabilised, and with the approval
of the GP, I refer patients back to their preferred community pharmacist.
We contact the pharmacist by letter to explain what medicines the patient
has been discharged from the LPS service on and how the pharmacist can
help with the patient’s management,” says Mr Abraham. This
arrangement should allay other pharmacists’ fears that the LPS
is all about poaching patients.
The LPS is also building links with other health and social service providers.
This was one of the key drivers behind the LPS and why the NDC has been
so supportive. “If I identify other needs, such as needing a care
worker to visit, I refer the patient on to other services,” explains
Mr Abraham. “We have an official referral form to the expert patient
programme and the carers’ liaison project,” he says. Other
referrals will be developed in the future as the links with other services
are built. One of the new positions recently appointed in the area is
a “healthy living officer” and Mr Abraham is expecting to
refer a number of patients to him since so many patients coming for medication
review have a chronic disease that might benefit from advice about exercise
and nutrition. Lifestyle advice, such as on smoking cessation, is also
given through the LPS.
Results so far
Evaluations of the service are currently under way at the Universities
of Manchester and Salford. It is still too early to know what the outcome
of these assessments will be but, going on anecdotal information, the
signs look promising.
Since the service started in June (and from a patient base of zero),
prescribing changes, such as changing doses, changing brands and stopping
unnecessary drugs, have resulted in a saving of £17,000. Two case
studies demonstrate the individual patient benefit. One patient was being
prescribed a toxic dose of metformin. Following contact with the GP,
this dose was reduced and a sulphonylurea added. In addition, the patient’s
weight and blood pressure are now being managed, and a statin has been
added.
The second example involves a patient who had been taking ketoprofen
for 10 years and was taking regular alginates. The ketoprofen was not
for a chronic condition and it had been added to a repeat prescription
accidentally. With input from the GP, the ketoprofen was stopped, a short
course of a proton pump inhibitor prescribed and the patient is now symptom-free.
The LPS service agreement specified a maximum number of patients that
the system has the capacity to handle. Although Ms Roe would not divulge
patient numbers, she is positive about the service’s viability. “Of
course the viability of any service depends on funding and, because of
the work needed on the premises, this service was only viable because
of the NDC support,” she comments.
And the downsides? “The paperwork is taking more time than we thought,” explains
Mr Abraham. “We allocated one hour per patient for the review.
This includes the review itself, which usually takes between 25 and 45
minutes, writing up the notes and supplying the GP with the care plan.”
Rowlands has been able to have an input into the design of the new health
and social care community centre. However, it has been hard work. The
PCT originally envisaged it as a health centre. It was not until February
that the original designs which contained a traditional-style pharmacy
were replaced with a more suitable set-up for the LPS service.
The health and social care community centre will include doctors from
several existing GP surgeries, the pharmacy-run LPS, social workers,
complementary therapists, and workers from the Community Health Action
Partnership, the Expert Patient Programme and a local food co-operative.
It will also serve as a community centre. There will be one receptionist
for all services in the building.
The new centre is about an entirely different way of working. And it
is one that Rowlands Pharmacy — through its LPS — is embracing. How the LPS was set up
Once a need for a medicines management service in the area was identified,
and LPS chosen as the vehicle to deliver it, the local primary care
trust invited tenders for the LPS. The Rowlands bid was accepted.
Although a Rowlands pharmacy already exists in the area, the LPS has
been set up in a separate building. Ms Roe explains: “It was always
intended that the LPS provider would end up in the health and social
care centre but that in the interim it would be offered from a pharmacy.
Our existing pharmacy did not have the space for a consultation area
so it was clear that we would need separate premises for the LPS.”
Finding the right building to house the LPS was an obstacle and, when
a derelict building in the right location was finally found, money was
needed to renovate it. This is where NDC stepped in. “NDC is not
just about health; it is about the environment too. We were offering
a new service and bringing a derelict building into use,” says
Ms Roe. The NDC funding was granted and it was then suggested that office
space was provided for two other service providers. This is how the local
carers’ liaison officer and the manager of the expert patient programme
found themselves working alongside the LPS team.
The key things the LPS had to offer were chronic disease management and
a minor ailments service. The minor ailments service created a bit of
a problem. “The solution was to subcontract the minor ailments
service to the existing Rowlands pharmacy which is just a few minutes’ walk
away,” says Ms Roe. When the building that houses the LPS was refurbished,
a decision was made not to sell or supply any medicine or product that
is not part of the LPS medicines management service. In no way does it
represent the traditional image of a community pharmacy: immediately
through the front door is a reception area offering health promotion
information with two consultation areas at the back. The dispensary is
upstairs, along with the office space for the carer’s liaison officer
and expert patient programme manager.
The LPS itself is funded by the PCT and other income comes from prescription
turnover. The LPS funding is complicated in that it has to be worked
out in advance. This has its advantages: the pharmacist knows exactly
what the funding will be. However, if the patient numbers go above those
agreed there is no guarantee of extra money so it is essential to get
the funding agreement right at the beginning.
Rowlands decided that one way to make the service cost-effective was
to make good use of skill mix. The LPS employs two pharmacy technicians
and one pharmacist. The technicians carry out the initial data collection
part of the medication review and the pharmacist then takes over to carry
out the clinical aspects: identifying problems and developing a care
plan. On busy days this means that consultations can run almost simultaneously,
with the pharmacist able to finish one and move to the next that the
technician has already started. Why did Mr Abraham want the job? After
experience in both hospital and community pharmacy, he thought the LPS
role would present new challenges and opportunities to use his clinical
skills: it has.
Health issues facing the community
What are the health problems in Charlestown and Lower Kersal? For
a start, the mortality rate is more than twice the national average
and one-third of the population has a chronic illness. The population
of 10,000 also suffers from a lack of access to health facilities:
although 52 GPs serve the area, only three GPs are actually located
within it and there is just one pharmacy and one part-time dentist.
Phil Greenham, health development manager for the NDC, says: “The
area isn’t the lowest of the low: it is poor but not the poorest
area. Our task was to put interventions in before it hit rock bottom.”
She explains that the key factor in any kind of social change is
getting the involvement of both the front-line workers and the local
people. So through the neighbourhood renewal programme of NDC, the
community became involved in deciding what services were wanted and
needed. “When we tried to glean from the community what they
wanted it was clear that expectations were low. There was an awful
benchmark of normality: for example, people expect to have respiratory
disease because everyone on their street does,” she says. A
health focus group was set up to develop the health agenda. A pharmacist
was involved from the start. Local people prioritised what services
they wanted: Monopoly money was used to help decide which priorities
money should be spent on. “Once we had all the data and research,
I translated the results into tangible services,” explains
Ms Greenham. A medicines management service was one of them, and
when the Government announced its plans for LPS, it seemed logical
to use LPS as a way of funding and providing the service.
Ms Greenham says that she is delighted with the progress so far. “I
think what we are doing here is three or four years ahead of what
is happening in the city, and the rest of the UK for that matter,” she
comments. She is particularly pleased with how the LPS and other
services are building links and cross-referrals. “We want all
the services to be integrated before they move into the new centres,” she
says. |
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The
Pharmaceutical Journal