| In January last year, an opportunity arose at a meeting of Glasgow’s
Cardiac Health Improvement Group to apply for funding for services in
heart disease and stroke. Two pharmacists — Richard Lowrie, lead
primary care pharmacist at NHS Greater Glasgow primary care operating
division, and Steve McGlynn, principal pharmacist at North Glasgow University
Hospitals operating division and clinical lecturer at Strathclyde University — are
members of the group. Their presence turned out to be key in getting
funding.
“Heart failure is a huge problem in Glasgow and its prevalence
is increasing,” says
Mr Lowrie. “Chronic diseases have a strong link to deprivation
and the extent of deprivation in Glasgow is one of the reasons for the
high prevalence of heart failure.”
Funding was to come from the New Opportunities Fund, which is financed
by the national lottery. It granted £2.6m to improve coronary heart
disease and stroke services in Glasgow. In particular, the NOF identified
heart failure clinics and optimising patients’ medication as priorities
for this money. It fell, in turn, to the Cardiac Health Improvement Group
to prioritise bids for this sum and the NOF gave final approval.
Mr Lowrie and Mr McGlynn knew
that this provided an ideal opportunity for a
pharmacist-run service and decided immediately to apply for some of the
funding. “With these priorities, it would have been hard for the
group to argue that our bid was not relevant,” says Mr Lowrie.
So perhaps it was not surprising that the team was awarded £300,000 (PJ, 25 October 2003, p571).
What is important is that the first time Mr Lowrie and Mr McGlynn heard
about the funding was at the Health Improvement Group meeting when they
had to indicate that they would bid for funds. Neither had been told
that it was on the agenda. “This shows that pharmacists have got
to get places on organisations at a decision-making level,” says
Mr McGlynn. The group has now become a Cardiac Managed Clinical Network
and both are members. These networks are multi-professional organisations
that plan delivery of health services across all care sectors.
Anfrances Duggan: primary care role |
The funding allowed three new pharmacist positions to be created: two
primary care pharmacists, Anfrances Duggan and Fiona Lambie, and one
hospital pharmacist, Pernille Sorensen, have been appointed. The three
started their new jobs
earlier this year and have since undergone an extensive training programme.
This has included a heart failure therapeutics course at Glasgow Caledonian
University, in-house training about medication
review, a phlebotomy course, blood pressure monitoring training and computer
training. The two primary care pharmacists have started a supplementary
prescribing course and it is intended that
Miss Sorensen will follow suit as soon as possible.
Primary care service
The starting point to any service is finding out exactly what the problem
is and then working out what needs to be done to solve it, says Mr
Lowrie. He knew the extent of the heart failure problem in Glasgow
from pilot work carried out by the existing team of general practice-based
prescribing support pharmacists (PJ, 29 June 2002, p911 PDF
(55K)). This team
of pharmacists, managed by Mr Lowrie and his colleague Alister MacLaren,
lead the way in rolling out clinical services to community pharmacy
in Glasgow. This is exactly what is planned for the new service. “Our
long-term vision is for the reviews to be undertaken by community pharmacists.
But first we need experts to establish the service: to make sure it
works and also to train the community pharmacists,” Mr Lowrie
explains.
The pilot work identified that 38 people for every 1,000 aged over
65 years in Glasgow have heart failure. Of these, two-thirds are taking
ACE-inhibitors but only one-third are on the correct dose. It is worse
for beta-blockers: one third of patients are taking beta-blockers but
only a third are prescribed a dose that is known to work. “The
point is there was a huge gap in terms of medicines being used correctly.
Yet in heart failure, medicines are the mainstay of therapy: they make
the patient feel better, they improve quality of life, they keep the
patient out of hospital and they prolong life,” says Mr Lowrie.
Using the pilot work, the team estimated that for the whole of Glasgow,
about 5,500 patients could be reviewed over the three-year funding period.
If successful, the service should prevent over 100 deaths and many more
hospital admissions in three years.
All 216 GP practices in Glasgow and the local homeless unit were invited
to take part in April. So far, 134 have agreed and only 11 have declined. “Heart
failure is in the new GP contract so that is probably a factor in why
we have had such a good response,” comments Mr Lowrie.
The pharmacists started reviewing patients in the middle of May. Their
first job is to identify which patients might have heart failure and
to create a disease register. Next, the heart failure diagnosis must
be confirmed by echocardiogram. Patients are then invited for a review
or a domiciliary visit is arranged. During the medication review, the
pharmacist examines which medicines have been prescribed, confirms their
suitability and ensures that doses are titrated to an appropriate dose.
Decisions between individual drugs are based on the Glasgow formulary.
The pharmacist also draws up a pharmaceutical care plan for the patient
and fills in a GP referral form if necessary. The patient is followed
up a couple of months later, perhaps by telephone, to ensure that any
changes have been made and to check no new problems have arisen.
Both pharmacists spend a day a week with a practice for as long as it
takes to review all the patients identified. Because of the number of
practices involved, priority has been given to those with the most deprived
population. Usually 10 patients are reviewed each day. Both pharmacists
have laptops in order to collect data and to enable them to plug into
GP practice systems and download information required for medication
reviews.
Fiona Lambie undertakes consultations in primary care |
Why did the two pharmacists take on the roles? “I wanted to get
involved because it was something new that I thought could make a difference
to patients,” says Ms Lambie. “My background is in hospital
pharmacy and I was intrigued by the primary care sector.” Mrs Duggan,
on the other hand, worked in community pharmacy. “So I was used
to seeing patients but sometimes felt restricted as to what I could do
for them. This service provides an extension.” She explains that
they have both had to learn to think like clinicians and to make decisions
based on evidence which has involved getting to grips with clinical trials
papers. “It has been a huge learning curve,” says Ms Lambie. “But
now we are at the stage of putting it into practice and our different
backgrounds have complemented each other well.”
Des Spence, a GP at Maryhill Health Centre, one of the practices already
involved, comments: “This is an important development for pharmacy.
There is a strong argument that pharmacists have a major role to play
in contributing to areas of unmet need and although this project is working
on heart failure perhaps other areas could be considered in due course.”
The service is expected to expand in the future. In the short term, the
two pharmacists are hoping to take on responsibility for initiating beta-blockers
in the community, something that has caused problems for GPs. In the
longer-term, plans are in place to continue the service after the New
Opportunities Funding has run out. “A key part of the bid was to
state how it will continue to work after the funding has stopped,” says
Mr Lowrie. “Greater Glasgow NHS Board has agreed to pay for one
whole-time pharmacist following the end of the funding.” This pharmacist’s
role will be to oversee the service as it is rolled out into community
pharmacy, provide training, monitor the service and provide a link between
the primary and secondary care arms of the service. He also hopes that
the service can be funded in the future through the pharmaceutical care
model schemes with all community pharmacists being able to offer reviews
to patients with heart failure. Secondary care
In secondary care, the impetus for setting up the new service was the
fact that the clinical pharmacy service for heart failure patients
was haphazard. “In some areas it was good but there was no consistency
across the population. One of the requirements for every service is
equity,” Mr McGlynn says.
Patients in Glasgow already benefited from a well-established heart
failure nurse liaison service under which patients with heart failure
were identified
by a dedicated nurse in hospital and then followed-up at home post-discharge. “But
lots of patients were missed for a variety of reasons,” Mr McGlynn
comments. These included problems with identification of heart failure
patients since they are likely to be admitted to medical, geriatric or
even surgical wards as well as cardiology wards. “And the nurses
do not have the same medication review skills as pharmacists.”
The outcome was that hospital pharmacists did not always have the opportunity
to take an in-depth look at the patient’s medicines. “Patients
were being discharged on sub-optimal therapy,” says Mr McGlynn.
This is what the new service aims to correct. The nurse liaison service
was central to the development of the new pharmacy service; the pharmacist
input aims to offer improvements.
Pernille Sorensen (right): hospital role |
Miss Sorensen explains: “We decided that we would need to find
the patients ourselves rather than rely on referral from the nurse liaison
service. The obvious answer was for ward-based pharmacists to identify
heart failure patients.” Criteria for ward pharmacists to identify
patients have been drawn up and these will be audited.
One of the key elements of the pilot is the development of a standard
pharmaceutical care plan which Miss Sorensen prepares and individualises
for each patient. A summary of this is provided to the liaison nurses
as a
transfer-of-care plan. The aim is to provide structured care and ensure
the nurses get good information about the patient. The care plan includes
a detailed drug history, investigations undertaken in hospital, compliance
and outstanding care issues. If any drug changes are needed to optimise
therapy, Miss Sorensen recommends these to a cardiologist or junior doctor
so that the patient’s prescription can be altered. “The cardiologists
have been very supportive,” she says.
At the moment, the new system is being piloted at one of Glasgow’s
hospitals, the Victoria Infirmary, but the plan is for it to be extended
to the others once it has been tested. “We have to ensure that
the system is safe and effective before it is extended,” says Mr
McGlynn. “Over the next quarter, I hope the service will be running
here and pilots will have begun at two other sites so about half of the
city’s hospitals are covered.” The service will then be rolled
out to the remainder as soon as possible after that.” As the service
is extended, Miss Sorensen’s role will change. She will carry on
providing direct patient care at the Victoria Infirmary but will also
take on roles in managing the service at other hospital sites and supporting
the pharmacists who provide the service there. Miss Sorensen is already
on hand to provide advice to the two primary care pharmacists if they
come across a patient with particularly complex needs that require her
specialist input.
A further extension to the service involves supplementary prescribing.
Miss Sorensen hopes to start training later this year and, at two other
hospitals in the city, pharmacist supplementary prescribing is further
ahead. Mr McGlynn has already completed the training and another pharmacist
is about to. The plan is for pharmacists to prescribe on the wards. Standardised
clinical management plans, to be used as part of the heart failure service,
are currently being developed.
Longer-term plans include a link with community pharmacy. “One
of the biggest concerns that the nurse liaison service has is what happens
to patients when they have finished with them. They don’t want
to just drop the patient. So we are exploring the possibility of nurses
referring the patients to community pharmacists,” explains Mr McGlynn. “The
pharmacist that patients will see regularly for the rest of their lives
is the community pharmacist so they need to be involved in long-term
care.” He envisages community pharmacists providing chronic disease
management covering compliance, education, monitoring and some dose adjustments. The future
How total care of heart failure patients in Glasgow will be structured
in the future will be determined by a new strategy currently being
developed across primary and secondary care by the Cardiac Managed
Clinical Network. This means that both Mr McGlynn and Mr Lowrie are
involved in the strategy’s development so the two-part pharmacy
service looks likely to feature. |
The
Pharmaceutical Journal