The Pharmaceutical Journal
Vol 273 No 7306 p12-16
3 July 2004

This article
Reprint   Photocopy

PDF 330K, Acrobat Reader

Pharmaceutical Care Awards

Pharmaceutical care in a double room: is UK pharmacy up to the challenge?

Foppe van Mil started his keynote speech at the conference for the Pharmaceutical Care Awards by pointing out that the idea of a pharmaceutical care “double room” was not the result of some language difficulty, although he hails from The Netherlands. He is a community pharmacist and a keen observer of pharmacy practice world wide and he hoped by the end of his speech listeners would understand what he meant.
The main strand running through his talk was what the pharmacy profession thinks is needed for the provision of pharmaceutical care and whether these conditions are found in the UK. Many of his comments proved controversial. “The definition of pharmaceutical care remains a bit unclear, but in general the European understanding is that pharmaceutical care is ‘the professional care provided by the pharmacist and his team around pharmaceuticals’. The ultimate aim is to improve the patient’s quality of life,” he said.

However, there are a number of problems, according to Dr van Mil. Although the professional role of a pharmacist is focused on pharmaceutical care, in many countries this role is not the major concern of the profession. He wondered if there were any future for pharmacists in selling or dispensing medicines because they do not require an academic education; for providing care and preventing or correcting drug related problems a critical approach and a lot of specialised knowledge and skills are needed, so combining dispensing with care provision seems difficult he argued.

Dr van Mil described the main requirements for pharmaceutical care to be carried out. Do pharmacists have enough time, room or money to offer pharmaceutical care? he asked. “From our data the licensed [registered] staff in Luxembourg, Spain and Great Britain has little time for care provision. With 76 prescription items per day per licensed team member in 1998, UK pharmacists are more than three times as busy with the mere act of dispensing as countries on the low end of the scale. Relatively large pharmacies, serving many patients per day, employing more pharmacists have more time available for their clients than smaller pharmacies,” he said.

Dr van Mil then went on to discuss the amount of space available in a pharmacy. “We calculated the space per patient served per day. There is a large variation, but that variation depends on the question if other products are sold in the pharmacy, or only medicines. For the provision of pharmaceutical care one should look at the available space for dispensing medicines, and not at space taken up by stands for sun lotion or rubber ducks. I do not have the UK data, but in Europe the space varies between 0.34 and 1.85 square meter per patient per day, Pharmacists providing pharmaceutical care must make it clear that their premises house a health care professional. “A separate consultation room is a must and there should be space for information leaflets on diseases and drug use in general. I fear that pharmacies in Great Britain are not doing very well in this respect,” he added. Counselling, advising and discussing with clients, is an essential part of pharmaceutical care. “For such counselling you need of course the skills and attitude, but also quiet surroundings and a separate room,” Dr van Mil recommended.

“ I think it is fair to say that when pharmacists provide pharmaceutical care, they also may expect some reward. This reward can be financial, but that must not necessarily be so. Recognition, esteem and satisfaction are also essential. I think that the fact that some of you present have been nominated for the British Pharmaceutical Care Awards for 2003, is a reward in itself and will stimulate you to continue even when no actual payment is available.”

Dr van Mil added: “Although the UK is one of the countries in the world that is most forward in many aspects of pharmacy, the translation of professional standards and concepts into pharmacy practice in my view leaves a lot to be desired.”

He also explained what he meant by the double room. “The double room that is needed for pharmaceutical care would, on one side, have actual physical space for consultation in pharmacies in professional surroundings. On the other side, I would like there to be more mental room for the concept of caring for the clients, in spite of the current lack of remuneration.”

The switch towards the patient can only be made if pharmacists are convinced that they are health care professionals. They should get rid of the detergents and cameras and focus on medicines and the patient.

Change creeps up at fast pace in pharmacy today

The Pharmaceutical Care Awards are particularly relevant because of the fast pace at which the pharmacy world is changing, according to Michael Thompson, vice-president, special business unit, GlaxoSmithKline.

Speaking at the Pharmaceutical Care Awards dinner, Mr Thompson said that GSK has been associated with the awards for 12 years. “When the awards started, the work they were given for was seen as really pioneering. Now some of that work is embodied in Government policy,” he said. “Today we have seen more outstanding work.”

The important issue is how to create ideas that bring about change. “Change creeps up on you. It was not that long ago that we did not have mobile phones. The question is where is the tipping point? We only notice change after it has happened,” he said.

Pointing to the introduction of repeat dispensing and supplementary prescribing, and the forthcoming new community pharmacy contract, Mr Thompson said that in a few years people would be exclaiming over how much had changed since today. “This is what makes these awards so enormously relevant.”

Mr Thompson added that through GSK Plus, the company would continue to support pharmacists in taking new ideas forwards. “The pharmaceutical industry and the pharmacy profession go back a long way, after all we have a common goal: improving the patients’ life through medicines,” he concluded.

Database leads to better shared care

Norfolk-wide lithium database
Stephen Bazire, MRPharmS (pharmacy services director) and Bren Holmes (lithium database manager), Hellesdon Hospital, Norwich

A lithium database and recall service set up by a pharmacist and a nurse has won one of the three Pharmaceutical Care Awards for 2003. It took the team three years, from the original idea, to get the project running — IT needed to be developed and stakeholders needed to be consulted. From 2003, a register of all patients who consent and who are taking lithium within Norfolk Mental Health Care Trust has been kept.

The database is used to send reminders to patients to ensure that their lithium levels are checked quarterly. If two reminders have been sent but no test is carried out, the patient’s GP is alerted and warned of the risks of continuing to write repeat prescriptions for lithium. However, the project is more than just a recall service On registering, patients are also provided with education, information and support.

Perhaps the project’s greatest achievement is that is has established shared care where none previously existed. For example, before the service was implemented there was wide variation with regard to when patients’ care was transferred from secondary care, a lack of a consistent approach to monitoring between GP practices and uncertainty as to who should act in the event of toxicity. The service has rectified all of this. And as a result of the project, the two pathology laboratories in the area were prompted to correlate their previously different ranges for optimum prophylaxis.

The authors say that their pharmacy-based system is reliable and relatively cheap (currently costing £25,000 each year). There are 1,650 patients registered and only 28 patients have declined the service. “We can now be confident that when lithium is prescribed in Norfolk, the service user receives education and information and will not go more than six months without a test, or at least without his or her GP being aware of this,” they say.

The database has been so successful that it is being extended to cover patients in West Norfolk and Waveney PCTs. And the team at Hellesdon are optimistic about future possibilities, suggesting that when an easily portable instrument for monitoring lithium levels becomes available, on-the-spot tests could be done for patients who have difficulty attending a normal monitoring appointment. Similar databases could be used for patients on other long-term medication, such as those taking anti-coagulant drugs.

Tailored approach overcomes cultural barriers

A culturally sensitive diabetes education programme
Lubna Kerr, MRPharmS (research pharmacist), Dawn Wilson, MRPharmS (primary care pharmacist) and Kate Allen (general manager of South East Edinburgh Local Healthcare Community Co-operative), Craigmillar Medical Centre, Edinburgh

A runner-up prize was awarded to a project that improved access to diabetes care for South Asian people in Edinburgh and reduced their health risks. Health care professionals were asked to refer patients of South Asian origin who had type 2 diabetes to the project, which involved providing a medication review in the patient’s home and educating patients about their condition.

The aim was to provide diabetes care in a “culturally sensitive environment”. A pharmacist who could speak Punjabi and Urdu was engaged so patients were able to speak to a health care professional, without language difficulties and in a relaxed manner.

Weight, HbA_1c, blood pressure and cholesterol were measured at the first visit and patients were asked to fill in a questionnaire so that education on diabetes could be tailored to their individual needs. Patients were also invited to attend cookery and exercise classes to encourage lifestyles that improve diabetes control. The cookery classes were designed to show how traditional dishes could be made using less oil, salt and sugar than normal, and without ghee.

Presenting the project at the care awards, Lubna Kerr explained that exercise is not a priority in the South Asian lifestyle. To remedy this, participants were encouraged to attend exercise classes, in an environment where they would feel comfortable. This included providing locations that were for men or women only and where modest attire would be the norm. In addition, Asian music was made available to exercise to.

At the end of the programme, participants had, on average, a 1 per cent reduction in HbA_1c. The authors say that this can be equated to an average of a 37 per cent risk reduction in microvascular events and a 14 per cent reduction in myocardial infarction. Cholesterol levels and body weight also decreased and patients had a better understanding of hyper- and hypoglycaemia.

The authors say that exploiting health care professionals who are bilingual can make a real difference. “It’s about providing outreach to patients — going into homes, work places and places of worship — not expecting them to come to you,” Dr Kerr said. The project could be extended to provide for other ethnic minorities who are at a greater risk of diabetes or coronary heart disease.

Getting medicines right from the start

Integrated medicines management service
Anita Hogg, PSNI (pharmacist project co-ordinator, Whiteabbey Hospital, Co Antrim), Shauna McNicholl, PSNI (pharmacist, Mid-Ulster Hospital, Co Londonderry), Peter Beagon, PSNI (pharmacist, Antrim Area Hospital), Alison Woods (technician project co-ordinator, Whiteabbey Hospital), Philip Campbell (technician, Mid-Ulster Hospital), Agnes Hunter (technician, Antrim Area Hospital), Carol Torrans (technician, Antrim Area Hospital) and Neil McWhirter (technician, Antrim Area Hospital). All part of United Hospitals Trust, Northern Ireland

An integrated medicines management service piloted at three hospitals in Northern Ireland has won one of the Pharmaceutical Care Awards for 2003.

The service involves improvements in three areas: medication history taking on admission, communication between secondary and primary care and product standardisation across the two sectors. The project is the first randomised, controlled study in the UK to assess a cross-sector approach to improving medicines management.

The new approach involves an accurate medication history being taken on admission to hospital using information from the patient’s GP, community pharmacist, the patient or the carer, and looking at the patient’s own drugs. This includes not only current medication but also information on allergies, side effects and concordance.

At discharge, a pharmacist prepares and authorises the discharge prescription. The prescription includes information about why medicines have been changed during the hospital stay, clinical chemistry results and any educational points that need to be followed up after discharge. This detailed form is faxed to the patient’s GP, community pharmacist and other health professionals (if appropriate) on the day of discharge. “They are not only getting the detail, but they are getting the information at a time when it is needed,” explained Ms Hogg.

The third part of the service is the standardisation of products across primary and secondary care so that patients do not encounter problems relating to different brands being used in the two sectors.

Results from the study of 928 patients show that patients managed under the new approach spend four fewer days in hospital. Re-admission rates were also cut: the number of re-admissions within three months was reduced by 11 per cent and within 12 months by 33 per cent.

Quality, in terms of safety, efficiency and user satisfaction, improved. Compared with the old approach, 4.2 discrepancies per patient were identified with the new more accurate method of medication history taking. Scoring using a medication appropriateness index found that patients receiving the integrated medicines management service had significantly more appropriate medicines at discharge compared with those managed under the old approach. In addition, 92 per cent of patients were satisfied or very satisfied with the service.

“The project has been so successful that additional funding has now been allocated to roll the project out to all wards within the main hospital site and to start a similar project within another major trust in Northern Ireland,” Ms Hogg concluded. “And we have got big plans for the integrated medicines management project in the short, medium and long term. So watch this space.”

Putting the pharmacy into intermediate care

Development of pharmacy services in intermediate care in Rochdale, Heywood and Middleton
Michael Johnson, MRPharmS (intermediate care pharmacist) Tudor Court, Heywood

Provision of a pharmacy advisory service to intermediate care teams has been awarded a runner-up prize in the Pharmaceutical Care Awards 2003.

The pharmacy advisory service was run by community pharmacist Michael Johnson and funded by Rochdale Metropolitan Borough Council social services department.

Patients using the intermediate care service at Tudor Court tend to be frail and elderly. They are admitted to one of the 12 beds for a programme of activities to rebuild their confidence and mobility.

“The majority have experienced at least one fall which may be due to medication, a fact that may not be apparent to other therapists,” explained Mr Johnson. The patients are often taking a number of medicines so it was decided that pharmacist input would be useful to provide a comprehensive overhaul of the patient’s medication.

A community pharmacist was chosen because he could provide insight into repeat prescription ordering, collection and delivery, monitored dosage systems, and difficulties in using certain dosage forms. “I could also liaise with local GPs and pharmacies following discharge from the service to ensure that the patient is stabilised in their home environment and less likely to go into crisis again,” Mr Johnson said. Before the pharmacist’s input, the therapists corrected physical symptoms without addressing the real cause of the problems which were often interacting or inappropriate medicines. “By including a pharmacist in the process, not only is this addressed but also quite often other unrelated problems are discovered and sorted out,” he commented.

A total of 187 interventions for 84 patients were made through the pharmacy advisory service between April 2003 and January 2004. “The interventions cover a broad spectrum from the simple changing of the time a sedating antidepressant was given from morning to night, to the potentially more life-threatening case of stopping a lady being prescribed an appetite suppressant that was contraindicated,” Mr Johnson reported.

Win for pharmacist at transplant clinic

Improving patient care in a transplant clinic: the introduction of a clinic pharmacist and medication delivery service.
Andrew Prowse, MRPharmS (transplant outpatient pharmacist) Oxford Transplant Centre, Churchill Hospital, Oxford, David Scott, MRPharmS (lecturer in pharmacy) pharmacy department, John Radcliffe Hospital, Oxford.

Counselling patients on their medication within an organ transplant clinic and providing a medicine home delivery service were initiatives which won a Pharmaceutical Care Award. A pharmacist was appointed to work in the transplant clinic to counsel patients and review prescriptions, which were then passed on to a home delivery service (provided by an external organisation).

The previous pharmacy service required patients to walk to the main hospital dispensary to receive their drugs. There, patients often experienced long waits. The pharmacist dealing with the prescription usually had limited transplant experience and would not have had access to patient records and blood results.

Under the new service, patients saw the specialist pharmacist in the clinic and were able to discuss their medication. The pharmacist had access to medical records and laboratory results allowing a comprehensive medication review. The pharmacist’s location within the clinic facilitated more clinical pharmacy interventions. In a four-month period, 41 per cent of consultations led to an intervention. Fifty-seven per cent of these interventions were classified as being of moderate or severe clinical significance, according to a multidisciplinary panel.

The pharmacist passed the “screened” (approved by the pharmacist for dispensing) prescriptions on to the delivery service, with drugs being dispensed and dispatched to patients within three days. The delivery service is a registered pharmacy specialising in home delivery. The delivery can be tracked to identify its location anywhere during the process, and a signature is required on delivery. This transplant centre is unusual in that responsibility for medicine supply is maintained by the hospital, rather than being passed to the GP.

In a questionnaire, 98 per cent of patients expressed a preference for the home delivery service as opposed to the previous system of collecting drugs from the hospital pharmacy. All clinic staff interviewed said that they consulted the pharmacist during every clinic, and believed that the quality and safety of prescribing had been improved.

Identifying older people for pharmacist referral

The London older people services development programme medicines management pilot.
Lelly Oboh, MRPharmS (senior prescribing adviser) Lambeth Primary Care Trust, Theresa Rutter MRPharmS (specialist pharmacist community health services) London Specialist Pharmacy Services, Pharmacy Department, St Charles Hospital, London, Val Jones (director [2001-3]), London older people services development programme, South West London Health Authority, London.

Older people with medicines-related problems are refer-red to a community pharmacist for assess-ment, in a project which was a runner-up in the Pharmaceutical Care Awards. Patients are selected for the service by staff from the health, social and voluntary care sectors. As part of a single assessment process (SAP) by non-pharmacy staff, assessors ask four medicines-related questions to patients or carers (eg, do you always take all of your medicines the way the doctor wants you to?). This project has integrated medicines management within the SAP, which will be the main way older peoples’ health and social care needs are identified by 2004/5.

The pilot project identified 50 older people with potential pharmaceutical care needs. After obtaining permission from the patient/carer and GP, a pharmacist gathered relevant information from GPs, community pharmacists and nurses, and carried out a medication assessment with the patient/carer. Pharmaceutical care needs were discussed with the patient/carer and recommendations were passed on to relevant health care professionals. The patient was referred to a participating community pharmacy of their choice.

The community pharmacist, who in some cases had performed the care assessment, implemented the pharmaceutical care package. Examples of services provided include providing suitable compliance aids, monitoring the patient’s knowledge and ability to use their medication and liaising with social services, home care and community nursing staff. The community pharmacist maintained responsibility for monitoring the care package, and a review of the care plan was carried out after six months.

Training of health and social care staff to use medication trigger questions within the SAP was provided, and a group of pharmacists were also trained to perform the pharmaceutical assessment.