Key points
1. Advanced services form the second tier of the new contract and
are a medicines use review and a prescription intervention service
2. Both services consist of the same medicines review, the only difference
is the way in which they are initiated: medicines use reviews are
planned but the prescription intervention is a response to a problematic
prescription
3. The aim of the service is to help people use their medicines more
effectively. It will involve identifying problems with medicines,
providing advice and suggesting changes to the GP
4. Both the pharmacist and premises will have to be accredited to
provide advanced services
5. The service will allow community pharmacists to start playing
a part in the management of long-term conditions |
The second tier of the new community pharmacy contract is formed of advanced
services. These are part of the core national contract, although not all
contractors will provide them from day one since accreditation of both
the pharmacist and the premises will be required before they can be offered.
It is hoped that eventually all pharmacists will offer advanced services.
There are currently two advanced services: medicines use review and prescription
intervention. They will be considered together in this article since both
consist of the same medicines review process; the only difference is the
way in which the review is initiated. Medicines use reviews are planned
in advance and undertaken regularly. The prescription intervention service
is unplanned, being initiated by the presentation of a problematic prescription.
The advanced services represent the first time that community pharmacists
have had a nationally recognised and remunerated clinical service. The
Pharmaceutical Services Negotiating Committee is clear that pharmacists
have to get this service right. If they do not meet the quality standards
set out in the specification for the service, it will be the first and
last national clinical service.
Service aims
The aim of both services is the same: to help people to use their medicines
more effectively. Specifically, the aims are to improve
patient knowledge, concordance and use of medicines. This will be achieved
through: · Establishing the patient’s actual use, understanding about and
experience of taking his or her medicines
· Identifying, discussing and resolving poor or ineffective use of medicines
· Identifying side effects and drug interactions that may affect compliance
· Improving the clinical and cost-effectiveness of prescribed medicines
· Reducing medicine wastage
Accreditation requirements
In order to provide advanced services, both the pharmacy premises and
the pharmacist will have to meet certain accreditation
requirements.
The premises must have a designated consultation area in which both
the patient and pharmacist can sit down together. The area should be
clearly
signposted and be distinct from the general public areas of the pharmacy.
Within the consultation area, the patient and pharmacist should be
able to talk at normal speaking volume without being overheard either
by people
in the pharmacy or by members of pharmacy staff. Initially, contractors
will be asked to self-assess their consultation area for compliance
with the criteria. Primary care trusts will check this compliance during
their
monitoring of the contract.
Every pharmacist who provides the service will have to be accredited.
This accreditation will be based on nationally agreed competencies.
These competencies
are currently being finalised but responsibility for accreditation
will fall to higher education institutes. How the service works
Case study
Mike Barbour has been offering medicines reviews
at his pharmacy in Thaxted, Essex, for over a year. His advice
is to think about
the
structure of the review, when to offer it and how to fit reviews
into current workload. “The key thing is to get the support
of the local doctors’ surgery,” he says.
Mr Barbour advises pharmacists to undertake training on how to
carry out a review. “Any pharmacist can offer reviews; you don’t
need a clinical diploma, you just need to be up-to-date and have
reference sources in the pharmacy.” |
Medicines use reviews will be aimed at people who are taking multiple
medicines on an ongoing basis. This service will be increasingly important
with
the Government’s current focus on improving the management of
long-term conditions. Medicines use reviews should ideally be carried
out every
12 months and the idea is that pharmacists will see patients regularly.
It is likely that PCTs will identify specific groups of patients that
pharmacists could target for medicines use review. This will depend
on the local population’s
needs and what other medication review services are being carried out
locally. Other health professionals may also refer patients to pharmacists
for review.
The prescription intervention service will be initiated when, during the
dispensing of a prescription, the pharmacist identifies a need for an intervention
to be made. The intervention will have to be over and above a basic
intervention that a pharmacist would be
expected to make as part of the essential
dispensing service (PJ, 25 September,
p421). To trigger the prescription intervention service, a problem will
have to be sufficiently complex that a detailed examination of the patient’s
entire medication regimen is needed to solve it, rather than a basic
intervention that could be dealt with in isolation.
All reviews will normally be carried out face to face with the patient.
Reviews conducted by telephone will be permitted, but only when it is not
practical for the patient to visit the pharmacy.
The review itself will involve identifying problems with a patient’s
medicines, providing advice to the patient and suggesting changes to the
regimen to the patient’s GP.
Pharmacists should offer advice on both prescribed and over-the-counter
medicines to introduce concordance and to develop compliance, including
ensuring that patients know how and when to use “when required” medicines.
Advice should also be given on tolerability and side effects of medicines,
and on use of different dosage forms. If practical problems with ordering,
obtaining, taking or using medicines are identified, pharmacists should
try to find solutions.
Pharmacists will not be able to change a patient’s prescription.
Instead, changes should be suggested to the prescriber. The following
issues should be considered:
· Lack of adequate dosage instructions
· Unwanted medicines
· Changes to dosage form
· Generic substitutions for branded items
· Dose optimisation (ie, a higher strength instead of multiple doses of
a lower strength)
· Improvements to clinical effectiveness. These could include interventions
agreed between the PCT, pharmacist and prescriber. For example, highlighting
patients on a treatment rather than maintenance dose of a proton pump inhibitor
Recommendations to the GP will be made using a nationally agreed reporting
template. A record of the review should be made on the patient’s
record at the pharmacy and a summary sent to the GP. A copy of both the
summary of the review and the recommendations should be given to the patient. |
The
Pharmaceutical Journal