Panel 1: Useful websites
Further information about out-of-hours services,
as well as guidance and examples of best practice are available from:
www.mmnetwork.nhs.uk/ooh
The Department of Health’s guidance on securing proper access to medicines
in the out-of-hours period is available from the medicines out-of-hours section
of the NHS’s Medicines Management Network website. The site contains
the National Out-of-hours Medicines Best Practice Database and an interactive
discussion forum and document store for anyone involved in providing or commissioning
out-of-hours services.
www.dh.gov.uk/outofhours
The out-of-hours care section of the Department of Health’s website contains
information on a range of out-of-hours topics, as well as policy documents,
non-clinical guidance, links and other resource. |
Since December 2004, primary care trusts in England have been expected
to implement all 13 of the recommendations made in the Department of
Health’s guidance produced in the wake of the Carson Review (“Securing
proper access to medicines in the out-of-hours period”, see Panel
1 and PJ, 5 February 2005, p140).
However, Helen Allanson, the Department of Health’s lead for out-of-hours
medicines and author of the guidance, has found that the recommendations
are not being implemented properly because out-of-hours service providers
either misunderstand them or are struggling to work out how to follow
the guidance. In addition, those commissioning and providing out-of-hours
care often fail to understand how important a contribution pharmacists
and pharmacies can make to the delivery of urgent care.
Visits
To tackle this issue, Mrs Allanson, together with Nicholas Reeves,
another member of the DoH’s urgent care team, set about organising visits
to organisations which have developed innnovative solutions for supplying
medicines out-of-hours and created opportunities for pharmacists to
contribute to the delivery of urgent care.
“We wanted to visit organisations where novel ideas and interesting
developments had been implemented in out-of-hours services, and where pharmacists
and pharmacies were contributing to these services,” Mrs Allanson
explains. “Our aim was to use the visits to develop new guidance
to help communities that have not yet developed effective out-of-hours
medicines services.”
They chose the sites to visit from the National Out-of-hours Medicines
Best Practice Database (see Panel 1). So far they have visited Cannock
Chase PCT (see Panel 2), Cheltenham and Tewkesbury PCT, Dorset Ambulance
Trust (which provides a service on behalf of Dorset and Somerset PCTs),
Durham and Chester-le-Street PCT, Easington PCT, Fylde Coast Medical
Services, Salford Royal Hospitals NHS trust (see Panel
3), South Warwickshire
PCT and Warrington PCT, and they are due to visit East Surrey PCT in
the near future.
“When we visited the trusts, we found some common difficulties and
misunderstandings of the guidance and legislation. But, we are now more
sure than ever
that the guidance is right,” she says. “There is no part
of the guidance that no one has managed to implement successfully but,
on the other hand, no one is carrying out the guidance in its totality — some
sites have taken some of it on board and some have taken other parts.”
Panel 2: Using a medicines management service
Cannock Chase Primary Care Trust provides an
out-of-hours medical service — run in accordance with the Department of Health guidance
on access to medicines out of hours — from a centre in Mid-Staffordshire
General Hospital in Cannock.
Before the service was set up, Mark Seaton, head of medicines management
at the PCT, and his colleagues looked at what services were already
in place. “When we began to look at out-of-hours services in
the PCT area, there was no consistency in the supply of medicines,” he
says.
“Some GPs were providing their own cover, issuing some bag stock and
dispensing FP10s, some GPs were contracting an out-of-hours service
through independent out-of-hours health care service providers [such
as Primecare] and there was an on-call pharmacy service for palliative
care drugs, but that was only through one pharmacy and only when
that pharmacist was available.”
Mr Seaton and his team, including senior nurse Ann-Marie Curtis,
considered a number of options for delivering an out-of-hours service,
including contracts with community and hospital pharmacies to provide
extended hours services.
However, opting for either of these solutions would not have enabled
them to comply with the medicines supply standards set out in the
DoH guidance and so they explored the idea of providing medicines
from within the medicines management service itself.
The centre uses FP10 PREC forms, produced by the prescription pricing
authority, to record supplies made direct to patients in the out-of
hours service. They are submitted to the prescription pricing authority,
which then produces reports on what has been issued.
This supports the governance, as well as the audit and monitoring,
aspects of medicines supply through the service, Mr Seaton says. “We
use these forms to record supplies made and we also use the reports
produced by the prescription pricing authority to monitor what is
being issued from within the service, as well as monitoring prescribing
reports for items issued on standard FP10 by the service.”
In addition, the centre has a contract with the hospital pharmacy
department to supply and prelabel formulary medicines to the service
and the PCT has also approved the funding of a part-time pharmacy
assistant technical officer, who works for half the week at the hospital
to provide the service.
“This post has proved fundamental to the project,” Mr Seaton
says. “The ATO provides a stock top-up service, increases stock
levels ahead of bank holidays and oversees all clinical governance
aspects relating to expiry date checking on stock, stock rotation,
labelling and medicines waste disposal.” And nurses at the
centre can also use medicines supplied under a range of patient group
directions to treat certain conditions, he adds.
The PCT has also solved the problem of supplying Controlled Drugs,
Mr Seaton explains, by applying for a Home Office licence so that
a nurse manager can control CDs in the service, rather than having
to have a doctor take responsibility for ordering and managing them. |
Panel 3: Using a satellite pharmacy in a casualty
department
The Pharmacy Department at Hope Hospital, in
collaboration with Salford Primary Care Trust, has opened a satellite
pharmacy to support
the local GP out-of-hours service. Following a period using the hospital’s
outpatient pharmacy facilities, the out-of-hours pharmacy is now
located in the hospital’s emergency care department and also
caters for patients attending casualty, the NHS walk-in centre and
the emergency clinical decision unit.
Ambreena Asghar, lead pharmacist for this “unscheduled care
service”, explains that locating the service in the casualty
department enables patients to find it easily and GPs to refer any
complex cases to casualty quickly. “At the meeting last week
we were highlighted as one of the few out-of-hours units with a fully
fledged pharmacy,” she says. “We manage to deal with
most requests made by our GPs, including emergency supplies of patients’ regular
and over-the-counter medicines.”
The satellite pharmacy is open 6pm–10pm on Monday to Friday,
4pm–8pm on Saturday, 2pm–6pm on Sunday and 2pm–10pm
on all bank holidays, except Christmas Day (open 2pm–6pm).
Patients attending the out-of-hours unit can also have their prescriptions
dispensed by the inpatient pharmacy from 9am until noon on Saturdays
and Sundays. There is also a minor ailments scheme available to provide
patients who are exempt from prescription charges with over-the-counter
medicines at no charge.
Now that the service has been running from the casualty department
for the past 6 months, Ms Asghar is beginning to look at ways in
which they can develop it. “We are currently working on ways
in which we can improve our service to palliative care patients,
especially with the supply of Controlled Drugs, which has also been
a difficult area to deal with in other units.
“At present, our pharmacy is available to provide any of our patients
with Controlled Drugs out of hours. Soon we should have measures
in place for our GPs to supply Controlled Drugs to patients requiring
palliative care in their homes,” she says.
“It would also be useful for the unscheduled care service to include
pharmacists more at the triage stage, as is done at the unit
in Warrington [PJ, 28 May 2005, p649], rather than just at the end of
the consultation process,” she adds.
“At the moment the patient is registered at reception and, after taking
basic details of the patient’s problem, the receptionist refers
the patient straight on to the GP. A lot of patients could be immediately
referred to the pharmacist, for any issues relating to their medication,
emergency supplies for example, or for a minor ailment assessment.” This
could reduce the workload on the GPs’ patients’ waiting
times, she says, and would be possible if the triage process was
more thorough, taken by a nurse rather than the receptionist, for
example. |
Collective experiences
Last week, Mrs Allanson and Dr Reeves brought all the teams they had
visited together to ask their views on what the DoH should do next to
support those providing medicines out-of-hours services.
“We thought that the collective experiences of those we had visited
would prove invaluable in helping us help others providing out-of-hours
services
find more effective ways of providing solutions to medicine supply,” Mrs
Allanson explains. “We wanted to examine the challenging issues
and the roles for key players in the out-of-hours service and to look
at approaches that had worked well, and those that had not, and to ask
everyone what they would have done differently with the benefit of hindsight.”
From the visits, Mrs Allanson and Dr Reeves pulled together several topics
which summarised the challenging issues that had been raised during the
visits and acted as a framework for the discussion during the meeting,
including: · Extending the role of pharmacists and pharmacies in delivering urgent
care
· Funding out-of-hours services
· Enabling prompt and easy access to Controlled Drugs, particularly for
palliative care patients
The discussions on extending the role of pharmacists examined the role
of primary care trusts in providing wider access to pharmacies and pharmacists,
in particular how primary care trusts can be persuaded to commission
pharmacy services which meet the specific needs of their own localities.
“PCTs need to use the flexibilities and opportunities provided
by 100-hour pharmacies and the new pharmacy contract — this includes
PCTs translating their own local requirements into specifications and
contracts for 100
hour pharmacies,” Mrs Allanson says.
In terms of access to funding, the most successful services were those
where PCTs actively commissioned the service in collaboration with out-of-hours
providers and other partners such as local hospital trusts, Mrs Allanson
says.
“Organisations collectively need to think about securing funding
both to set up the service and to also keep it running. The actual drug
costs
involved in an out-of-hours medicines service are usually minimal — in
many instances only a few thousand pounds that should be paid for from
primary care trusts’ prescribing budgets, as outlined in the guidance.
However, for services to be maintained, there needs to be an ongoing,
preferably shared, source of income and an ongoing commitment to the
creative use of skill mix,” she says.
Some sites are, nonetheless, beginning to find innovative ways of funding,
she adds, such as providing cover for local GP study days, private hospitals
and prisons. And many of these arrangements maximise spare capacity of
staff employed by the out-of-hours provider during the “in-hours” periods.
Although Mrs Allanson and Dr Reeves had identified six main areas of
difficulty, in fact the problems often simply came down, she says, to
difficulties in working across teams.
“Co-operation between different teams within each trust was not always
evident and we also found instances where medicines management teams — usually
because of misunderstandings themselves — had not helped those
setting up the out-of-hours service in the way we know they can,” she
says.
“Many of the problems were centred on providing access to Controlled
Drugs, but there were also cases where clinical governance groups or medicines
management teams would restrict other professionals, such as nurse practitioners
and emergency care practitioners, from supplying antibiotics using patient
group directions,” she adds.
Problems like these led to different solutions having to be developed
for different times of day, depending on whether GPs or nurses are providing
the cover, she explains, and so a consistent service — particularly
from a patient’s perspective — cannot be maintained through
the whole of the out-of-hours period or between neighbouring PCTs.
Solutions
“Now we have had the meeting, we need to bring together everything
that people told us on the day,” Mrs Allanson says. “We are
planning to relaunch the NHS out-of-hours medicines website and share
more widely
the information we have gathered, including useful forms, documents and
protocols.”
There are also plans to revise the best practice database and introduce
a picture gallery, she explains. “We found that people were really
keen to see exactly how particular solutions were worked out — how
packs were fitted into mobile units and doctors bags, for instance.”
Even though a lot of the work has still to be done, the meeting has already
had some impact, Mrs Allanson says. “A lot of those who attended
the day said they found it useful and some have told us that they have
already gone back to their trusts and changed the way the service is
being run.”
Next week, Mrs Allanson and Dr Reeves have one of their regular scheduled
meetings with representatives from the Company Chemists’ Association, the National
Pharmacy Association, the Pharmaceutical Services Negotiating Committee and
Royal Pharmaceutical Society.
They plan to use this to discuss the findings from the visits, talk about pharmacy
services out-of-hours, share best practice and to see what more the DoH should
be doing to support out-of-hours services. Contacts
Mrs Allanson is also happy to receive any queries or suggestions about
supplying medicines out-of-hours. She can be telephoned on 01772
647019 or e-mailed at helen.allanson@northwest.nhs.uk
Karen Hatch, medicines development and improvement manager at the
Medicines Management Network is happy to receive queries about the
Medicines Management
NetWork out-of-hours services website. She can be telephoned on 01772
647017 or
e-mailed at karen.hatch@northwest.nhs.uk |
The
Pharmaceutical Journal