The practice medicines managers at a group training session |
The demands of a changing health service, an increasingly elderly population
and the current financial climate within the NHS mean that it is essential
to develop efficient and cost-effective ways of working. A scheme in
Cumbria is using non-clinical staff to improve medicines management in
general practice. The two-year pilot scheme achieved a year-on-year substantial
reduction in prescribing costs growth, improved patient safety and quality
of medicines management services, reduced waste, and enhanced satisfaction
for patients and practice staff. It has now been extended to neighbouring
primary care trusts.
The scheme involves appointing a dedicated non-clinical member of staff — called
a practice medicines manager (PMM) — to take on administrative
tasks and systems management activities. The initial pilot involved all
21 practices in West Cumbria PCT, each of which recruited and employed
a PMM using PCT funding equivalent to 1 per cent of the annual drug budget
(£200,000). The scheme allows practice pharmacists, who are in
short supply in Cumbria, to delegate tasks to the PMMs leaving them free
to concentrate on more clinical and strategic work.
“We already had a prescribing network of pharmacists and GP prescribing
leads in the practices but we wanted to increase the medicines management
activity and we could not get enough pharmacists or pharmacy technicians,” explains
Mel Bradley, prescribing adviser at what is now Cumbria PCT. “We
also recognised that a lot of the jobs did not need a clinical pharmacist
to do them — it was not a good use of pharmacists’ time.”
A training programme was developed and delivered by the PCT prescribing
team, which comprises Jeff Rudman, PCT GP prescribing lead, Lynn McFarlane,
PMM facilitator, and Mrs Bradley. The training programme started with
a two-day residential course, followed by monthly half-day training sessions.
The course has gained accreditation from the Open College Network as
a diploma in medicine management — it is the first qualification
of its kind in the UK and is equivalent to NVQ level 3. The modules include:
medicines management and prescribing quality; waste management and stock
control; medicines, patients and the law; therapeutics; repeat prescribing
and medication review; prescription process and analysis; and management.
“It is a generic qualification but the teaching is designed so
that we can pull in local issues,” Dr Rudman explains. “The
PCT has a prescribing agenda and the idea is that we tackle the same
issues with
the PMMs, the prescribing lead GPs and practice pharmacists,” he
says. The emphasis is on a collaborative learning style to encourage
sharing of good practice. At the monthly sessions the PMMs present their
practice projects (see Panel) and discuss any problems and potential
solutions.
Practice projects
The PMMs took on a number of individual practice projects, including:
· A structured approach to medication review
· Prioritising patients for medication review
· Medication and systems review in residential and nursing homes
· Structured review and stock control of the contents of doctors
bags
· Formulary implementation
· Dose optimisation
· Patient information and education around medicines
· Concordance monitoring
· Elderly care medication review clinics |
The PMMs have taken on day-to-day tasks, such as managing the repeat
prescribing system (including staff training), being a point of contact
for medicines-related queries within the practice team and between practices
and outside agencies, dealing with hospital discharge information and
interventions from community pharmacists, and managing care home orders.
Most of the PMMs were recruited from within existing staff, mainly senior
receptionists. Mrs McFarlane provided them with essential on-the-ground
support. “Part of the success [of the scheme], however, is the
ownership. We wanted the practices to own this person and for them to
be part of the health care team. We did not want them to be seen as someone
parachuted in from the PCT to interfere with the practice,” says
Dr Rudman.
“Initially the pharmacists may have felt the PMMs were encroaching on
their territory,” Mrs Bradley admits. However, she says that they
now appreciate that by delegating non-clinical tasks to the PMM they
have time for more clinical and strategic work. Dr Rudman adds: “They
can see something to do strategically and then delegate, which magnifies
their power and effectiveness.” Mrs Bradley emphasises the efficiency
of the system. “In the past it might have taken months to get through
projects. It has revolutionised the amount of medicines management work
practices can now do.”
Results
The PCT previously had one of the highest expenditures per head and
the highest costs growth on medicines. Four years into the scheme, it
had
the lowest costs growth in the strategic health authority (–6
per cent). The reduction in costs growth over the two-year pilot was
equivalent to £714,000.
The scheme also demonstrated universal improvement in the repeat prescribing
measures of the medicines management service collaborative. For example,
prescription items out of synchronisation fell from 65 per cent to 32
per cent, prescriptions without dosage instructions fell from 15 per
cent to 2 per cent and generic prescribing rose from 3.1 per cent to
83.1 per cent.
Prescribing quality indicators improved in seven of the 13 areas measured
and were better than the national average in eight out of 13 areas, including
volume of benzodiazepine prescribing, cost of drugs prescribed of limited
clinical value, cost of ulcer healing drugs and cost of modified release
cardiovascular drugs.
The PMMs resurrected a previously unsuccessful intervention scheme whereby
community pharmacists are paid for recommending changes to repeat prescriptions.
These changes are now implemented via the PMM. In one year, 3,148 suggestions
were made, of which 88 per cent were implemented, generating savings
of £64,798.
The PCT now funds the scheme on a permanent basis. In addition, it has
been extended to two neighbouring PCTs and now operates in 53 practices
across Cumbria and 50 across Northumbria. The scheme has proved universally
popular with PCTs, clinicians, practice staff and patients. |
The
Pharmaceutical Journal