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Lelly Oboh, older people adviser, Specialist Pharmacy
Services, London, South Eastern and Eastern NHS
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
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I read with interest the reports and discussions about monitored dosage
systems in The
Journal and cannot help thinking how we seem to be regressing
instead of progressing. Whether or not to fund MDSs and who should
fund them are contentious issues that remain unresolved in many primary
care organisations, trusts and social care organisations.
But this is
a convenient distraction from the real issue: the lack of a clear and
joined-up system across health and social care to support people who
need help taking medicines. Short-term solutions that focus on implementing
in-house policies (or otherwise) that have not taken into account the
impact on other organisations
only add to the problem, with patients caught in the middle when they
move across care settings.
Older people are probably the greatest users of medicines and MDSs. Providing
an MDS, however, is only one way to help people take medicines. There
is no reason (aside from historical use) why this method should be chosen
in preference to others, particularly as MDS use is fraught with many
problems. Lambeth Primary Care Trust’s drug error incident reporting
system shows that a high proportion of incidents are related to the use
of MDSs. In addition, a number of disputes between community pharmacists
and other practitioners relate to MDSs. Other options
In spite of their widespread use and associated costs there is little
evidence to validate the benefits of MDSs. And, given the current financial
pressures and the burden of adverse drug events on the NHS, can we
continue to justify their inappropriate use? Many other interventions
can support medication. For example, pharmacists can initiate a collection,
delivery or repeat dispensing service; and supply winged tops, large
bottles, compliance aids (eg, Haleraid), tablet cutters, reminder charts
or alarms.
Similarly, prescribers can change formulations, dosage times
or frequency, and prescribe medicines with fewer side effects to improve
compliance. Sadly, the uptake of medicines use reviews, which are fully
funded, patient centred and a key tool to facilitate concordance, remains
low.
Home care workers can prompt or assist the taking of, and administer,
medicines. Relatives and friends are an untapped but useful resource.
Older people sometimes devise their own routines for taking medicines
and, in some cases, the only intervention required may be to work with
them to reduce any risks.
I suggest two main reasons for the inappropriate use of MDSs. First,
a poor understanding of, and a fragmented approach to tackling, the wider
factors that affect medicines use in older people. Even within pharmacy,
the barriers to delivering effective support across care settings are
not fully appreciated (eg, large font labels given in hospitals may not
be a practical option in the community unless they can be reproduced).
Supporting older people to take medicines is everybody’s business.
However, pharmacists have a key role as medicines experts and should
be driving improvements, providing information and support to older people
and their carers. To do this we must give consistent advice based on
the law, robust evidence or available best practice.
Although grey areas exist, the Medicines Act is quite clear and should
be our starting point. Instead, pharmacists are pressured by social services
and care home managers, etc, to provide MDSs even when there is no apparent
benefit. The Disability Discrimination Act is often misquoted as the
means to secure MDSs from community pharmacy. In care homes, MDSs are
used for staff convenience or as a poor substitute for adequate training.
There is no justification for this or the associated drug wastage when
most patients do not self-administer medicines.
I have seen drugs like alendronate dispensed in MDSs with no consideration
for the fact patients can have difficulty identifying the tablet from
several in a compartment and, therefore, may not take it as instructed.
I have seen many older people taking medicines in ways that do not reflect
the prescriber’s intentions; medicines inadvertently littered in
MDS compartments as patients struggle to manipulate the device, and medicines
to be taken before and after food placed in the same compartments.
Confusion
from an inability to identify individual tablets in the device can also
hinder decision-making about what to take. Often, prn medicines (and
liquids and inhalers etc) cannot be dispensed in MDSs. Such situations
can lead to further confusion and defeat the original aim of using MDSs
to simplify drug regimens. Other problems can arise from drug instability,
the complexities of the repeat prescribing and dispensing process, drug
changes and wastage.
The question we need to ask is: are we leading medicines management improvement
or being led down a risky path? Our position should be that standard
labelled containers remain the main way to dispense medicines, and deviation
should only follow a documented assessment showing that the benefits
outweigh the risks for the individual.
Second, there is no shared vision across organisations around what is
needed to support older people with medicines and how to provide this
support. For frontline staff, the absence of a clear pathway and guidance
on practical solutions for those who need help is why most settle for
MDSs as a “one size fits it all” solution. A care pathway
is about how people work together and communicate with each other around
the needs of the patient. An integrated medicines management pathway
will allow whoever identifies or assesses a medicines need, as part of
routine care, to offer practical help or refer to the most appropriate
individual with the skills required to meet the need.
Mapping the current pathway and determining existing resources and interventions
should be the starting point to identify gaps and ensure the best use
of resources. Where specific devices or support over and above these
are required, health and local authority funding streams (eg, primary
care contracts, practice-based commissioning) should be sought to develop
local services. For older people with complex needs the expertise of
pharmacist prescribers, pharmacists with special interests, consultant
pharmacists and case managers can be used. Solutions
Moving forward, the priority is for all provider and commissioning
organisations to agree a pathway that will improve the older person’s journey
across care settings. It should include the identification and assessment
of medicines management needs (within the context of wider health and
social care circumstances), planning with the individual how needs
will be met, and then delivering and monitoring these services. Part
of this process will involve reviewing existing care and capacity then
redesigning services around the patient rather than professions or
organisations. Pharmacists are well placed to lead and drive this process.
The advantages of a whole systems approach include better understanding
of the issues across the board, provision of a variety of services by
a spectrum of individuals, teams and organisations to match the patient’s
need, better access to support, more capacity and sustainability in the
local economy. I am optimistic that such an approach will reduce the
current problems with MDSs and ensure their use only in those who would
truly benefit from them. |
The
Pharmaceutical Journal