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Miall James is a part-time pharmaceutical adviser
to a care home company in the home counties
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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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As I move inexorably towards my three score years and ten — and the end of my practising life — I have been lucky enough to find an “occasional” job advising a care home group on their medication arrangements.
I say “lucky” because in my last 10 or so fully
practising years I was heavily involved both with the inspection of homes
and with the training of social services and other care staff, so I am
much better qualified for this than for working as a locum. (The pay
and hours are better, too.)
I am not, of course, saying that the company did not have adequate,indeed
excellent, policies and procedures in force long before I arrived on
the scene. However, pharmacists are the experts on the safe handling,
administration, storage and disposal of medicines, and although there
are always matters where nurses and experienced care workers can make
a good stab at solving problems, pharmacists bring to the party different
mind- and skill-sets.
And there is wide awareness by competent care home
staff that pharmacists see things they do not see and are aware of
clinical issues of which they are unaware.
We should not denigrate the unique contribution we are able to make,
or ignore the high opinion others hold of us. Correspondents to The
Pharmaceutical Journal and elsewhere often express concern as
to whether our contribution is recognised and valued; I can assure
them
that my experience is that
it is, but we have to make it so. And, of course, contrary to the apparent
beliefs of many who ought to know better, care homes are rarely staffed
by nurses unless the health demands of all the the residents warrant
it, so that even a nurse’s limited understanding
of pharmaceutical concepts often is not
available.
About 20 years ago pharmacy’s unique contribution, so far as care
homes are concerned, was recognised by the NHS but, sadly, the formal
introduction of pharmaceutical services was badly botched, partly because
of the coincidental arrival of monitored dosage systems and a campaign
by one major multiple to dominate the market, and partly because the
Pharmaceutical Services Negotiating Committee failed to appreciate the
opportunities. However, although missed opportunities rarely come twice,
it may be happening in this area.
It appears that consequent upon the new contract and the new responsibilities
placed upon primary care trusts, that some PCTs are taking a good, hard
look at what the pharmaceutical needs of their area are, including those
of the residents of care homes, and how they should be met and paid for.
What should these services be? Well, first of all there has to be a recognition
that, like community pharmacy, the proportion of owner-managed homes
is falling and, again like community pharmacy, this trend will almost
certainly continue. The managers of the homes in the company I know best
have a set of rules and policies to which they must adhere — a
similar situation to that in most community pharmacies.
Pharmacists,
therefore, do not need to write policies and procedures; these have been
written by the companies, approved by the Commission for Social and Care
Inspection and only require amendment, when visiting pharmacists’ participation
will be needed, after some exceptional occurrence.
However, pharmacists are well placed to explain the reasons behind policies
and procedures with regards, for example, to the administration of medicines.
Time of administration is often a mystery to care home staff: why should
one medicine be administered before food, and another after, and what
is the effect of getting it wrong?
A review of medication administration
record (MAR) charts will often highlight issues for a particular resident,
as well as whether policies and procedures are routinely complied with.
An explanation, too, of why a particular mode of administration is important
will help staff to comply with administration regimens, as well as highlighting
issues where residents refuse the care offered.
One of the big gaps in care home services is medicines use review (MUR).
The PSNC has agreed to a situation which makes it exceptionally difficult
for pharmacists to monitor either the clinical or cost-effective use
of medicines in a home. A pharmacist has to get permission to conduct
conventional MURs in a home from a PCT, and it appears that any such
review must be with the patient, not the carer, an obvious impracticality
for many, although not all, care home residents.
A clinical and cost-effectiveness
monitoring service is possible, but only as part of an enhanced package,
meaning that it only available where PCTs are prepared to pay for the
whole care home package. I am, however, certain that, if minds were focused
and activities targeted, reasonable savings could be made in many homes,
and substantial ones in some.
One problem that I come across is the lack of continuity of pharmacist
in pharmacies providing services to homes. Locums (and agency care staff)
often have an unreasonably bad press, and I suspect that the problem
as far as homes are concerned is not the locum but the recording systems
in some company pharmacies.
I would, therefore, propose a contract between home and pharmacy contractor
which recognises the corporate structure often found on both sides, and
includes two named pharmacists — one with managerial responsibility
and one as implementer. The implementer should have completed both MUR
training and an agreed homes-related course. The home should be visited
at a mutually convenient time four times a year for the purposes of reviewing
storage, MAR charts etc, and conducting MURs, especially for new residents.
Normally,
of course, if the pharmacist is also dispensing for the home clinical
and cost-effectiveness reviews will be conducted at the time
of dispensing and, of course, any findings for the GP and, if appropriate,
the PCT concerned will be logged. The pharmacist should also be prepared
to liaise with hospital discharge teams.
Homes should sign a three-year contract, with three months’ notice
on either side and ensure that their records show what advice has been
given and what action has been taken as a result.
How much would that cost, and who should pay? Some of this is to the
benefit of the homes and they should be prepared to meet their fair share;
some will benefit the PCT by a reduction in drug costs, so some must
be down to them.
I propose that PCTs pay the pharmacist and recoup an
agreed percentage from the home; there would then be an independent
monitor of the scheme whose prime interests were patient benefit and
value to
the public purse. |
The
Pharmaceutical Journal