The Pharmaceutical Journal
Vol 275 (Supplement) F19-F20
October 2005

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FIP Congress 2005

Doctor-pharmacist case conferences bring about promising outcomes

Pharmacists are among the most accessible and frequently consulted health professionals,said Simon Bell, of the University of Sydney, Australia. Addressing the burden of adverse drug events is a challenge and an opportunity for the pharmacy profession. Collaborative models of practice, including doctor-pharmacist case conferences, have been associated with promising outcomes.

By way of background information, Mr Bell pointed out that there were 200 million prescriptions dispensed each year in Australia, that 33 per cent of Australians are aged over 65 years and take four or medicines (13 per cent take six or more) and that adverse events due to medication are responsible for 140,000 admissions to hospital annually at a cost of AUS$660m — “a startling statistic that was not peculiar to Australia”. It has been shown that up to 69 per cent of medication-related hospital admissions were avoidable and so pharmacists have an important role to play, he said. So, with those statistics in mind, a range of services have been implemented to improve medication safety, including case conference meetings, home medicines review and giving consumer advice at the point of dispensing, which community pharmacists are paid to provide.

Regarding home medicines review, Mr Bell pointed out that, since the Australian government had made AUS$114m available over five years to remunerate pharmacists and medical practitioners to provide the service, doctors were paid a fee for referral to a pharmacist and the pharmacist has paid AUS$140 per review. He added that, as of May 2005, 67,000 home medicines reviews had been provided by accredited pharmacists across Australia.

Mr Bell went on to explain how doctor-pharmacist case conferences worked in practice, paying particular attention to mental health. He said that GPs are responsible for the majority of prescribing in mental illness and so his research had focused on how that could be improved. The model developed for case conferences in primary care was as follows.

First, it was necessary to get pharmacists and GPs in a local area to collaborate. They would then exchange clinical information about patients. The pharmacist would then interview the patients at home and write a report for discussion with the prescriber at a case conference. There, the GP and the pharmacist would agree a shared treatment plan.

Mr Bell’s research was carried out in two distinct areas of Sydney, and involved 26 GPs and 47 pharmacists. The GPs recruited and referred 56 patients for home medicines review by a pharmacist. However, one was hearing impaired and six could not be contacted by the pharmacist. The remaining 49 patients each received a home visit and a medicines review, and 44 of them were reviewed at a doctor-pharmacist case conference meeting.

Case conference meetings were audio-taped and transcribed verbatim. Most last about 10 minutes (range two to 45 minutes) and were conducted in GP surgeries. At the meetings community pharmacists presented 377 findings and made 337 recommendations for 44 patients. GPs accepted 252 (92 per cent) of 274 recommendations made for 37 patients for whom documentation was available. “It is encouraging that GPs took notice,” said Mr Bell. “So the project was well worth carrying out.”

However, some educational preparation is important. Mr Bell said that most mental health education programmes for pharmacists have focused on the properties of psychotropic medicines rather than on patients. A lack of confidence and sub-optimal communications with mentally ill people has also limited community pharmacy service provision. “It is recognised that this is an area that pharmacists have found difficulty with in the past, so the development of educational programmes is key,” said Mr Bell. “Consumers have an important role in the education of health professionals, not just in mental health but in other areas as well,” he concluded.

Role development in England and Wales

Sue Sharpe, chief executive of the Pharmaceutical Services Negotiating Committee, UK, told the congress that the PSNC had achieved what it set out to do in formulating a new contract for community pharmacists in England and Wales. She said the new contract built on the present community pharmacy service, fitted in with Government health policy objectives, and made use of pharmacists’ clinical skills more effectively.

She said that, in developing the new contract, the PSNC had set itself some goals. These were to increase understanding of the present value of community pharmacy services, to develop a new service proposal, to secure adequate funding, to integrate community pharmacy into primary care provision and to create a structure for future growth.

To achieve these goals, there was a need to establish a sound evidential base for service costs and income needs. The PSNC also analysed key Government policy objectives, because, if any new framework did not “hit the spot” with regards to Government policy, it would be difficult to secure funding. So a collaborative working relationship with the Government was crucial, she said.

It was important to engage pharmacy contractors in the process. This had been done through a series of meetings, publications, roadshows and websites. It was also important to ensure that any services were practically manageable by pharmacists. The PSNC had also identified other key stakeholders and made sure, for example, that the new contract would fit in with Department of Health policies and had the support of GPs. Developments were also discussed with patient groups and local NHS authorities. “It was important that there was no substantial opposition from any source,” said Mrs Sharpe.

What the PSNC developed was built on community pharmacists’ traditional functions, ie, dispensing and sale of medicines. It also involved the promotion of healthy lifestyles, because it was recognised that pharmacy reached a wide audience, not just patients. The new contract would also support self-care and appropriate use of NHS services, and medicines use reviews, which were critical for community pharmacists’ clinical role development. It also provided a basis for a future lead role in management of long-term conditions.

There were two elements to healthy lifestyle promotion, said Mrs Sharpe. First there was the provision of opportunistic advice to patients receiving prescriptions and, second, there were health promotion campaigns on such subjects as inoculations, sun protection and allergies. Thus lifestyle promotional activity was to be aimed at all pharmacy users, not just those receiving prescriptions. In terms of supporting self-care and the appropriate use of NHS resources, Mrs Sharpe said that unnecessary use of NHS resources, ie, access to GPs, had been identified as an issue. The new contract, she said, would encourage people to talk to their pharmacist first and would promote the use of the pharmacists as a signpost, directing people to the best source of help. She stressed that this was not a paternalistic model: it was important to help people become confident in self-care for minor ailments and long-term conditions. It would be essential, therefore, for pharmacists to keep records of advice given where it was judged to be of clinical significance.

Turning to medicines use reviews, Mrs Sharpe said that this process involved discussing and recording actual use of medicines by individual patients, and increasing patients’ understanding and experience of using their medicines. She emphasised that the purpose was not to judge GP prescribing but to educate patients, resolve their problems, and identify side effects and interactions, then report to the prescriber with recommendations for change.

In the future, the PSNC believed that management of long-term conditions would fall to pharmacists when medicines use reviews became a standard part of the community pharmacy service. Mrs Sharpe also foresaw electronic communications and sharing records between community pharmacists and prescribers and the provision of diagnostic testing in pharmacies. It was also likely in future that patient group directions would be developed in such a way as to allow pharmacists to authorise changes in medication. She told the congress that supplementary prescribing by pharmacists was already in place and that it was hoped that there would soon be legislation in place to permit independent prescribing.

“We now have a contract that will help us meet our goals,” said Mr Sharpe. “But it does put demands on pharmacists, who have to ensure through training and accreditation that they have the clinical skills necessary to deliver it. It is also essential that pharmacists document their interventions and other clinical activities.”