All-party pharmacy group

Medicines management in community pharmacies - a report to Health Ministers

Chair: Dr Howard Stoate MP
Vice Chairs: Dr Jenny Tonge MP & Rt Hon Lord Newton of Braintree OBE
Treasurer: David Heath CBE MP
Secretary: Mark Todd MP

Background

A substantial and growing portion of NHS expenditure is accounted for by medicines. In 1998/99, the cost to the NHS of medicines was £5.5 billion, a 7.2 per cent increase on the previous year. It is important for patients and taxpayers that this expenditure delivers clinical and cost effectiveness, and that health professionals work closely together to achieve that end.
In that context, the knowledge, expertise and accessibility of community pharmacists represents an important NHS resource, and could be deployed to greater effect to maintain and improve clinical and cost effectiveness. At present, interventions by community pharmacists to ensure compliance and drug effectiveness generally take place in an unstructured fashion, although the provision by pharmacists of prescribing advice to GPs has been successfully piloted in structured trials by a number of health authorities. The provision of prescribing advice is, however, only one component of the range of services that community pharmacists could provide in delivering the objectives of clinical and cost effectiveness.
The All-Party Pharmacy Group wishes to see full use made by the NHS of the skills and expertise that community pharmacists have to offer in the active management of patients' medication.

Our deliberations

The Group met on 4th April 2000 to examine these issues, and in particular to discuss a new service proposal recently developed by the organisations representing community pharmacy known as medicines management. Medicines management is a structured service based on a professional partnership between community pharmacists and GPs, the aim of which is to manage actively the medication of individual patients with chronic conditions in order to deliver better health outcomes for patients.
The Group heard presentations from two guest speakers: Professor Sir Michael Rawlins, chairman of NICE, and Allen Tweedie, a community pharmacist who has been closely involved in developing the medicines management proposal.
A range of parliamentarians and invited guests attended the meeting, including representatives of various Primary Care Trusts, the BMA, the Doctor Patient Partnership, the ABPI, the PAGB, the British Heart Foundation, and various pharmaceutical companies. Representatives of the major community pharmacy organisations also attended, as did members of the press.
The main points arising from the presentations and the subsequent discussion were:

• interaction between NICE and community pharmacists is essential if the objectives of clinical and cost effectiveness are to be met;
• community pharmacists can assist NICE by taking a greater role in the identification of costs, assisting in the appraisal of new technologies and treatments, ensuring access to services, encouraging self-medication where appropriate, working closely with GPs to provide patients with continuity of care, and providing accurate information to patients about treatments;
• NICE is keen to encourage the initiation and monitoring of treatment in the setting of community pharmacies;
• partnerships between primary care professionals, especially between GPs and community pharmacists, are too often unstructured and not audited;
• the NHS incurs considerable avoidable cost as a result of hospital admissions caused by drug interactions and non-compliance;
• medicines management by community pharmacy would support clinical excellence and deliver substantial financial savings (in excess of £100 million per annum) through, for example, reduced drug costs and fewer hospital admissions.

The medicines management proposal

The Group has examined closely the document submitted to the Department of Health proposing funded pilot trials of medicines management in community pharmacy, and notes in particular the following points made in that document:

• 43 per cent of UK adults living at home are taking prescribed medication;
• among those aged 65 to 74 this proportion increases to 71 per cent, and for those aged over 75, 82 per cent;
• 27 per cent of elderly patients admitted to general medical and care of the elderly wards have experienced adverse drug reactions;
• these statistics illustrate the scale and nature of the problems caused by the current lack of active management of medication;
• community pharmacists are ideally placed to provide an active medicines management service - they have expert knowledge of medicines, they know patients' medication history, they are conveniently located and accessed without the need for an appointment;

We also noted that medicines management will consist of two major components.

First, regular and frequent structured discussion with the patient, comprising counselling in relation to the following:

• compliance and commitment to therapy;
• side effects and toxicity;
• ineffective treatments;
• adverse reactions;
• suitability of dosage form;
• perceived acceptability of medication;
• food interactions;
• lifestyle;
• general feeling of well-being;
• family support systems;
• GP referral system.

Secondly, a structured assessment of the patient's prescribed medicine(s), to inform discussion and review with the patient's GP, including the following:

• monitoring for drug interaction;
• consideration of replacement of patent expired brands with generics;
• reduced side effects;
• therapeutic interchange;
• reduction of polymedicine;
• more economic prescribed quantities;
• more effective drug regimens;
• evidence based practice.

The proposal submitted to the Department of Health is that this service is piloted in the first instance. A specific patient group would be used in the pilot programme: patients with coronary heart disease (CHD). It is proposed that 10 pilot areas be chosen, each containing three GP practices with eight GPs, served by seven community pharmacies. In the trials each community pharmacy would work with around 50 CHD patients, thus making 350 per pilot area and 3,500 patients in total.
The document invites the Department of Health to fund the pilot trials and the process of evaluation. The total cost, spread over two years, is £1.8 million.
We understand that the proposal has the support of the British Cardiac Patients Association.

Our recommendations

The Group was impressed by the medicines management proposal. We believe it will enhance clinical and cost effectiveness in the use of NHS medicines, and in the process bring tangible benefits to patients. It will also result in improved team-working between GPs and community pharmacists. In addition, it is clear to us, on the basis of comments made at our meeting by Sir Michael Rawlins, that medicines management would assist NICE in achieving its objectives.

We therefore recommend the following:

• Ministers consider the medicine management proposal in the context of its potential to deliver benefits to patients, remove gaps in existing service provision, and achieve clinical and cost effectiveness;
• the Department of Health provides funding of £1.8 million for the pilot trials set out in the proposal document, so that the trials can commence as soon as possible;
• subject to evaluation of the trial results, the Department of Health works with the pharmacy organisations to introduce medicines management from community pharmacies on a nationwide basis, and considers additional patient groups for whom medicines management would deliver clear benefits .

April 2000