Medicines Management
Issue no 1, pp8-11
January/February 2002

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Features

Practice-based medication review for the elderly

What direction do you take when you are given a budget and told to design a programme to support the targets of the National Service Framework for Older People?

And what if the programme was to be within a PCG where a large proportion of GPs believed that the money should be given directly to their practices and were highly sceptical of the value of pharmacists in reducing drug costs and improving the health of older people? The comment "It would not be in the interest of pharmacists to reduce medications prescribed because they would lose money" was heard on more than one occasion.

However, these attitudes could be ignored to a certain extent by the existence of two milestones. First, that by April 2002 all people over 75 years should normally have their medication reviewed annually and those taking four or more medicines should be reviewed every six months; and, secondly, by April 2004 all PCTs will have schemes in place so that older people will get more help from pharmacists in using medicines.

Furthermore, the programme had to be up and running by April 2002 to comply with NSF guidelines. Add to this, alterations to the traditional health authority structure and the change in status from PCG to PCT, which would also occur at the beginning of the financial year.

This is what I faced when I was asked to design and implement a medication management scheme that would run across the entire East Elmbridge and Mid Surrey PCG area. I accepted the challenge.

Medication reviews were already being done but one only has to read the NSF and articles in the medical press to see that not all GPs are reviewing all their patients medication all of the time. By having a practice-based programme led by the medicines experts (pharmacists) we hoped to ensure that reviews are conducted appropriately. The patient would benefit by increased concordance and compliance leading to improved patient health.

Funding

The Primary Care Incentive Scheme allocated the PCG funds to conduct these reviews with the promise of a second tranche in April 2002. An allocation of reward funding would be made down to practice level provided each practice participated in all three elements of the EE&MS schemes funded from the incentive scheme (the other two were an educational programme and an extension of the clinical governance scheme). This certainly helped to focus the GPs' minds.

Planning

Know your primary care organisation.

This PCG has a population of 260,000 of which about 32,000 would be over 75 years.

But there was only one pharmaceutical advisor in the PCG, Neelam Bhargava, who was responsible for 38 practices (the phrase overworked comes to mind).

Planning started during August 2001 with implementation to begin early 2002. Other primary care organisations will have different schemes in place but we think we have covered as many bases as possible given our starting point.

Research

Research was conducted to ascertain the scope of other schemes within the UK and in other parts of the world, eg, Canada, New Zealand, Australia and Europe. In some ways we were starting behind other PCOs because there were no practice-based pharmacists in our PCG, but a small pilot had been conducted with a hospital pharmacist reviewing medication for older people in five practices.

We believed strongly that the case for pharmacist cost effectiveness had already been made before by countless trials not the least of which has been the work done by Dr Zermansky et al.¹ However, it was essential that any programme would be sustainable and would focus on patient outcomes.

This was not to be another hit and run scheme but a robust programme that would make structured medication reviews an integral part of the working practice within the surgery.

The NSF implementation team were contacted and when asked if they had any ideas on how to target patients and relate their age to the number of medicines the rather surprising answer was: "No". Despite coming up with guidelines they had little idea on how they were to be achieved or implemented.

Our search revealed there were few existing robust medication review services although there were a number of small pilots and ad hoc schemes throughout the country. This cleared the way for us to get on with it in the knowledge that whatever we did would be a progressive step and could be used as a stepping-stone for future programmes.

Everyone I have contacted who had run a review service in some form was extremely positive and helpful and the network I developed was of great benefit. There was no point re-inventing the wheel, so we gathered the best ideas from all over the world and tailored them to our environment, adding innovation when required.

Resources

To conduct an annual review in our PCG area alone would require four full-time pharmacists, the cost of which was prohibitive at this stage, not to mention the recruitment difficulties.

Was there any way we could involve community pharmacists? The incentive scheme fund was only to be used in practice-based services and data protection required that the medical notes could not be removed from the practice. This excluded full medication reviews taking place in community pharmacies. The programme was trying to achieve the highest possible outcome for the patient yet to conduct a review without the medical notes would not achieve this.

The solution was to have a number of pharmacists implementing and encouraging appropriate medication reviews that would be conducted in the main by GPs and nurses. Individual face to face review clinics could be conducted by pharmacists, for high-risk groups or difficult cases. This would enhance multidisciplinary working, and being on site improves communication and respect between all members of the primary care team.

Preparation

An advertisement was placed in the PJ for self-employed pharmacists who could work on a sessional basis at £70 for 3.5 hours (a six-month contract). Individuals with drive, enthusiasm and good clinical and communication skills were required. To encourage applicants who had a thirst for knowledge we offered to fund participation at the Keele University Short Course in Medication Management.

We were lucky: 16 pharmacists applied and after much consideration we chose seven, which would allow 20 practices to have a pharmacist for one session a week for a 12-week period leaving two sessions available for training.

A MIQUEST was written using existing practice Read codes providing listings in Excel spreadsheets to match patients over 75 years with 16 BNF drug categories that specifically affect the elderly, eg, hypnotics, diuretics, analgesics etc. This made it possible to:

• View all patient information eg, name, age, sex etc for every patient

• Count all of the patients over 75 years on any medication

• Count the number of drugs prescribed per patient in the last three months

MIQUEST is already used in GP practices and staff are familiar with reading and interpreting data. Our design could thus be easily run in any practice throughout the country. It is also cheap to copy once written. A Read code for completed reviews allows a baseline assessment and regular audits on how many reviews have been done in each practice.

Patient information sheets and simple review forms (single-sided A4) were designed for paper, and face to face reviews. These forms can be filled out by any reviewer — GP, nurse or pharmacist — and include communication, packaging and co-ordination factors as well as proposals for change of medication dose, indication etc. Each completed form must contain an outcome for the patient as well as the practice. Liaising with the local community pharmacist is another important role for the practice support pharmacist and communicating any agreed changes to a patient's prescriptions will ensure a smooth medication supply.

A chart was produced with six simple questions to be placed in obvious places around the practice.

• Does the patient still need the medication?
• Does the dose need to go up or down?
• Is there a generic or more effective alternative?
• Do biochemical levels need to be monitored?
• Are there any drug interactions or adverse event issues?
• Compliance?

It would be the decision of the practice and the individual practice- based pharmacist to decide which patients they will target although outcome measures were explained to each practice before they signed up. It was highlighted to practices that the goal of a structured medication review was to:

• Minimise adverse drug events
• Reduce polypharmacy
• Ensure compliance

Progress

At the closing date for applications 32 out of 38 practices had agreed to the scheme and the practice support pharmacists will start in late January 2002.

As with all new programmes we have had a few knockers (Australasian slang for those people who obstruct progress). They usually sit on committees criticising innovation and claiming to represent professions while failing to produce any results themselves.

Our programme has allowed pharmacists with an interest in working within a practice to have a shot, regardless of their background. Five of the seven pharmacists were community pharmacists (but this did not prevent them from being criticised at one of our launch meetings by a minority of contractors who felt the pharmacy contractor had been left out).

The funds for this particular scheme require it to be practice-based but despite this restriction there are other strong arguments for work of this nature to be done within a GP practice. Being part of the primary care team in a physical sense with full access to the medical history is an advantage that cannot be ignored.

All pharmacists who have an interest in this work should be encouraged to seek further training if required and have a go.Time will tell how our team got on but I would wager that they will have a positive influence on patients and the practice, and that we may have difficulty getting GPs to give them up at the end of their 12-week stint! The outcomes are yet to be revealed but we have made a positive start.

The future

Other medicines management programmes that look towards the April 2004 deadline include a medicine record card given to at risk patients by their pharmacist and a training programme for care workers and nursing homes entitled " Medication in the elderly, what you need to know". And other MM schemes including repeat reviews and brown bag type services will continue to be developed for practice based and community pharmacy.

Contact details

If you would like further information on our Medication Review Service or Medication Management in East Elmbridge & Mid Surrey PCG contact Gabrielle Clezy. Tel: 01372 227 362 or e-mail gabbyclezy@aol.com