Medicines Management
Issue no 1, pp19-20
January/February 2002

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Features

NSF targets: it's communication, communication, communication

National Service Frameworks (NSFs) are a mechanism for setting standards and reducing variation in the quality of health care delivery by the NHS. They contain broadly-defined aims (standards), more specific statements of things that must be done if these standards are to be achieved (goals) and achievements required by a specific date (milestones).

Many medicines management projects are based on NSFs and this article will show how important effective two-way communication is, between many different groups of individuals, if NSF requirements are to be met.

The NHS is complex. It has more employees than any other organisation in Europe and these people come from a many different backgrounds: scientific, clinical, technical and managerial are only a few examples. In addition, NHS services are supported and delivered by many ancillary staff working in a range of sites from intensive therapy units to GP practices and patients' homes. Successful service delivery also involves working extensively across traditional agency boundaries with staff from social services, local district and county councils and the voluntary sector, including many patient groups.

Effective team work essential

The complexity of modern health care systems and the diversity of those involved in any significant area of the service make effective team work an essential component of successful delivery. Many pharmacists have experience of working in isolation, and we have to develop the skills that enable us to work effectively in a team, either as a member or as the leader/coordinator. Guidelines and protocols, however appropriate, will fail to find widespread acceptance and use if developed by an individual or a small group working in isolation. A sensible first step when asked to perform a complex task within a large organisation is to define the task, and develop a plan for its delivery. This will always involve gathering a team, or teams, who will together get the job done. Pharmacists can be invaluable facilitators of groups that are historically not used to working together. Teams are not fixed and members will enter or leave at various stages in the project.

Take the NSF for coronary heart disease (CHD) as an example. Chapter two of the NSF for CHD contains the following standards: "GPs and primary care teams should correctly identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks" and "GPs and primary care teams should identify all people at significant risk of cardiovascular disease but who have not yet developed symptoms and offer them appropriate advice and treatment to reduce their risks."

Four milestones are set out as an aid to achieving the standards. Mile-stone three states: "By April 2002, every practice should have a protocol describing the systematic assessment, treatment and follow-up of people with CHD agreed locally and being used to provide structured care to people with CHD."

What the NSF requires is that good quality evidence-based care is made available systematically to patients, and that mechanisms are in place to ensure that they do not slip through the net and fail to be offered optimal treatment. Clearly, GPs cannot do all this work themselves. Other primary care workers must be involved.

Data storage and handling

There are issues of data storage and handling since the rigorous nature of the NSF demands will be unachievable without good quality, easily accessible data. This means that information about patients with CHD must be coded and computerised. The parties involved in this exercise must include IT specialists familiar with GPs' computer systems, clinicians from a number of disciplines, practice managers and administrative staff who will be responsible for accurate gathering of data and its entry into the computer.

The coding system needs to be consistent between practices and compatible with a number of different software packages. In the New Forest PCT, this is being achieved through the use of the PRIMIS system, which can interrogate the GPs' computers to provide high quality data on patients who have a diagnosis such as CHD. This data includes current and past drug therapy and also information about what tests and follow-ups have (or have not) been done. Using PRIMIS, it is possible for example, to identify the patients who have had a myocardial infarction but no subsequent blood cholesterol measurement. The practice would then use an agreed mechanism to review these cases and ensure that a test is offered.

For such systems to work effectively within a practice, many members of the practice team need to understand the intentions and rationale underlying what they are asked to do. They need to know that it is about improving treatment and not just about satisfying some bureaucratic requirement.

To achieve consistency between practices, ideally, those within a given PCO should work to similar protocols. Data could then be shared so that patients within the locality receive the same high standard of care whichever doctor they are registered with. For this to happen, members of different practices must agree the relevant protocols and procedures.

Overlying this is the need to ensure that locally-developed practices are evidence-based. Almost all clinical networks involve the use of medication and thus skilful pharmaceutical support is essential. As treatment for CHD is not solely about drug therapy, prescribing advisers will often also be called upon to play a leading role in NSF implementation. Even if someone else is leading the process, a primary care pharmacist needs to be closely involved. Normally, local consultants will also be involved in developing protocols and guidelines. A key role for a PCT/G pharmacist is to ensure that these are evidence-based where possible and that primary care has effective input to the end result.

Chapter seven of the NSF contains a goal requiring that: "85 per cent of people discharged...are offered cardiac rehabilitation and that one year after discharge at least 50 per cent should be non-smokers, exercise regularly and have a BMI of <30".

For this to be achieved, we need to involve smoking cessation, obesity and health promotion services, and agencies that run leisure facilities (eg, local authorities), in addition to the many groups within the NHS already discussed. Their personnel will need training to ensure that the services offered to patients are safe and effective. In South West Hampshire we may be able to involve the developing New Forest National Park authority (guided walks, the "Green Gym") and a number of voluntary groups.

Health care in the UK is now subject to a greater level of command and control from government than before. This has resulted from dissatisfaction with the way services have been delivered, and from a realisation that the quality of service has been very varied. The number of high-profile disasters involving the NHS means that an increased level of politically-accountable direction, and a reduction in the degree of self-regulation by the health professions, have a broad base of public support. Pharmacists working within NHS primary care organisations can play a pivotal role in the delivery of NSF targets and should take steps to ensure that they are in a position to do so.