Medicines Management
Issue no 1, pp12-13
January/February 2002

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Features

Setting up a scheme for older people

The NHS Plan highlights the need to develop the role of community pharmacists beyond that of dispensing and particularly mentions our role in supporting medicines management. The greater support needed by patients in using their medicines is reaffirmed in the National Service Framework for Older People.

The framework describes a number of interventions that should be promoted, including the review and rationalisation of medicines. It is recognised that polypharmacy presents a particular risk for older people; adverse drug events and readmission to hospital following discharge being well documented in this patient group.

Community pharmacists could easily address some of the key problems associated with repeat medication if the right infrastructure was put in place.

Roots of our plan

The idea for developing a local service originated from a local pharmaceutical committee- (LPC-) organised pharmacy contractors' meeting held in January 2000 in Barking & Havering and Redbridge & Waltham Forest health authority areas. As a result the two HAs established a multidisciplinary steering group to develop a proposal based on the work of the Glasgow scheme which provides pharmaceutical care for the elderly (see Panel). The group was also to oversee the design and implementation of the project with the support of Robert Gordon University.

From the conception of the scheme, the LPC continued to encourage pharmacists to develop their role in medicines management. They contacted all pharmacists at the early stages of proposal development and secured 100 per cent support in principle for the development of a medicines management project.

Following local approval of the scheme the health authorities wrote to all pharmacists and GPs with details of the scheme and invited pharmacists to apply.

The project was designed to offer patients receiving long-term drug therapy in the community a programme of ongoing assessment and review by community pharmacists. The programme was to target patients over 65 years and on four or more medicines.

Although the Glasgow scheme organised its service through formal clinics based within GP surgeries, our project was to offer a more flexible service based within the community pharmacy premises, providing patients with a choice over the location of the review.

However, GP practices were matched with participating pharmacists. Pharmacists were asked to indicate which surgeries they intended to work with and whether they had discussed the scheme with the practice. In some cases the PCG prescribing advisers helped facilitate discussions between pharmacists and practices.

The evaluation is to be undertaken by the Academic Department of Pharmacy, Barts and the London NHS Trust and the School of Pharmacy, University of London, in collaboration with Robert Gordon University.

Selling the idea to local GPs

To make the pharmacy-led medicines management service a reality it had to be sold to GPs and PCGs. GP support for the medication review scheme was vital for access to patient records and to ensure that pharmacist interventions were acted on.

Although many GPs had initially appeared interested, the consultation process revealed that some of them perceived the proposal to be a criticism of their current practice. These GPs felt that they already provided medication review and that funding should be directed to them to provide the service rather than to pharmacists.

So when the proposal was discussed with PCG boards and the local medical committee (LMC), it was particularly important to define "medication review" and outline how pharmacists could add value to this service.

Few GPs understood, for example, the time commitment that a full and structured medication review would involve. But GPs are feeling the strain of the additional workload required through implementation of the NSFs and this was seen as a way of helping to manage the workload.

Securing the support of GPs who could champion the scheme also proved helpful in achieving LMC approval. Nevertheless, one PCG decided not to support the scheme. From the PCT perspective the scheme was seen as a way of achieving NHS Plan and NSF for Older People targets.

Timing of and funding the project

The time taken to initiate a project such as this should not be underestimated and strong determination is needed to move things ahead. Following local consultation the scheme required approval from the local ethics committee and audit committee.

The chief executive of Barking & Havering Health Authority played a major role in securing funding (from the performance fund) to launch the scheme and additional funding (from the regional office) for project management and evaluation.

The scheme was funded to enable 50 per cent of eligible pharmacies to be in the pilot, which was felt to be the most realistic and affordable option. A substantial investment was earmarked for pharmacists' training, which was seen as a foundation for many of the new roles for pharmacists.

The LPC was unhappy about the prospect of turning pharmacists away due to insufficient funding. However, it was recognised that there were competing demands for local resources.

Unfortunately, Redbridge & Waltham Forest Health Authority was unable to identify funding for 2001/02 and discussions are ongoing about entry in 2002/03.

Training

There is a temptation for pharmacists to concentrate specifically on the medication regimen. We really wanted to ensure that the patient was fully involved in the review and that pharmacists were able to take a holistic view of the patient from their medication profile, medical records and a face to face interview. Training began in November 2001 with a weekend course for pharmacists facilitated by Robert Gordon University. The course covered pharmaceutical care planning with particular focus on patients' experience of their medicines and how to conduct a medication review.

Despite initial anxieties about the training requirements feedback was excellent: "It made me think. Initial apprehension disappeared after the first day" and "A very motivating experience" were among the comments.

Most pharmacists surprised themselves by discovering that they knew more than they thought and all left motivated to continue with the training. The remainder of the training is to be through distance learning, and local peer group meetings are planned to facilitate this. The challenge now is to support pharmacists through this period and maintain their enthusiasm.

State of play today

It has been almost two years since the LPC pharmacy contractors' meeting first mooted the possibility of a medicines management scheme and we expect to start the review process at the end of January.

In total 42 pharmacists have been recruited to the scheme, which covers 50 per cent of pharmacy premises in Barking & Havering. Some GP practices have already signed up to the project and the health authority is holding a briefing meeting in February to recruit additional practices.

The project has slipped by around six weeks largely due to clarification of the financial management arrangements. The project is being launched in a period of organisational change as health authority functions are being devolved to PCTs. It is essential that PCTs are fully involved in the management of the project and that organisational change does not destabilise the support mechanisms put in place.

The medicines management project group has evolved into a project management board that reports quarterly to the PCT. Local support has been crucial in taking the project forward and has been achieved by collaborative working and strong relationships between the health authority, LPC, CHC and PCGs (now PCTs). We are confident that early results will demonstrate the valuable contribution of community pharmacists in medicines management.