Medicines
Management
Issue no 6, p5-6
November/December
2002
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Medicines
Management |
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Features |
Evolution of medicines management across primary and secondary care
Until about three years ago, the entry of new pharmaceutical products and the introduction of changes to the usage of existing products went along in a similar manner in North Cumbria to the way it happens in many other parts of the country. There are two acute hospital trusts here based around two district general hospitals 42 miles apart. In the east there is also a mental health trust and a community trust. In the west there is a single trust that combines acute, mental health and community services. Both functioned reasonably well with the two main hospitals having drugs and therapeutics committees that involved GP members. There was also a separate committee for the Mental Health Trust. Adopting drugs used to be ad hoc
Before the formation of primary care groups, adopting new drugs and altering the use of those better established in general practices were ad hoc activities and depended on individual doctor's decisions. There was an overarching group (the district drug advisory group) that looked at the introduction of new products, and was chaired by the Medical Director of North Cumbria HA. It had panel members from the two main hospitals, GPs and three prescribing advisers. But for about 10 years, one of us (Ken Ball) had pursued the dream of developing a medicines service which crossed the boundaries of primary and secondary care. It would be a decision-making body and would be able to use all the resources available in primary and secondary care. The pharmacy department based in the east produced a business plan in 1998 which was designed to show how a medicines resource unit could be established offering a high level of analysis and advice. It was obvious at this stage that pharmacists at the two trusts had conflicting views about the potential for this unit, but there was a common thread and a willingness to change the way services were provided. Some of the conflicting ideas, and the less than clear definition of themes in medicines management, have recently been described by Simpson (2002). The same author (2001) has compared medicines management and pharmaceutical care. What is clear is that medicines management is about improving the quality of medicines use in an area where collaboration by all parties involved in the process is needed. The pharmaceutical parties continued to argue their relative positions. In the interim, the demise of the HA and the designation of new trust structures required a replacement for the district drugs group and, as a result, the concept of a medicines management unit was created. The proposal for the unit structure would leave it somewhere between a resource centre and a decision-making body. The terms of reference were written by us both, with input from Dr Peter Weaving and with the excellent support of Dr Rob Walker (chairman district committee). The idea was that the North Cumbria Medicine Management Group (NCMMG) would replace the district drugs group and take over the hospital drugs and therapeutics committees. All decisions that would affect medicines use in primary care were to be referred to the NCMMG. The new amalgamated DTCs from the two previous main hospitals would consider items only used in secondary care. Additionally, the DTC in the mental health sector was retained to consider items for use in its own specialised area but also to report to the MMG on items that affected primary care. The boards of the acute trusts supported the proposals, as well as the three PCGs and the mental health trust. The new structures, as described above) came into being on April 1, 2001 and the MMG began work in September, 2001. The group has considered a number of new preparations, reviewed groups of drugs (ACE II inhibitors) and looked at the use of unlicensed medications across primary and secondary care and formulated a policy. The group appears unwieldy (see p5) but contains all the members required to take decisions that will ensure a common thread of evidence-based recommendations. How drugs are adopted now Portfolios of data, including economic analyses, are presented to the group by the committee secretary or physician requesting the drug, and decisions are made on the evidence available. So far decisions have been well supported but have not always been easy to make. So, what happens if somebody decides not to follow the recommendations? This becomes the responsibility of the governing bodies of the trusts where the decision not to follow recommendations takes place. It is not a problem in secondary care because if a product is not recommended then it is not purchased, although by-passing the system by using FP10(HP)s can be a problem. Restricting their issue is one method of control but feedback from GPs and support in not continuing to prescribe has helped. In primary care, the medical director and clinical governance officer will be used to convince errant prescribers of the reasons for not recommending their drug of choice. We cannot enforce the issue but continued monitoring of prescribing will tell us of the effectiveness of the group. The latest project is the agreed introduction of the electronic version of the Lothian Formulary, adapted for local use. So what do you need to form a group to take medicines management forward? Our view is that it needs a clinical and pharmaceutical champion: people with real passion to make the structure work. This could, of course, be said of any organisation but you need real enthusiasts to make this type of group function across five separate independent organisations. It could even be possible for primary and secondary care to join forces and be managed by a single organisation. The group could function in the same way as a trust board and we could concentrate our actions on specific areas and avoid duplication of work. The initial impetus needs to be maintained but so far the structure appears to work.
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