Simple, sensible and straightforward: Bolton's joint prescribing
strategy
| A joint prescribing strategy involving
the primary care trust as well as the hospitals trust in Bolton
has proved highly successful. Naomi Kempner reports |
Naomi Kempner is a freelance
journalist
|
They say that the best ideas are the simple
ones. And a simple innovation in Bolton’s primary care and hospitals
trusts is working so well that it has led to the recent creation of
a new pharmacy post.
 Alison Baker, pharmaceutical adviser Bolton PCT, and Peter Gibson,
chief pharmacist, Bolton Hospitals NHS Trust, cannot believe that more
trusts
are not doing the same as theirs — using a joint prescribing strategy
across both primary and secondary care, or in their words “across
the whole health economy”.
“The joint strategy doesn’t seem to have developed to the same extent
in other districts,” Mr Gibson believes.
Mr Gibson outlined the approach taken a number of years ago within the
hospital pharmacy service to
examine alternative models for picking the most appropriate medicines
for patients, instead of sticking to the idea of a rigid hospital formulary.
New approach to medicine choice
The hospital concentrated on a more “holistic” model where
the preferred medicines were incorporated into much more useful disease
management plans.
This proved to be more acceptable to both hospital consultants and GPs
and made sense, particularly from the hospital perspective, but was one
which only skimmed the surface of primary care prescribing issues.
“We are sensible, straightforward and pragmatic people here in Bolton,” says
Ms Baker, describing how the whole idea started in an effort to improve
medicines use. Both she and Mr Gibson wanted to see joint guidelines
and formularies and to put their ideas into practice. “Our neat
geography has helped,” Ms Baker says, explaining that the area
comprises one PCT and one district general hospital.
After the first few meetings between representatives of primary and secondary
care, they all became more adaptable and accepted changes for the good
of patients. The improvements in collaborative working have evolved over
several years, starting even before the primary care groups merged to
form a trust.
The hospital pharmacy reviewed its approach to “best deals” to
ensure that patients had consistent prescriptions — whether in
or out of hospital. For example, when various inhalers were changed to
CFC free, it was primary care that had the price advantage.
To prevent patients from being switched back and forth as they came in
and out of hospital, primary care funds were transferred to secondary
care to enable the transition to take place uniformally and seamlessly
across the whole health economy.
“Although some of the drugs chosen could potentially increase hospital
medicines expenditure, these costs were relatively insignificant in the
scheme of things and they were in the interest of all,” Mr Gibson
says.
Joined-up approach
A joined-up approach reduces changes in care, with patients in hospital
for far shorter stays than before, and with access to a much larger
choice of drugs. To help support this, patients are now encouraged
to bring their own medicines into hospital for use during their stay,
following assessment by pharmacy staff that the medicines are suitable.
Discharge medications may be a combination of the patient’s own
drugs and hospital supplies, with original manufacturers’ packs
being used.
It is hoped soon to move some of the more routine outpatient dispensing
to community pharmacists through use of FP10HP forms, except for complex
or hospital-only treatment.
Medication reviews are a feature across the trusts, with all patients
on four or more items to be offered this service in the community (focusing
initially on the over75s). All acute hospital admissions are reviewed
shortly after admission.
A borough-wide clinical care group has recently superseded the medicines
management group. It is looking not only at medicines, but issues beyond
drugs, such as A&E pathways, and respiratory and diabetes care across
the health economy. This might include matters such as specialist GPs, “hospital
at home” services and intermediate care. Subgroups work on different
topics and produce draft documents that are circulated widely for approval
in both primary and secondary care. Decisions are evidence-based but
take into account local treatment choices.
The clinical care group will also contribute to disseminating and implementing
national guidelines.
The membership consists of the hospital’s medical director and
hospital doctors, GP representatives from within the PCT, and primary
and secondary care pharmacists, as well as
financing and commissioning staff and lay and local authority representatives.
Medicines issues have included guidelines on respiratory drugs,
antibiotic prescribing, hypertension, management of heart failure and
the use of proton pump inhibitors. In the next year the management of
a number of conditions, including chronic pain, osteoporosis, HRT, anxiety
and schizophrenia, will be addressed. The clinical care group aims to
produce advice on any significant new drugs within a month of launch.
New pharmacist post
The trusts have just recruited Andrew White in the new shared post of “clinical
effectiveness pharmacist” to help accomplish many of these aims.
His job is to concentrate on developing, reviewing and implementing guidelines
and managing the introduction of new drugs, in partnership with both
primary and secondary care.
Mr White is relishing his new role. Having worked for nine years in community
pharmacy he feels he is well placed to introduce a primary care practitioner
perspective to help gain consensus.
Updating guidelines
Although only a few weeks into the post, Mr White is already updating
guidelines on lipid-lowering therapy, with HRT, chronic pain and dermatology
close behind. He is also looking at the implementation of nicotine
replacement therapy in hospital using experiences from primary care.
Mr White will be undertaking a
pilot study analysing admission and discharge processes. This is to help
ensure that adequate and appropriate information is given to the right
people at the right time in an initiative to help prevent unnecessary
readmissions.
Ms Baker is delighted that a dedicated pharmacist will have the time
to concentrate on these issues.
As the post does not include the practice work of a pharmaceutical adviser
it can be totally focused on disease management strategy and adherence
to it.
“It’s an exciting role and I hope I can make it a real success of
it,” Mr White says. Ms Baker believes that existing models of working
have given him a good start.
Mr Gibson states that the continued development of guidelines in a collaborative
manner between primary and secondary care ensures that general practitioners
are heavily involved in the process. This contrasts with the widely held
perception that hospital consultants enjoy a high level of influence,
in an unstructured manner, on GP prescribing habits.
“I think that GPs do feel that they have more involvement in the production
of the guidelines and formularies, and the joint approach promotes consistent,
high quality prescribing across the interface” Alison Baker says.
GPs are sent monthly reports on their prescribing and, while not expected
to switch stable patients, they should prescribe within the guidelines
for most new cases.
“The guidelines cover around 80 per cent of patients,” according
to Ms Baker.
Ownership of guidelines
To increase the sense of ownership and joint working, draft guidelines
may be circulated for discussion at joint educational meetings. For
example, recommendations for managing chronic obstructive pulmonary
disease were disseminated at a recent series of workshops on the topic.
In addition, the team attempts to keep guidelines short and simple.
Although essentially the same, two versions may need to be produced — one
for the PCT audience and another for acute care because their respective
needs may differ.
Mr White knows that pharmaceutical advisers from around the area will
be watching closely to see how the new role develops. P&MM will be
too.
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