Prescribing & Medicines Management
page PM1-2
March 2005

Features

What the renal-specific medicines management document has achieved

In April 2004, the Department of Health published a renal-specific medicines management document to support the National Service Framework for Renal Services. The guidance focuses primarily on part 1 of the NSF — which deals with preparing patients for renal replacement therapy, dialysis and transplantation — and provides a resource for specific medicines management issues relating to the treatment of patients with renal disease.

For each of the issues covered in the guidance, the Department sets out an aim. It also sets out rationale and actions that could be taken to achieve the aims. The document gives names and contact details of pharmacists who have been involved in schemes that are provided as examples of best practice. So has the guidance changed practice over the past year, what are pharmacists views on it and what future plans do they have for renal services?

Andrea Devaney, principal pharmacist, renal transplant, Oxford Transplant Centre, Churchill Hospital, contributed to the development of both the renal-specific medicines management document and the NSF. She said that the renal-specific medicines management document had been well received over the past year. “The whole renal community was pleased to have a firm stake put in the ground for renal services with both the publication of part 1 of the NSF and now, more recently, part 2, and the medicines management document in between,” she said.

Ms Devaney commented that the medicines management document is essentially a reference tool and perhaps more useful to those pharmacists who are new to the area of renal care. It enables them to see what other renal units were doing at the time the document was written that was considered to be good practice, she said.

Examples of good practice

Ms Devaney has been involved in two of the schemes mentioned in the document as examples of good practice — a home delivery service for transplant outpatients (which won a Pharmaceutical Care Award in 2004) and the Oxford self-medication scheme for transplant recipients. So far, over the past year, three renal centres have been in contact with her to ask for further information about the self-medication scheme.

Caroline Ashley, principal pharmacist, renal services, Royal Free Hampstead NHS Trust, and chairman of the UK Renal Pharmacy Group, said that the document had been useful in terms of providing ideas for improving the use of medication record cards for renal patients at the Royal Free Hospital. Ms Ashley said that the hospital now has a computerised medication record card system and a computerised record of each card is kept in the pharmacy department. Previously, the cards were written on an ad hoc basis on the renal unit. “So now, when a patient gets readmitted, we have a good idea of their medicines. Our records are often more accurate than what was on the discharge summary,” she said.

Resources

Ms Ashley also contributed to the development of the renal-specific medicines management document. She explained that “a huge problem for implementing change is manpower”. For example, many renal pharmacists would like to set up pharmacy-run medication review clinics for haemodialysis patients and, although not yet widespread practice, it has been achieved by a few pharmacists in renal units around the UK. The document provides examples of best practice in this area. However, implementing such a service is difficult because of the small number of renal pharmacists employed by trusts across England and the service is often provided on an ad hoc basis rather than full time.

Ms Ashley is hoping to put forward a business case, off the back of both the renal-specific medicines management document and the NSF, to employ another renal pharmacist at the Royal Free with the aim of trying to formalise this type of service within the trust. “Renal patients are polypharmacy nightmares and doctors do not always have enough time to sort though their medicines with them,” she said. Having pharmacist-input “would ensure that the patients are taking their medicines correctly and that medication records are up to date, and would help to eliminate unnecessary prescribing.”

Renal pharmacists should be using the document to put forward business cases, according to Mark Lee, renal transplant pharmacist, Leeds Teaching Hospitals NHS Trust. However, Mr Lee is sceptical about exactly how many pharmacy managers have used the document as a resource to build business cases over the past year. He commented that although he thought the document was important when it first came out, because of the potential of using it to develop pharmacy services, he is not convinced that renal pharmacists are actually using it in this way or that the guidance is the only influence for change. Within Mr Lee’s trust, the guidance has not been used specifically to push for resources or to change practice over the past year. However, “We are aware of the recommendations in this document when we make our own developments,” he said.

Mr Lee pointed out that the majority of renal pharmacists were probably already undertaking most of the recommendations specified in the document. “In many respects this document drew together the kind of practices that were happening already,” he said. Mr Lee added that the document had been useful in pointing renal pharmacists in the right direction and giving ideas of best practice. There are not many forums to identify what other renal centres are doing and what best practice is, other than, for example, the UK Renal Pharmacy Group conference, he said.

Mr Lee said that he did not have any specific plans for using the document in the future. He does, however, intend to carry out an audit of the UK Renal Pharmacy Group’s standards of practice for renal pharmacists, which were developed in 2001 and referred to in the document. He also hopes to become a supplementary prescriber — another area highlighted in the document.

Changing hospital practice

Elizabeth Lamerton, senior renal pharmacist, Hope Hospital, Salford, said that on a scale of 1 to 10, the document probably scored “about a 6 because there was not a lot of specific targets in it”. She commented: “There were lots of recommendations and examples of good practice but it is difficult to get support you need within the hospital or department you work in unless you have got a distinct target to aim for.” Nevertheless, she has used the document as a bargaining tool to enable a renal pharmacist to attend a consultant ward round at least once a week and to increase the number of renal pharmacists employed at Hope Hospital.

The document has changed some of the hospital’s practice. “This time last year, renal pharmacists did not have any involvement in outpatient clinics at all. Now I participate in some outpatient dialysis clinics and review clinics,” she explained. In addition, Hope Hospital’s scheme for using compliance aids for haemodialysis patients, referred to in the guidance, is now being run as part of the hospital’s core renal service, rather than on a pilot basis. This was as a result of it being accepted as an example of good practice.

In terms of future plans, Miss Lamerton intends to develop further the hospital’s multidisciplinary approach to phosphate management and bone disease, which involves a dietitian-led clinic. The aim is to involve a pharmacist formally in the running of the clinic and addressing medicines in conjunction with diet. Miss Lamerton hopes to complete a supplementary prescribing course to move this forward. She is also developing a multidisciplinary approach to the cardiovascular management of renal patients. The aim is to develop a cardiovascular risk assessment tool and to run some cardiovascular review clinics jointly with the lead clinician for haemodialysis at the hospital, one of the hypertension nurse specialists, a dietitian and a pharmacist.

Lynn Ridley, renal pharmacist, York Hospitals NHS Trust, said that within her trust the renal multidisciplinary team had already done a lot of the work mentioned in the guidance before it was published. The team had already produced a guide for patients and their families to help them make informed choices about treatment options as they approach end stage kidney failure. They had also already set up a robust anaemia management programme and produced guidance for calcium and phosphate management, blood pressure management and the treatment of restless legs syndrome.

The team at York Hospitals NHS Trust are proactive with dosage adjustment and nephrotoxicity management on the wards and the trust has a well established self-medication programme in place, she said. As a supplementary prescriber, Dr Ridley manages typical chronic medical conditions such as anaemia and renal bone disease in haemodialysis patients. “One area mentioned in the document that we have not yet developed is shared care guidelines between primary and secondary care for the control of hypertension in established renal failure, but this is usually managed by the consultants in clinic anyway,” she said.

In the future, one of the consultants is keen that she should run some outpatient hypertension clinics but the resource is not available at the moment, she said. Dr Ridley added that following the change in legislation for the supplementary prescribing of Controlled Drugs, which is currently waiting for parliamentary approval, the renal team hope to be able to progress with pharmacist prescribing of repeat medication for haemodialysis patients.

District hospitals

So what does a renal pharmacist in a district hospital think of the guidance? At Lincoln County Hospital, funding has recently been found for Caroline Taylor to spend half her time at work as a renal pharmacist. Previously, Mrs Taylor’s post was as a clinical pharmacist with a specialist interest in renal pharmacy. She commented that working in a district hospital “we tend to see fewer renal patients and in that respect the document is helpful because it directs our care of these patients”. She added that the document has helped confirm that she is working along the right lines for the care of renal patients. Mrs Taylor plans to spend time with haemodialysis patients on the renal unit, taking medication histories and updating electronic records, as well as using patient held medication cards to improve communication both between primary and secondary care and between members of the multidisciplinary team so as to reduce medication errors and duplication. Although implementing medication review clinics is “not a reality at this stage in a district hospital”, Mrs Taylor has plans to introduce a bone management clinic for pre-dialysis and end stage renal failure patients, once she has completed a supplementary prescribing course.

Paediatric medicines management

Guidance is also provided in the document for paediatric renal medicines management. According to Sue Patey, lead pharmacist for nephrourology at Great Ormond Street Hospital, the document had not really changed practice for paediatric patients over the past year but it had “probably clarified practice and confirmed that we are already doing the right thing”. She commented that the document “is really reiterating what it says in the NSF for children but just particularly pertaining to renal services”. It could not be taken in isolation for paediatric patients and both time and funding were needed to put the recommendations in place.

In terms of what has been happening over the past year at Great Ormond Street in relation to the renal-specific medicines management document, Ms Patey said that the hospital was now more proactive in shared care issues with GPs. However, until medicines become licensed and preparations are made specifically for children there is always going to be the problem of GPs being reluctant to prescribe them, she said.

Other areas of progress included a major review of hypertension guidelines to enable a move to once-a-day medicines for children (where possible) and piloting a fact file for renal transplant patients which provides information on patients’ medicines. The renal unit has also introduced more patient group directions. However, Ms Patey was unable to say that the document had driven progress in these areas.

The future

Ms Devaney advised pharmacists to assess the needs of their local population and consider how the guidance could be used to advance the renal service being provided. With regard to the document itself, she said that it should be updated as new guidelines are introduced. However, at the time P&MM went to press, the document, which is available on the Department of Health’s website, had not yet been updated with, for example, the National Institute for Clinical Excellence’s recent guidance on immunosuppression. Mark Lee advised pharmacists to use the recommendations given to flag up what they currently do and what they aspire to do while the document is still relatively fresh.