Post on 21-Jan-2016
description
How Pharmaceutical Advisers Can Ensure Quality and
Effectiveness at the Interfaces
Sue Carter MRPharmSSue Carter MRPharmSHead of Prescribing & Pharmacy,Head of Prescribing & Pharmacy,
Adur, Arun & Worthing tPCTAdur, Arun & Worthing tPCT
And Co-Founder, And Co-Founder,
Primary Care Pharmacists’ AssociationPrimary Care Pharmacists’ Association
Sue Carter BPC 2005
Overview
Interfaces – where are they?Interfaces – where are they? How are the interfaces shifting? How are the interfaces shifting? What are the medicines and What are the medicines and
pharmacy issues?pharmacy issues? How can those issues be addressed How can those issues be addressed
by primary care pharmacists? by primary care pharmacists? Some points to ponderSome points to ponder
Sue Carter BPC 2005
Interfaces – Where (and What) Are They? Classical description – when a patient goes into or Classical description – when a patient goes into or
comes out of NHS hospital – elective and non-comes out of NHS hospital – elective and non-electiveelective
……. But also out-patient activity and out-reach. But also out-patient activity and out-reach ……. And also social care, intermediate care, self-. And also social care, intermediate care, self-
carecare ……. And also out-of-hours services. And also out-of-hours services ……. And also private providers. And also private providers CommunicationCommunication
Pharmacists Pharmacists GPs GPs patients patients secondary secondary care care social care social care community healthcare community healthcare health service managershealth service managers
Sue Carter BPC 2005
Interface
Discharge & admissionDischarge & admission CommunicationCommunication Local guidelinesLocal guidelines Integrated medicines Integrated medicines
review as part of review as part of seamless patient seamless patient care care
GP medical recordsGP medical records Ensuring quality of care Ensuring quality of care
and managing riskand managing risk
Shared care Shared care Shared care Shared care
guidelinesguidelines Prescribing Prescribing
responsibilityresponsibility MonitoringMonitoring Service redesignService redesign
Policies – D&TC, APC, Policies – D&TC, APC, FormularyFormulary Service level Service level
agreementsagreements
Sue Carter BPC 2005
Policy Changes: the Road AheadPolicy Changes: the Road Ahead
Patient choice = pluralityPatient choice = plurality Chronic disease management & managed careChronic disease management & managed care Primary care contracting & innovationPrimary care contracting & innovation Payment by results & tariffs – foundation trustsPayment by results & tariffs – foundation trusts Service modernisation – secondary to Service modernisation – secondary to
community shift, tier 2 services,community shift, tier 2 services, Non-medical prescribingNon-medical prescribing Practice based commissioningPractice based commissioning Demand management & resource Demand management & resource
managementmanagement
Sue Carter BPC 2005
Intermediate care
Primary Care pharmacy
Social care
Hospital Pharmacy
GP Surgery
Community Pharmacy
Admission & Discharge
Home & Self Care
Secondary care
Tertiary care
Sue Carter BPC 2005
Intermediate care
Primary Care pharmacy
Social care
Hospital Pharmacy
GP Surgery
Community Pharmacy
Admission & Discharge
Home & Self Care
Secondary care
Tertiary care PLURALITY
CHOICE
INDEPENDENT SECTOR
Sue Carter BPC 2005
Sue Carter BPC 2005
Intermediate care
Primary care pharmacy
Social care
Hospital Pharmacy
GP Surgery
Community Pharmacy
Admission & Discharge
Home & Self Care
Sue Carter BPC 2005
Where Do Medicines & Pharmacy Fit? 4 in 5 over 75s take at least one medicine 4 in 5 over 75s take at least one medicine
and 36% of them take 4 or moreand 36% of them take 4 or more Half of people with long term conditions Half of people with long term conditions
fail to take medicines properlyfail to take medicines properly 5 to 17% of hospital admissions may be 5 to 17% of hospital admissions may be
due to older people’s problems with due to older people’s problems with medicines medicines
……. And while in hospital 6 to 17% will . And while in hospital 6 to 17% will experience an adverse drug reactionexperience an adverse drug reaction
Sue Carter BPC 2005
Where Do Medicines & Pharmacy Fit?USA evidenceUSA evidence Estimated 44k to 98k Estimated 44k to 98k
deaths per year due to deaths per year due to medication errors medication errors (including adverse drug (including adverse drug events)events)
66thth most common cause of most common cause of death in the USA (higher death in the USA (higher than RTAs, suicide, than RTAs, suicide, homicide and AIDS) homicide and AIDS)
Costs estimated at 76.6 Costs estimated at 76.6 billion dollars per annum billion dollars per annum in the USAin the USA
(Ref: JAMA 2002; 9:479-490)(Ref: JAMA 2002; 9:479-490)
USA long term condition USA long term condition managed care outcomes:managed care outcomes: Decreased use of Decreased use of
medicines with medicines with benefits to healthbenefits to health
Reduced medicines-Reduced medicines-related adverse related adverse events events
39% of patients incr. 39% of patients incr. compliance with compliance with medicationmedication
Sue Carter BPC 2005
Where Do Medicines & Pharmacy Fit?UK - Importance of ADRs UK - Importance of ADRs Estimated to take up 4 out Estimated to take up 4 out
of 100 hospital bed daysof 100 hospital bed days Estimated 15 to 20 x 400 Estimated 15 to 20 x 400
bed hospital equivalentsbed hospital equivalents Annual UK cost £380 Annual UK cost £380
million per yearmillion per year One in 10 of all NHS bed One in 10 of all NHS bed
days are taken up by days are taken up by consequences of ADR or consequences of ADR or hospital-acquired infectionhospital-acquired infection
(ref: Bandolier Extra, June 2002, Adverse (ref: Bandolier Extra, June 2002, Adverse Drug Reactions in Hospital Patients: A Drug Reactions in Hospital Patients: A systematic review of the prospective systematic review of the prospective and retrospective studies. Whiffen P, and retrospective studies. Whiffen P, Gill M, Edwards J, Moore A. Gill M, Edwards J, Moore A. www.ebandolier.com)www.ebandolier.com)
Has led to UK focus on Has led to UK focus on managed care, managed care, community matrons, community matrons, transforming long term transforming long term care programmes, etccare programmes, etc
Medicines management has Medicines management has huge, as yet largely huge, as yet largely undeveloped, potential to undeveloped, potential to ensure quality and ensure quality and effectiveness at new and effectiveness at new and existing interfacesexisting interfaces
Pharmacists are the Pharmacists are the experts in all experts in all aspects of aspects of medicines usemedicines use
Sue Carter BPC 2005
Medicines Management
Medicines managementMedicines management is a is a broad term which encompasses broad term which encompasses every aspect of use of medicines every aspect of use of medicines at both organisational and at both organisational and individual patient level individual patient level
Sue Carter BPC 2005
Medicines Management
Service improvement & Service improvement & demand management demand management
Policy, strategy and Policy, strategy and performance performance management management
Budgets, incentives & Budgets, incentives & monitoringmonitoring
Statutory Statutory responsibilities & legal responsibilities & legal framework framework
Workforce planning & Workforce planning & skillmixskillmix
Rational prescribing Rational prescribing Clinical governanceClinical governance Dispensing Dispensing Access to medicinesAccess to medicines Patient-centred Patient-centred
medication reviewmedication review Concordance, Concordance,
compliance & patient compliance & patient partnership / supportpartnership / support
Sue Carter BPC 2005
Evolved Approach to Medicines
Proactive, patient-centred and systematic Proactive, patient-centred and systematic approach to medicines approach to medicines Patient partnership for improved self-carePatient partnership for improved self-care
Stratifying patient population to identify high Stratifying patient population to identify high riskrisk
Individualised care plan to prevent adverse Individualised care plan to prevent adverse event & improve outcomes, based on need, event & improve outcomes, based on need, preference & choicepreference & choice Pharmaceutical carePharmaceutical care
Service redesignService redesign Opportunities in new contractsOpportunities in new contracts
Sue Carter BPC 2005
Medicines Management – Ensuring Quality and Effectiveness
Make sure it is -Make sure it is - SafeSafe EffectiveEffective EfficientEfficient SystematicSystematic Needs basedNeeds based Patient centredPatient centred
AccessibleAccessible MultidisciplinaryMultidisciplinary IntegratedIntegrated SustainableSustainable Supported with Supported with
clinical leadershipclinical leadership
Sue Carter BPC 2005
Safe – Guidelines & Protocols
Prescribing by new groups Prescribing by new groups of professionalsof professionals
NHS increasingly protocol / NHS increasingly protocol / guideline drivenguideline driven NICE guidance and NICE guidance and
guidelinesguidelines NSF standardsNSF standards ProdigyProdigy NHS directNHS direct Local health economiesLocal health economies
Performance management Performance management - healthcare commission- healthcare commission
Joint formulariesJoint formularies Practice formulariesPractice formularies Reviews and adviceReviews and advice Formal local guidelinesFormal local guidelines
DevelopmentDevelopment ConsultationConsultation ImplementationImplementation MonitoringMonitoring AuditAudit
Shared care guidelinesShared care guidelines
Sue Carter BPC 2005
Effective
Evidence based practiceEvidence based practice Only part of decision makingOnly part of decision making
Monitor outcomesMonitor outcomes AdmissionsAdmissions Quality and outcome frameworkQuality and outcome framework Spend or prescribing patternsSpend or prescribing patterns InterventionsInterventions Pharmaceutical care – record outcomes!Pharmaceutical care – record outcomes!
Sue Carter BPC 2005
Systematic
PractitionerPractitioner Assess, plan, evaluateAssess, plan, evaluate Ongoing – not just a Ongoing – not just a
single point reviewsingle point review Identify problems, Identify problems,
implement plan to avoid implement plan to avoid or monitor for problemsor monitor for problems
Set therapeutic goals for Set therapeutic goals for each drugeach drug
Pharmacist (or Pharmacist (or ‘practitioner’) takes ‘practitioner’) takes responsibility for responsibility for outcomesoutcomes
CommissionerCommissioner StrategyStrategy Equity of accessEquity of access MonitoringMonitoring Clinical governanceClinical governance ResourcesResources Workforce Workforce
developmentdevelopment
Sue Carter BPC 2005
Medicines are unique as a clinical interventionMedicines are unique as a clinical intervention Vast majority are self (or carer) administeredVast majority are self (or carer) administered …….And so factors other than disease .And so factors other than disease
prevalence dictate the need for careprevalence dictate the need for care Prioritisation should be based on agreed valuesPrioritisation should be based on agreed values Stratified approachStratified approach Patient and public involvement Patient and public involvement Equity, fairness, effectiveness, cost – Equity, fairness, effectiveness, cost –
Health needs assessmentsHealth needs assessments Health equity auditHealth equity audit Systematic prioritisationSystematic prioritisation
Needs Based
Sue Carter BPC 2005
Patient Partnership in Medicine Taking Empowering patients to take an active role in Empowering patients to take an active role in
managing their own care.managing their own care. Prescribing needs to be based on an Prescribing needs to be based on an
agreement between the patient and the health agreement between the patient and the health care professional.care professional.
Pharmacists can help in this processPharmacists can help in this process educating about treatments and options educating about treatments and options interpreting and explaining risks and interpreting and explaining risks and
benefitsbenefits Proactive support & resource to patientsProactive support & resource to patients
Sue Carter BPC 2005
Accessible - Services
Pharmaceutical services Pharmaceutical services distribution distribution Contract regulation Contract regulation
reformreform Competition & choiceCompetition & choice WorkforceWorkforce Commercial pressureCommercial pressure Professional pressureProfessional pressure Local pharmaceutical Local pharmaceutical
servicesservices ResourcesResources
Out of hoursOut of hours Pharmacists and Pharmacists and
NHS directNHS direct Dispensing out-of-Dispensing out-of-
hourshours Access to Access to
pharmaceutical pharmaceutical carecare
Supporting self-careSupporting self-care Minor ailmentsMinor ailments
Sue Carter BPC 2005
Accessible - Medicines
Patient group directionsPatient group directions POM to PPOM to P P to GSL?P to GSL? Walk-in centresWalk-in centres One-stop primary care One-stop primary care
centrescentres Health centre Health centre
pharmacies v. High pharmacies v. High streetstreet
Electronic prescribing &Electronic prescribing & e-pharmacy e-pharmacy
Non-medical prescribingNon-medical prescribing Supporting self-careSupporting self-care
Sue Carter BPC 2005
Integrated
Consistent approach – driven by policy, Consistent approach – driven by policy, protocol, standards etcprotocol, standards etc
Responsibilities clearly definedResponsibilities clearly defined ……And accountability (duty of care?)And accountability (duty of care?) Communication should be effective, Communication should be effective,
efficient and responsive – but not as easy efficient and responsive – but not as easy as it seems!as it seems!
Single assessment – develop national SAP Single assessment – develop national SAP for medicines?for medicines?
Sue Carter BPC 2005
How Are Primary Care Pharmacists Dealing With the Agenda? Practice, locality commissioning Practice, locality commissioning
board, (new) PCT levelsboard, (new) PCT levels All have operational and strategic All have operational and strategic
need for primary care pharmacistsneed for primary care pharmacists Additional statutory roles at PCT Additional statutory roles at PCT
levellevel
Sue Carter BPC 2005
Primary Care TrustFewer, larger PCTsFewer, larger PCTs PCT-wide cross-health PCT-wide cross-health
economy engagementeconomy engagement Co-ordination of local Co-ordination of local
health economy health economy medicine-related medicine-related policiespolicies
Performance Performance ManagementManagement
Interface medicines Interface medicines managementmanagement
Primary care Primary care contractingcontracting
Procurement initiativesProcurement initiatives Shared care Shared care Influencing clinical Influencing clinical
practicepractice Workforce Workforce
developmentdevelopment Policy development & Policy development &
implementationimplementation Statutory rolesStatutory roles Local delivery plan / Local delivery plan /
priorities planning / priorities planning / horizon scanninghorizon scanning
Sue Carter BPC 2005
Locality Commissioning Board Commissioning – Commissioning –
medicines issuesmedicines issues Service redesign – Service redesign –
secondary to primary secondary to primary care shiftcare shift
Demand managementDemand management Performance Performance
managementmanagement Repeat Prescribing Repeat Prescribing
Review Review Practice prescribing Practice prescribing
analysis analysis
Audit SupportAudit Support E.g. NSAIDs, E.g. NSAIDs,
Asthma, Statins, Asthma, Statins, NewsletterNewsletter Local health economy Local health economy
formulary formulary development & development & supportsupport
Proactive and reactive Proactive and reactive adviceadvice
Local interface issuesLocal interface issues
Sue Carter BPC 2005
GP Practice nGMS general nGMS general
involvementinvolvement Input to QOF and Input to QOF and
assessmentsassessments Practice visits & 3 Practice visits & 3
agreed action points agreed action points Many medicines issuesMany medicines issues
Repeat Prescribing & Repeat Prescribing & other practice other practice systemssystems
Provision of patient Provision of patient centred medicines centred medicines services services
Practice prescribing Practice prescribing analysis analysis
Audit SupportAudit Support Internal practice Internal practice
formulary formulary development & development & supportsupport
Proactive and Proactive and reactive advicereactive advice
Interface issuesInterface issues
Sue Carter BPC 2005
Targeted Medicines Management
POPULATION APPROACH - HEALTH PROMOTION AND SELF-CARE
ONE - MAJORITY OF PATIENTS TAKING MEDICINES FOR LONG TERM CONDITIONS
TWO - HIGH RISK PATIENTS
THREE - HIGHLY COMPLEX
PATIENTS
Level 1 – population managementLevel 1 – population management Supporting self-careSupporting self-careLevel 2 – care managementLevel 2 – care management Disease specific interventions Disease specific interventions
for at-risk groupsfor at-risk groups Supporting patients to optimise Supporting patients to optimise
medicines usemedicines use Pharmacists with special Pharmacists with special
interest interest - e.g. as disease-specific care - e.g. as disease-specific care managersmanagers
Level 3 – case management Level 3 – case management E.g. Targeted medicines E.g. Targeted medicines
support at dischargesupport at discharge Proactive pharmaceutical careProactive pharmaceutical care
Sue Carter BPC 2005
The New Pharmacy Contract – Major Themes
1.1. Support for self-careSupport for self-care
2.2. Management of long-term Management of long-term conditions (CDM)conditions (CDM)
3.3. Public Health – health Public Health – health promotion pluspromotion plus
Sue Carter BPC 2005
Strategic DirectionStrategic Direction Investment to help older people keep Investment to help older people keep
healthier at home for longerhealthier at home for longer Intensive case management - “Evercare”Intensive case management - “Evercare” CDM - better, stratified care for people with CDM - better, stratified care for people with
long term illness – ‘care closer to patient’long term illness – ‘care closer to patient’ Developing services in community & Developing services in community &
primary care settings – secondary to primary care settings – secondary to primary shiftprimary shift
New organisational systems, structures New organisational systems, structures and processes – clinical governance & risk and processes – clinical governance & risk managementmanagement
Multidisciplinary focusMultidisciplinary focus
Sue Carter BPC 2005
Some Points to Ponder ... How will future primary care led self-care, How will future primary care led self-care,
disease management and medicines disease management and medicines management initiatives impact on pharmacy management initiatives impact on pharmacy workforce and workload?workforce and workload?
Can better use of skillmix make enough Can better use of skillmix make enough difference?difference?
Will the forthcoming white paper take some of Will the forthcoming white paper take some of these issues on?these issues on?
Can quality and effectiveness at interfaces be Can quality and effectiveness at interfaces be ensured in an NHS with constantly shifting ensured in an NHS with constantly shifting structures, ‘rules’ and personnel?structures, ‘rules’ and personnel?