Medicines Optimisation Opportunities and Examples, Challenges on

levels of engagement/knowledge Presented by Dr Jill Loader,

Regional Pharmacist, NHS England South

Optimising the use of medicines for respiratory disease across the South West 1st October 2013

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• Put patients at the heart of everything the NHS does (“No Decision About Me Without Me”)

• Focus on continuously improving those things that really matter to patients - the outcome of their healthcare • Empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare services

Medicines Optimisation –The Policy Context

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“Pharmacists working with doctors and other health professionals, have an important and expanding role in optimising the use of medicines and in supporting better health” “The community pharmacy contract, through payment for performance, will incentivise and support high quality and efficient services, including better value in the use of medicines through better informed and more involved patients”.

Medicines Optimisation –The Policy Context

Medicines Optimisation Principles

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NHS | Presentation to [XXXX Company] | [Type Date] 5

ACT on Asthma Programme Opportunities and Challenges

Pre April 2013

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PCT

Medicines optimisation

Consultation with LPC

Pharmaceutical Needs Assessment

Complaints

Accountable officer for Controlled Drugs and LIN

Public Health

Waste medicines

Patient engagement

Clinical leadership and engagement

Pharmaceutical Applications

Medicines strategy

Medicines QIPP

Accreditation

Fraud

Poor performers

Contract monitoring

Commissioning essential, advances and enhanced Pharmaceutical services Medicines safety

Transfers of care

Care Homes

Access to medicines out of hours

Post April 2013

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NHS England

Medicines optimisation

Consultation with LPC

Pharmaceutical Needs Assessment (H&W Boards)

Complaints

Accountable officer for Controlled Drugs

Public Health

Waste medicines

Patient engagement Clinical leadership and engagement

Pharmaceutical Applications

Medicines strategy

Medicines QIPP

Accreditation

Fraud

Poor performers

Contract monitoring

Commissioning essential, advanced and enhanced Pharmaceutical services

Medicines safety Transfers of care

Care Homes

Access to medicines out of hours

Quality improvement CCGs

Direct commissioning of public health services from pharmacy

Contract monitoring LAs

Commissioning services direct from pharmacy e.g. minor ailments, palliative care medicines

Safe use of controlled drugs Patient pathways Networks

Primary care prescribing

NHS Outcomes Framework

Senates [12]

Strategic Clinical

Networks

Local Professional

Networks

Operational Delivery

Networks

Other Local

Networks “The conscious and guiding intelligence”

“Engines for change and improvement across complex care systems”

“Gathering frontline knowledge and expertise”

“Mapping patient pathways to ensure access to specialist support”

“15 AHSNs: Masters of science and evidence based practice”

Multi-professional

i.e. Cancer; CVD; Maternity and Children’s; Mental Health / Dementia / Neurological Conditions

i.e. Pharmacy; Eye health; Dental

e.g. Adult Critical Care; Neonatal Intensive Care; Trauma; Burns; Paediatric NM; Paediatric IC

e.g. Academic Health Science Networks, Research Networks

NHSCB Network Support Teams (AT-based)

Annual national priorities from the NHSCB Medical and Nursing Directorates All supported by Improvement Body and Leadership Academy

Different Types of Network

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Effective Patient Involvement

•  Clearly define remit of each member of group

•  What is needed and why and what they will get out of it

•  Make sure patient reps are properly prepared

ü appropriate background

ü a good pre-brief (include roles, jargon, expectations, behaviours)

ü  opportunity to ask questions in a non threatening environment

•  Ensure support available from both an NHS buddy and another patient rep

•  Be clear about training provided, claiming expenses etc.

•  Keep engaged and give regular feedback re the difference their contribution is making

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NHS England – London, commissioning differne

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Almost 1 million people across London who were eligible for a seasonal flu vaccination had not received one in 2012/13

Rotavirus and shingles more pressure on existing system Outcome needed to decrease overall impact of seasonal flu

Less commissioning capacity in NHS England.

Case study 1

NHS England -London •  New service level agreement, service specification, single

Patient Group Direction •  Agreed criteria for accreditation of pharmacists and

premises, list of training providers, assessment of competency of new vaccinators

•  IT platforms - Expressions of Interest and distribution of documents, as well as data collection and transfer of certain data to GP systems to allow them to update their information (and thereby inform the NHS England data collection), and invoicing NHS England

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Working differently •  The design, production and delivery of posters and

leaflets which NHS England has commissioned from the National Pharmacy Association

•  The LPCs taking responsibility for communication with their contractors rather than this coming directly from NHS England.

•  The LPCs also taking responsibility for discussions with manufacturers and wholesalers to ensure sufficient supply of vaccine stock for community pharmacies.

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Surrey and Sussex Partnership NHS Trust

•  Medicine-taking has a huge impact on recovery and outcomes in mental health

•  Side-effects, disease symptoms and chaotic lifestyles are real problems and adherence is notoriously poor.

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Lisa  Stanton,  Specialist  Pharmacist  Early  Interven7on  &  Learning  Disabili7es    We  are  really  ge)ng  to  understand  views  and  beliefs  of  individuals  and  their  families  about  medicines  at  the  outset  of  treatment,  using  evidence-­‐based  mo:va:onal  interviewing  techniques  and  joint  decision-­‐making  to  increase  the  likelihood  that  medicines  will  be  taken  and  ul:mately  improve  

recovery  and  long  term  outcomes.  

Case study 2

Adherence therapy intervention in early psychosis: effect on relapse rates, Prof Richard Grey UWE

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http://www.adherencetherapy.co.uk/clinical-evidence.php 25/9/13

The best medication in the world is ineffective unless people take it.

Case study 2

Key elements of adherence therapy •  A structured assessment •  Dealing with resistance •  Exchanging information •  5 key skills: problem solving; looking back;

exploring ambivalence; talking about beliefs about medication; looking forward.

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http://westengland.academia.edu/RichardGray 25/9/13

Case study 2

NHS | Presentation to [XXXX Company] | [Type Date] 16

http://www.choiceandmedication.org/sussex/medications/21/

Case study 2

NHS | Presentation to [XXXX Company] | [Type Date] 17

Impact Bristol in partnership with Teva

Case study 3

IMPACT - Bristol

Results of Asthma Directed Medicines Use Review (MUR)  Average  

Yes %   No %  

Has the patient had an asthma review in the last 12 months?   63.4   36.6  

Is the patient experiencing symptoms of poor asthma control? (Using the 3 RCP Asthma Control questions)   55.9   44.1  

Is the patient adherent to their inhaler medication regime?   72   28  

Did the patient have the correct inhaler technique?   68.8   31.7  

Did the pharmacist provide advice to the patient, as a result of something they identified during the MUR?   89.6   10.4  

Did the pharmacist demonstrate correct inhaler technique to the patient?   56.3   43.7  

Is the patient using their peak flow meter at least once a week and recording the results in their diary? (Once weekly as recommended by respiratory clinicians)   12.5   87.5  

Does the patient have an asthma action plan (so they know what to do in an asthma attack)?   19.5   80.5  

Is the patient a smoker?   27   73  

If smoker, did the pharmacist sell NRT to the patient or refer them to smoking cessation services?   75.3   24.7  

Did the pharmacist identify any concerns during the MUR which necessitated referring the patient back to their GP/Asthma Clinic?   54.2   45.8  18

Case study 3

ACT on Asthma Programme •  90% of deaths from asthma are potentially preventable

(Asthma UK) •  75% of hospital admissions for asthma are avoidable

(Asthma UK) •  Non adherence results in poor outcomes, Lasmar et al, 2009 •  Non-adherence aggravates airway inflammation which may

result in exacerbations, need for health care intervention and even death. Williams et al 2004, Bender et al 2004

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Rowlands Pharmacy and GSK

Case study 4

ACT on Asthma •  419 community pharmacies, 3737 asthma patients •  Intervention ACT 1 tMUR ACT 2 •  1445 patients tMUR (or CMS) and both tests within

timescale •  982 (68% improved ACT score)

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ACT 1

ACT 2

Total control (25) 5.3% 10.1% Well controlled (20-24) 29.2% 48.0% Uncontrolled (<20) 65.5% 41.9%

Rowlands Pharmacy and GSK

Case study 4

To improve outcomes…

The causes of medication non-adherence

are complex but observational studies

suggest that failure to elicit and address

patients’ individual circumstances and goals

or preferences regarding their regimen may

contribute to treatment non-adherence.

Osterberg and Blaschke, 2005

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3Overarching indicators

Improvement areas

Helping people to recover from episodes of ill health or following injury

3a Emergency admissions for acute conditions that should not usually require hospital admission3b Emergency readmissions within 30 days of discharge from hospital* (PHOF 4.11)

Improving outcomes from planned treatments3.1 Total health gain as assessed by patients for elective procedures

i Hip replacement ii Knee replacement iii Groin hernia iv Varicose veins v Psychological therapies

Preventing lower respiratory tract infections (LRTI) in children from becoming serious3.2 Emergency admissions for children with LRTI

Improving recovery from injuries and trauma3.3 Proportion of people who recover from major trauma

Improving recovery from stroke3.4 Proportion of stroke patients reporting an improvement in activity/lifestyle on the Modified Rankin Scale at 6 months

Improving recovery from fragility fractures3.5 Proportion of patients recovering to their previous levels of mobility/walking ability at i 30 and ii 120 days

Helping older people to recover their independence after illness or injury3.6 i Proportion of older people (65 and over) who were still at home 91 days

after discharge from hospital into reablement/ rehabilitation service*** (ASCOF 2B) ii Proportion offered rehabilitation following discharge from acute or community hospital

Enhancing quality of life for people with long-term conditions2

Overarching indicator2 Health-related quality of life for people with long-term conditions** (ASCOF 1A)

Improvement areas

Ensuring people feel supported to manage their condition2.1 Proportion of people feeling supported to manage their condition**

Improving functional ability in people with long-term conditions2.2 Employment of people with long-term conditions** * (ASCOF 1E PHOF 1.8)

Reducing time spent in hospital by people with long-term conditions2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive

conditions (adults) ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under

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Enhancing quality of life for carers2.4 Health-related quality of life for carers** (ASCOF 1D)

Enhancing quality of life for people with mental illness2.5 Employment of people with mental illness **** (ASCOF 1F & PHOF 1.8)

Enhancing quality of life for people with dementia2.6 i Estimated diagnosis rate for people with dementia* (PHOF 4.16)

ii A measure of the effectiveness of post-diagnosis care in sustaining independence and improving quality of life*** (ASCOF 2F)

Preventing people from dying prematurely1Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults ii Children and young people1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature death in people with serious mental illness1.5 Excess under 75 mortality rate in adults with serious mental illness* (PHOF 4.9)

Reducing deaths in babies and young children1.6 i Infant mortality* (PHOF 4.1)

ii Neonatal mortality and stillbirthsiii Five year survival from all cancers in children

Reducing premature mortality from the major causes of death1.1 Under 75 mortality rate from cardiovascular disease* (PHOF 4.4)1.2 Under 75 mortality rate from respiratory disease* (PHOF 4.7)1.3 Under 75 mortality rate from liver disease* (PHOF 4.6)1.4 Under 75 mortality rate from cancer* (PHOF 4.5)

i One- and ii Five-year survival from all cancersiii One- and iv Five-year survival from breast, lung and colorectal cancer

Reducing premature death in people with a learning disability1.7 Excess under 60 mortality rate in adults with a learning disability

4Overarching indicators

Ensuring that people have a positive experience of care

4a Patient experience of primary carei GP services ii GP Out of Hours services iii NHS Dental Services

4b Patient experience of hospital care4c Friends and family test

Improvement areasImproving people’s experience of outpatient care4.1 Patient experience of outpatient services

Improving hospitals’ responsiveness to personal needs4.2 Responsiveness to in-patients’ personal needs

Improving access to primary care services4.4 Access to i GP services and ii NHS dental services

Improving women and their families’ experience of maternity services4.5 Women’s experience of maternity services

Improving the experience of care for people at the end of their lives4.6 Bereaved carers’ views on the quality of care in the last 3 months of life

Improving experience of healthcare for people with mental illness4.7 Patient experience of community mental health services

Improving children and young people’s experience of healthcare4.8 An indicator is under development

Improving people’s experience of accident and emergency services4.3 Patient experience of A&E services

Improving people’s experience of integrated care 4.9 An indicator is under development *** (ASCOF 3E)

Reducing the incidence of avoidable harm5.1 Incidence of hospital-related venous thromboembolism (VTE)5.2 Incidence of healthcare associated infection (HCAI)

i MRSAii C. difficile

5.3 Incidence of newly-acquired category 2, 3 and 4 pressure ulcers5.4 Incidence of medication errors causing serious harm

Improving the safety of maternity services5.5 Admission of full-term babies to neonatal care

Delivering safe care to children in acute settings5.6 Incidence of harm to children due to ‘failure to monitor’

Treating and caring for people in a safe environment and protect them from avoidable harm5

Overarching indicators5a Patient safety incidents reported5b Safety incidents involving severe harm or death 5c Hospital deaths attributable to problems in care

Improvement areas

NHS OutcomesFramework 2013/14

at a glance

Alignment across the Health and Social Care System

* Indicator shared with Public Health Outcomes Framework (PHOF)** Indicator complementary with Adult Social Care Outcomes

Framework (ASCOF)*** Indicator shared with Adult Social Care Outcomes Framework**** Indicator complementary with Adult Social Care Outcomes

Framework and Public Health Outcomes Framework

Indicators in italics are placeholders, pending development or identification

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