www.sps.nhs.uk www.sps.nhs.uk

The first stop

for professional

medicines advice

National Developments in

Polypharmacy, Deprescribing and

Multiple compartment compliance

aids (MCAs)

Lelly Oboh Consultant pharmacist, care of older people

Specialist Pharmacy Services and Guys & St Thomas NHS Trust

27th November 2019

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OVERVIEW

• Polypharmacy and deprescribing

• NHS Long Term Plan

• National Overprescribing Review

• Structured Medication Reviews in GP contract

• Right Care Pathway Frailty, Toolkit

• IPMO

• Multiple compartment Compliance Aids (MCCAs)

• RMOC report

• CARE that is fit for purpose to deliver the LTP : So

WHAT? and WHAT NOW?

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A COMPLEX SITUATON

Ageing

Frailty

Multiple LTCs

Poly

Pharmacy

MCAs

Deprescribing

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HOW TO INFLUENCE CHANGE TO ADDRESS COMPLEX

PROBLEMS LIKE Deprescribing, inappropriate

polypharmacy and use of MCA

• They work outside single hierarchies and across systems cant

be solved in isolation need collective intelligence vs individual genius

• Conversations are important to get understanding and buy in to address questions more useful than arguments or logic.

• Using Bricoleur (DIY trying, testing) approach and clumsy solutions learn about and improve the situations sometimes we must break rules.

• In working out partial solutions fully understand problem. • Need good leadership vs management or command

Wicked Problems & Clumsy Solutions’ by Keith Grint

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THE CASE FOR CHANGE IN CARE PROVISION

• Rising ageing population increasing need for the

limited NHS resources available

• Move beyond investing in clinical & cost

effectiveness what gives patients the most value

• Health definition as ‘absence of disease’

wellbeing Incl. ‘the ability to adapt and to self-

manage’ in the face of social, physical, and

emotional challenges (Huber et al BMJ 2011).

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INVOLVING PATIENTS IN THEIR CARE

• People want it

• Ethical & right thing to do Professional bodies expect us to!

• What patients want often differ from what Drs think they want Kings Fund 2018

• Well informed, people make different choices about treatment

less unwanted interventions

• Patient and clinicians consistently overestimate the benefits of

treatments and underestimate the harms

• Enhances the way resources are allocated reduce

unwarranted clinical variation.

• NICE Shared decision making guidance – 2021

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INVOLVING OLDER PEOPLE with FRAILTY

& MULTIMORBIDITIES • LTCs maybe well controlled, but QoL & functional status in

decline

• Trying to control one disease worsens another

• More we ask people to do (treatment burden) more

overwhelmed less likely to do

• Uncertainty about clinical decisions is considerable when

evidence is unclear re potential benefit or harm.

• Population not usually included in clinical trials

• Clinical trials often measure survival/disease events vs.

functional outcomes (matters to patients)

• Don’t often measure consequences of ‘no drug’/ ‘lower dose’

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NHS LONG TERM PLAN Shift in our approach to providing care

• Personalised care will become ‘business as usual’ across the health and care system

• Based on ‘what matters’ to people, their individual strengths and needs

• Through Universal Personalised Care (model) • Shared decision making • Personalised care and support planning • Enabling choice, including legal rights to choice • Social prescribing and community-based support • Supported self-management • Personal health and integrated personal budgets.

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PATIENT CENTRED CARE • Providing care that is respectful of, and responsive to,

individual patient preferences, needs and values, and

ensuring that patient values guide all clinical decisions Institute of Medicine 2001

• Incorporates use of clinician skills, evidence-based

knowledge and patient perspective to provide

personalised, co-ordinated care which enables people to

make the most of their lives The Health Foundation, 2014.

• Views individuals as a bio-psycho-social and physiological

whole

• Emphasises that building relationships and good

communication are critical to meaningful involvement

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STRUCTURED MEDICATION REVIEW &

OPTIMISATION A five-year framework for GP contract reform to implement the NHS Long

term plan. (NHSE & BMA 2019 Sec 6.11 & 6.12)

• One of 5 PCN DES starting April 2020

• Directly enabled by clinical pharmacists working in PCNs Take responsibility for the care management of patients with LTCs and undertake clinical medication reviews to proactively manage people with complex polypharmacy

• Inappropriate use of antibiotics,

• withdrawing medicines no longer needed

• NHSE low priority prescribing

• Support medicines optimisation more widely

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SMR and OPTIMISATION

• Clinical pharmacists will support patients to take medicines to get the best from them, reduce waste and promote self-care.

• NHS LTP commitmentsdedicated focus on priority groups, incl. but not limited to: • asthma and COPD patients; • Stop Over Medication for People with learning disabilities or autism

program (STOMP) • frail elderly • care home residents; and • patients with complex needs, taking large no of different medicines

• Support with Digital technology • Support with analytical tools to identify right patients for

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PROCESS AND PRACTICALITIES

• NHSE, NHSI working group to outline the spec due 2020

• Identify who will benefit

• Set minimum standards for undertaking SMR

• Align with community pharmacies, CCG medicines

optimisation teams, specialists and acute Trusts

• Which patients for SMR?

• Which clinicians will undertake SMR?

• How to/process for SMR (incl tools)?

• Consultation Time? Face to face? Remote?

• Measuring benefits, outcomes and value

• Future of MURs?

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LIKELY TO BE IMPORTANT

• Systematic (tools) and opportunistic (relationships) methods for identifying patients

• Identification Tools and MDT referrals • Utilise principles from existing patient centred approaches e.g.

NHS Scotland Polypharmacy, NHS SPS 7 steps,

• A Tool box of Resources (therapeutic, clinical, comm. skills) • Evidence base tools for drug selection and deprescribing

Inappropriate meds screening tools e.g STOPP/START, NICE Single LTC database

• Tools for Shared decision making and goal setting • Tools for Person centred-consultations

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LEARNING FROM THE PAST

Holland R et al . Does home based medication review keep older

people out of hospital? HOMER Study RCT 2005 https://www.bmj.com/content/330/7486/293

•n: 872, ≥80 years taking 2 or more medicines, discharged from acute or community hospitals in Norfolk and Suffolk.

•Intervention: 2x home visits by pharmacist within 2 weeks and at 8 weeks post discharge. Control arm received usual care.

•Visits lasted 23 (1st) and 19 (2nd) minutes

•933 recommendations to GP. Mean no of medicines per patient: 5.9

•Main outcome measure: Total emergency readmissions to hosp at 6 mths.

•Results at 6 mths 178 readmissions in control vs 234 intervention group. 30% increase

•Conclusions: intervention associated with a significantly higher rate of hospital admissions and did not significantly improve quality of life or reduce deaths. Further research needed to explain this counterintuitive finding and to identify more effective methods of medication review.

https://www.bmj.com/content/330/7486/293

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OR HAVE WE NOT LEARNT?

What types of recommendations do pharmacists make, do GPs

action them and do they reduce complexity? 3D Study. 2018. Polly Duncan et al

•Sub-study of the 3D Study (n=797)

•RCT for patients with multimorbidity (>3 LTC) Ave 71yrs

•1 of 9 pharmacists reviewed patients’ GP computer records

•Remote med review up to 4 reccs for the GP to discuss with patient.

•76% of intervention patients had a pharmacist review

•19% had no pharmacist recommendation

•Of 1100 recommendations made, 20% were either vague, indirect or a

question.

•Of the recommendations advising changes to prescriptions, over half

were not actioned by the GPs..

•Most common interventions were to stop/reduce a medication (26%),

switch medicines within the same class (18%) or ‘review’ medicine (16%).

Therefore intervention had no effect on no of meds prescribed!

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MEDICINES OPTIMISATION IN CARE HOMES

(MOCH) 2018

• STPs and (ICS) to implement NHSE MOCH program

• Integrate new pharmacists/techs into existing 10 & soc care teams

• MOCH pharmacy teams improve patient centred care, quality, reduce

risk of harm from meds and release healthcare resources

• Optimise medicines (stop inappropriate or unsafe medicines)

• Ensure medicines add value to patient’s health and well-being

• Patient centred care (shared decision making about which medicines

care home residents take and stop)

• Create better med systems to reduce waste and inefficiency

• Train and support CH staff to enhance safer meds admin

• CPPE bespoke training pathway (NHSE)

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NATIONAL OVERPRESCRIBING REVIEW

• 2018: Mandate by Secretary of State (SoS) for Heath and Social care to review overprescribing in the NHS (esp primary care)

• Chief Pharmaceutical Officer, Keith Ridge appointed to lead review and make recommendations to SoS

• May 2019 National Overprescribing Review Opening symposium. Overprescribing Review Short Life Working Group (SLWG) appointed

• 2020: Recommendations to SoS

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TO LOOK AT, AND PROVIDE NATIONAL

FOCUS TO TACKLE OVERPRESCRIBING

1. Addressing polypharmacy – where patient is taking multiple medicines unnecessarily

2. Creating a more efficient handover between 10 and 20 care e.g GPs have data they need and feel able to challenge and change prescribing initiated in hospitals

3. improving management of non-reviewed repeat prescriptions incl. encouraging patients to ask questions about their treatment so they don’t take medicines no longer needed

4. The role of digital technologies in reducing overprescribing 5. The increased role for other forms of care, including social

prescribing

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RIGHT CARE FRAILTY TOOLKIT June 2019

•Expert practical advice & guidance on how to commission and provide best systems wide care for people living with frailty

•Resources to support systems to concentrate their improvement efforts on where there is greatest opportunity to address variation and improve population health.

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Problem

• people at risk of frailty

•2x mortality and 4x cost vs fit older people

• admission and delayed ToC

•Can be managed OOH

•Acutely ill older people more sensitive to delays in care

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Increase communication • between practitioners across

MDT/agencies • and in hours and OOH services Increased integrated services, timely access to • 10 care GP, social care, community

based services • Increase understanding and

confidence to manage common frailty syndromes and CGA

POLYPHARMACY INDICATORS

•% prescribing ≥ 15 medicines in 75+ and 85+ •>6 anticholinergic burden

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RIGHT CARE FRAILTY TOOLKIT June 2019

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Integrating NHS Pharmacy and Medicines

Optimisation (IPMO) program

• Approach to “test” the principles of a framework for integrating pharmacy and medicines within STPs and ICS pilot areas during 2018/19.

• Highlight the collaboration and leadership needed across the system, and the governance required to support this.

• Embed clinical and professional leadership to optimise medicines for populations and individual patients and encompass all specialties and healthcare professionals

• Many have polypharmacy workstreams e.g SEL ICS

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MEASURING OUTCOMES

Seven Core Outcomes for evaluating medicines optimisation reviews Beuscart et al 2018

• ADE drug related hospital admission

• Medicines use o overuse

o underuse

o potentially inappropriate medicines

o clinically significant drug interactions,

• Patient reported outcomes o Health related QoL

o Pain relief (patient requested)

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Social

care

CCG

Ph

Hosp

Ph

Com

Ph

3rd

Secto

r

Acute

Hosp MHT

Specialst

& Consu

Ph

Specialist

s

GPs & staff

PCN Ph

Social rx Therapists

Nurses

EMERGING VISION: Medicines Optimisation integrated and centered

around patient’s needs. PCN Pharmacists as ‘tour guides” for

patient’s journey , through robust handover & referral to & from MDT

Com

Ph

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Multiple compartment

Compliance Aids (MCCAs)

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LONDON REGIONAL MEDICINES

OPTIMISATION COMMITTEE (RMOC) REVIEW

• No legal requirement to provide MCCA

• No high quality evidence about use,

appropriateness and safety of MCCAs

• Impact on adherence unknown

• Associated with increased risks of harm

• Supply only if needed after patient centred

assessment, assess suitabilty for patient

and monitor frequently

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LONDON REGIONAL MEDICINES OPTIMISATION

COMMITTEE (RMOC) Review

FAQ coming soon….. • Reasons non adherent behaviours are complex and

multifaceted

• Interventions supported by behavioural models and theories

are more successful e.g COM-B model to resolve the problem

• Capability-memory, dexterity and ability to plan

• Opportunity-social support and regimen complexity

• Motivation- feeling about the necessity and benefits of drug

• Behaviour (taking medicines or not)

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MEDICINES ADHERENCE SUPPORT

PROJECT 2019

2-year project commissioned by the AHSN NE England and N Cumbria

• Investigate policies/practices that drive the use of MCAs

• Gather information about current practice across health and social

care Raise awareness in NHS and social care providers re +ve & -ve.

• Produce simple assessment tool for all sectors

• Monitor impact of the introduction of the assessment tool across

health and social care

Reasons for MCA use multifaceted and systems driven

Once a patient is on an MCA they never come off.

Root cause for many MCA patients is Polypharmacy

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64 MILLION MCA DISPENSED IN ENGLAND

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CHALLENGES FOR PRACTITIONERS

• Competency, ongoing supervision and support for

pharmacists to do SMR safely and effectively

• SMRs vs. other competing work in general

practice/PCNs

• Time and resources to follow through and monitor

managing complexity requires time!

• Managing expectations and pace of change

• Developing resilience and pharmacy team Wellbeing

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Enablers to bridge knowing- doing gap to enable PCN pharmacists deliver safe and effective CARE

•Explicit to tacit

knowledge

•Experiential learning

•Outcome focused self

reflection through peer

supervision

•Incorporate into

routine practice

•Build resilience and

sustain healthy

workforce

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SO WHAT? NOW WHAT?

Individual pharmacists Getting ready!

•Start conversations with your practice

•Negotiate to have your own case load for med reviews

•What will you measure and how?

•Your training and competencesidentify gaps

•Don’t be scared to challenge constructively

•Identify local specialists and members of MDT/integrated teams,

networking (RPS, PCPA, UKCPA)

•How would you receive support and supervision to allow you to

do the job safely and confidently.

•Come out of the shadows and Lead!

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SO WHAT? NOW

WHAT? (ACTION)

ALL pharmacists Getting Ready! • What is our strategy to deliver and demonstrate added value

of pharmacy?

• How will we ALL support each other to manage the tensions between needs of pharmacists managed by individual PCNs/practice vs. needs for the greater good of all pharmacists irrespective of practice setting?

• How can we ensure a capable and sustainable Pharmacy workforce to deliver on SMRs?

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Transformation to a deliver medicines

optimisation will only happen if…....

• Shift our focus from medicines to the patient

• Ask what matters most to the patient, prioritise and agree

shared goals

• Then use the right tools and our clinical expertise to

jointly agree a shared plan (shared decision making)

• Our interventions (e.g deprescribing, prescribing) become

part of the patient’s solutions

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