Progress in practice

Editorial Consultant, HPE

During the first few months of her new job as a heart failure specialist pharmacist (HFSP), Joanne Bateman (HFSP, Countess of Chester Hospital) was “frightened beyond belief”, she told the audience. As part of this role, she underwent training as an independent prescriber and she also undertook a clinical examination course, she explained.

Nearly one million people in the UK have heart failure. Moreover, heart failure accounts for approximately one million inpatient days, 2% of all NHS bed days and 5% of emergency admissions. Treating it utilises 2% of the NHS budget, mainly due to inpatient costs – and readmissions are common. Ms Bateman’s appointment was part of a redesign of the in-patient heart failure service. The objectives were to reduce the length of inpatient stay and readmission rates. A heart failure specialist nurse (HFSN) was also appointed at the same time.

During 2010–11, 252 patients with left ventricular systolic dysfunction were referred to the heart failure team, compared with 187 in 2011–12 and there was no change in the overall length of stay. However, whereas 15% of patients were readmitted during 2010–11, this proportion fell to 11% in 2011–12. The HFSP was responsible for 69% of prescribing. Furthermore, she recorded 57 clinical interventions and referred several acutely unwell patients to the cardiologist. Cardiologists have been very supportive when her role has been questioned by others, commented Ms Bateman. Asked whether she should leave physical examination to the HFSN and concentrate on prescribing, Ms Bateman pointed out that she needs to listen to the patient’s chest before she adjusts heart failure drug treatment in order to do the job most effectively.

Joanne was presented with the Hameln Pharmaceuticals award for the best short communication.

Shisha is a type of tobacco that is flavoured with fruit and flavourings and soaked in honey and molasses. Although commonly (and erroneously) believed to be harmless, the risks are similar to those of conventional cigarette smoking.

A poster presented by Carianne Hill (MPharm student, Bradford University) and colleagues showed that a biofilm forms inside the water bowl of shisha pipes. Microbes could move from the surface of the bowl into the vapour (which is inhaled) and the mouthpiece of the pipe. As pipes are commonly shared this could present an infection risk. In addition, it would be difficult to remove the biofilm by simple washing. As part of the project, the authors had also investigated students’ experience of shisha smoking. Nearly 40% of the 265 students interviewed were shisha smokers but many did not consider themselves to be ‘smokers’ and said they would tell their doctor that they did not smoke. Ms Hill explained that shisha bars provide warm places to work where food, drinks, video games and shisha tobacco are available and are therefore popular with students.

A collaborative project involving a number of hospitals, commissioning groups and health and social care services in Yorkshire has produced some ground-breaking initiatives. Chris Acomb (Clinical Pharmacy Manager, Leeds Teaching Hospitals) and Duncan Petty (Lecturer Practitioner. School of Health Care, University of Leeds) described how three such initiatives had developed.

The cross-sector project involved pharmacy technicians performing domiciliary medicines use reviews (MURs) for patients who were receiving daily help from either Local Authority Adult Social Care or Independent Sector Home Care. A team of four technicians was seconded from the acute trust. Lists of clients were obtained from adult social services, lists of medicines were obtained from general practitioners (GPs) and technicians telephoned patients to make appointments to visit them at home. Copies of the completed MUR form were then sent to the GPs. “Technicians frequently identified potential clinical problems as well medicines use issues”, commented Mr Acomb. To provide appropriate back-up for this situation, arrangements were made for an Advanced Clinical Pharmacist to be available for telephone consultation while the technician was with the client. Two examples illustrate the types of problem that were encountered. In one case, a 96-year-old patient was filling her own compliance aid but, because her sight was severely impaired, she had to identify the tablets by feeling their size. In this case, the technician arranged for a weekly delivery of a filled compliance aid. Another case involved an 83-year-old patient who was found to have three large plastic bags full of unused medicines, valued at £300. The technician arranged for the GP repeat prescribing system to be updated to reflect patient’s actual needs.

The results show that, in the first 12 months, two full-time technicians performed 708 MURs with clients in their own homes. Some 627 recommendations were made to GPs to try to improve the cost-effectiveness of prescribing and there has been an estimated annual saving of £43,430 in the primary care prescribing budget. Mr Acomb said that there has been good feedback from relatives and requests for more MUR services from Social Services. As a result of this positive experience, a joint Health and Social Care – Pharmacy Technician service has been commissioned to ensure that the annual planned medication review service continues, he added.

Another arm of the project was concerned with medicines reviews in care homes. This involved patients in nursing, residential and learning disability homes. “Care home patients get a raw deal”, said Dr Petty. Indeed, one study published in 2009 had reported that there were problems with the prescribing, monitoring, dispensing and administration of medicines to care homes residents. Typical problems include over-use of antipsychotics in dementia, use of antimuscarinic drugs in older people, use of medicines associated with falls and polypharmacy.

In this project, lists of care home residents were identified for participating GP practices and medicines reviews were carried out using the patients’ records. Next, the pharmacist visited the care home to check the medicines administration charts and to discuss issues with residents and careers. This was particularly helpful for patients who had been prescribed inhalers – although more than 50% of patients are demented, commented Dr Petty. Recommendations were passed to the GP and, if agreed, were implemented.

Numerous problems were found. One example was a patient who had been prescribed methotrexate 20mg weekly for rheumatoid arthritis, but on transfer to the home the dose was accidentally changed to 10mg weekly. Another example was a patient taking senna and docusate who had faecal incontinence. The GP had prescribed loperamide but the senna and docusate were not discontinued.

In total, 643 reviews had been over a period of 11 months, resulting in 2355 recommendations that led to 1921 changes – a mean of three per resident. This included 12 occasions when antipsychotic treatment prescribed for dementia was reduced or discontinued, noted Dr Petty. Some 448 prescriptions were discontinued resulting in a gross saving of £105,000.

Joint working with GPs presented no problems at all but demonstrating the clinical value of the service still has to be refined, said Dr Petty.

The third arm of the project involved an experienced clinical pharmacist working together with a community matron. Community matrons are experienced, senior nurses who work closely with patients (mainly those with a serious long term condition or a complex range of conditions) in a community setting. They act as case managers, who provide, plan and organise care.

In this project, patients with complex medicines management needs were referred to the pharmacist by the community matron. After reviewing the patient’s GP records, a joint home visit was arranged during which the pharmacist carried out a clinical medication review. Actions and recommendations were discussed with the patient and the community matron. Finally, a report with recommendations was produced and sent to the community matron, GP and any relevant consultant. One problem that emerged during the project was poor communication between the Acute Trust and Community Matrons when patients were admitted and discharged, said Mr Acomb.

Community matrons and GPs both felt that the project had had positive outcomes and, as a result, a new consultant pharmacist post has been appointed to continue developments in this area.

“Pharmacists need to brave enough to re-engineer services”, said David Taylor (Professor of Pharmaceutical and Public Health Policy, University College London School of Pharmacy). In light of intensified competition and ongoing resource restraints, he posed two questions: “What future relationships do you want with members of the medical profession – is there a fundamental choice to be made between being an integrated support service supplier or an alternative clinical service provider?” and “Do you believe that a full transition can be made from being a medicines-supplier to a medicines-use and health outcomes optimiser?” All communities need to promote healthcare efficiency and optimise health outcomes. Specialist hospital pharmacists could play an important part in achieving these goals. Pharmacists will need to overcome their dependence on past practice models, develop new skills and closer relationships with the public. This may require new competitive and cooperative working links with other professional including social care staff.