Progress in practice

“Clinical pharmacy is the future – have no doubt”, Keith Ridge CBE (Chief Pharmaceutical Officer NHS England) told the audience. He went on to say that all clinical pharmacists should be prescribers on registration. According to the NHS Five Year Forward View

(www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf), a radical upgrade in preventive healthcare will be needed together with efficiency and investment measures and new models of care to improve the quality of services.

Collectively these changes should ensure that patients’ needs can be met in a sustainable way in future. There are still numerous problems in the way that medicines are used, including information gaps for patients, poor adherence, medicines’ wastage and hospital admissions caused by preventable adverse effects of medicines, Dr Ridge said. In addition, the level of medication errors continues to be unacceptably high.

Medicines optimisation (MO) (see Figure 1), which has the support of the Chief Medical and Nursing Officers, is seen as key to tackling the problems. It is important to remember that MO is about improving patient outcomes and measuring and monitoring of medicines use. “We are trying to shift a lot more hospital pharmacy effort into medicines optimisation”, he said.

Personalised medicine and genomics will have a significant influence on future practice. Medicines are less effective than might be expected in up to 60% of patients because of genetically determined factors, said Dr Ridge. Clinical pharmacists should be at the forefront of clinical effectiveness research; they should be leading the research and publishing in this area, “and that would position pharmacy right at the forefront of personalised medicine”, he added.

“We now need to transform pharmacy to be even more clinical and to provide 24/7 services”, he continued. A tenfold increase in the number of consultant pharmacists is now needed – both for career development and for improved services. There are now about 250 clinical pharmacists working in GP practices.

There has been an “overwhelming response from GPs” and it looks as if more funds need to be allocated to this initiative. “Pharmacists working in GP practices should be the lynchpins of the pharmacy service”, said Dr Ridge.

There is a real desire to ensure that more clinical work is done in community pharmacies and as the shift towards medicines optimisation accelerates, the community pharmacy sector is likely to shrink. “I think there are too many community pharmacies in this country”, commented Dr Ridge. “The future lies in medicines optimisation, including personalised medicine – and clinical pharmacy is right at the heart of wherever pharmacy is practised”, he concluded.

A domiciliary pharmacy service in Exeter has prevented 62 hospital admissions in a six-month period by optimising medication for housebound and frail elderly patients. Ian Nash (Cluster Pharmacist, North Devon Healthcare Trust) explained how the Exeter cluster pharmacy service performs clinical medication reviews and medicines reconciliation in patients’ homes in response to referrals from GPs and the community health and social care team. The service is delivered by a team of three pharmacists and two technicians and its objective is to enable patients to manage their own medicines safely at home.

A three-month prospective audit of 112 patients was undertaken. The majority of the patients were aged 80 years or more and most were housebound. Many were taking more than ten medicines and 85% had some form of impairment that affected their ability to manage their medicines.

The risk of harm from medicines was assessed as ‘high’ or ‘extremely high’ in 76% of patients at referral (using the National Patient Safety Agency (NPSA) risk assessment tool). At the final contact only 21% of patients were at high risk of harm. The adapted Risk Index Outcome (RiO) tool was used to assess the probability of avoidance of hospital admission. The scores, which were independently verified, showed that on 85% of occasions hospital admission was genuinely avoided.

On this basis, 108 hospital admissions, at a cost of £2230 each, could be avoided each year – a gross saving of £240,000 per year. Even allowing for staff costs of £140,000 per year, this would leave a saving of £100,000 per year, said Mr Nash.

“Ten percent of the patients I visit live in utter chaos”, said Mr Nash, and much of the job involves reconciling medicines because the GP’s record is often not up to date. He added that his background as a community pharmacist helped.

As a result of the success of this project, the service is to be retained. It has been concluded that it offers a sustainable medicine management delivery model integrated into a multidisciplinary team.

When dealing with frail elderly people at home, one of the most important considerations is to take into account patients’ experiences and their perspectives, “because medicines-related problems start at home”, according to Lelly Oboh (Consultant Pharmacist, Care of Older People, Guy’s and St Thomas NHS Foundation Trust (Community Health Services), London).

Frailty makes people less resilient to minor stressful events and they are unlikely regain their previous level of independence after a fall or infection, for example. This can have a significant impact on medicines’ use.

The starting point for discussion of medicines should always be the patient’s list, said Ms Oboh. The hospital discharge list and the GP’s list often differ from what the patient is actually taking, she added. It is also important to listen for clues in the patient’s narrative when taking a history. For example, one patient did not take her alendronic acid tablets. On further questioning, it turned out that the word ‘acid’ had made the patient think the tablets would cause acid indigestion.

As an illustration, Ms Oboh described a 79-year-old woman with a number of medical problems, including osteoarthritis, colitis and thyroid disease, taking a total of ten prescribed medicines. She had a good relationship with her pharmacist and was knowledgeable about her medicines. Her main problem was uncontrolled pain in her wrists, feet, hands and back that kept her awake most nights. She was unable to open the blisters on a medication compliance aid because of the pain in her wrists and fingers and was not taking all her prescribed treatment.

She said she would prefer “old-fashioned bottles with easy tops”. After taking a detailed history of the medicines the patient actually took, the pharmacist decided to focus on improving the pain management first and leave other medicines until a later date. “Frailty is the point where disease-based guidelines are no longer a priority – instead the priority becomes what matters to the patient”, said Ms Oboh.

In this case, the pharmacist explained how the treatments could work together and formulated a plan that involved larger doses of gabapentin combined with regular paracetamol and slow-release tramadol. The patient agreed to try the new regimen and after three weeks her pain was significantly reduced, she was sleeping better and requested a written summary of her treatment plan.

One of the key findings to emerge from Ms Oboh’s work is that there is a need for a long-term commissioning strategy with the pharmacy workforce leading medicines optimisation across care settings, she concluded.

Kevin Dooley was the last of 18 children born into a family in a deprived area of Glasgow, who steadily progressed to alcoholism, Class A drugs use and a life of crime. After 25 years of being “stoned or drunk”, his life was changed through rehabilitation. He now works as an addiction recovery consultant and he described his experiences to the audience.

Mr Dooley’s overriding memory of his childhood was one of fear combined with feelings of awkwardness with people. By the age of 12 years he had already been slashed cross the face in a knife fight. He recalled that without alcohol he never felt he belonged – “I discovered that I hated being sober”, he said.

He never felt valued and all relationships were doomed because he did not trust anyone. He was imprisoned for drug dealing but, “all you do in prison is get drugs, take drugs and ferment alcohol”, he said. When he left prison there was no support; he was homeless and he quickly returned to drug-taking.

After rehabilitation, he learned that investigations into adverse childhood experiences showed that trauma in childhood is associated with decreased life expectancy and serious health and social problems in adulthood. Experiences such as witnessing inter-generational violence can “hijack the pre-frontal cortex”, he said.

Emotional attunement helps people to develop good brains but an emotionally impoverished childhood leaves a brain “primed for addiction” and “not resourced enough to take on life”, explained Mr Dooley. Emotional attunement is a key part of effective rehabilitation: “Put someone in a nourishing and emotionally attuned environment and they will rebuild their pre-frontal cortex”, he added.

Pharmacists have a big role to play in the management of drug addicts. Speaking directly to his audience he said, “Every one of you is powerful – you can change your own lives and other peoples; you can make a difference”.

Ideally methadone treatment should be used to manage stress, he suggested. “You don’t take drugs to get high, you take them for emotional distress”, he said. Looking back on his life, he said that little moments of kindness, notably from a pharmacist and a police officer, had left a lasting impression on him.

The introduction of a 24 hour, seven-day pharmacy service at the 1900-bed Leeds Teaching Hospital NHS Trust resulted in more rapid delivery of discharge prescriptions and improved patient flow; “the difference was massive”, according to one senior nurse. Andrew Lowey (Lead Clinician, clinical pharmacy and technical services, Leeds Teaching Hospital NHS Trust) explained how the change had been introduced. The pharmacy team in Leeds wished to improve medicines’ reconciliation at weekends, to provide better support to multidisciplinary teams and timely information about medication changes to GPs and to improve the consistency of access to specialist pharmacy advice.

In order to achieve this, new, integrated seven-day rotas were introduced for all pharmacists, technicians and support staff. A patient prioritisation system was devised together with a staff ‘huddle’ at the beginning of shifts to ensure that pharmacy support was directed to the areas of greatest need. A new pharmaceutical care section was incorporated into the medicines chart; this really helps pharmacists to keep track of outstanding problems, commented Dr Lowey. This is further helped by an electronic handover tool that identifies outstanding and high-risk issues that require follow up. A shift system now ensures that there is a pharmacist available round the clock. In addition, the aseptic service now operates for 12 hours during the week and from 08.00 to 18.00 at weekends.

As a result of these changes, some critical improvements have been made. There is now regular near-patient validation of electronic discharge advice notes (eDANs) and 96% of discharge prescriptions are turned round within two hours, 84% within one hour. Specialist pharmacists are now available seven days a week and so, “you no longer have pharmacists trying to answer [specialised] questions outside their area of competence”, said Dr Lowey. Medicines reconciliation rates within 24 hours of admission had increased from 68% in September 2014 to 79% in March 2015, despite winter bed pressures. Over the same period, medicines’ reconciliation on Saturdays rose from 0% to 41%.

One pharmacy technician commented that the improved weekend service to the acute wards made Mondays less chaotic with less ‘catch-up’ work and fewer delayed or missed doses.

All the changes have been made within the existing staff budget and without changing any existing staff contracts. However, the service depends heavily on highly-skilled pharmacy technicians and appropriate use of technology, said Dr Lowey. Overall, there has been considerable progress towards better matching of pharmacy resources with risks and priorities but there is more work to do to improve yet further and build more resilience into the service, he concluded.