David RP Terry, PhD, MRPharmS
Deputy Chief Pharmacist, Birmingham Children’s Hospital
Senior Lecturer, Aston University, Birmingham, UK
The concept of seamless care is not difficult to understand. Nor is it difficult to recognise how important it is for patient care. Yet trying to ensure that seamless care supports patients as they move from one healthcare sector to another is a challenge, and perhaps especially so in the UK where the vast majority of care is provided free of charge by the National Health Service (NHS). Nonetheless, a lot of work has been undertaken over the last few years to improve pharmacy-related seamless care in England. This article aims to describe some of the current problems and how national guidance is seeking to address these issues and ensure service integration is appropriate for all patients, including children, at the healthcare interface.
The term ‘seamless care’ has been used in relation to pharmacy services since the mid-to-late 1990s. Much of the early work in this area was undertaken by Canadian pharmacy organisations. In 1998, a pharmacy workshop in Toronto defined seamless care as: “The desirable continuity of care delivered to a patient in the healthcare system across the spectrum of caregivers and their environments. Pharmacy care is carried out without interruption such that, when one pharmacist ceases to be responsible for the patient’s care, another pharmacist or healthcare professional accepts responsibility for the patient’s care.”1
Passing on the baton of care from one healthcare professional to the next is dependent on timely and accurate transfer of information. Interruptions in providing essential medication information can lead to unintentional omissions or changes in drug therapy, with the potential for poor patient management and increased clinical risk.
It has been estimated that around 60% of all medication errors in UK hospitals occur as a result of poor communication at the point of transfer of care, usually during admission to, or discharge from, hospital, or when a patient is transferred from one ward to another.
Much has been done in the UK to support good communication through electronic access to patient information. Connecting for Health is the NHS organisation responsible for this work; it is part of the Department of Health Informatics Department. Whilst the multi-billion pound National Programme for Information Technology has recently been abandoned in England, work continues to develop and provide a national Summary Care Record (SCR) service. The SCR holds information on the medications needed by the patient and records details of any allergies.
The aim is to provide healthcare staff who may be treating patients in an emergency with faster access to their patients’ key health information, ensuring joined-up care. However, at present only 5.5 million SCRs have been created, accounting for less than 10% of the population, and access to these is mostly via secure internet portals rather than integrated healthcare systems. Pharmacists caring for patients on admission to hospital in England are therefore at present unlikely to be able to access patient information electronically and must rely on other processes to identify useful medication data.
Recent developments towards seamless care
Over the last few years a number of national guidelines have been published to direct pharmacy services involved in the transfer of care process. In 2005–6, national pharmaceutical bodies published the document: ‘Moving Patients, Moving Medicines, Moving Safely. Guidance on Discharge and Transfer Planning.’2 The accompanying workbook states that the aims of this guidance is to: “… provide practical guidance in developing systems to tackle discharge and transfer problems between different settings and is based on experiences and evidence available, including examples and paperwork from existing schemes.” This document emphasises the importance of seamless care to reduce risks at the point of transfer and describes potential interventions that can support this process. These include drug history taking at admission, providing medication discharge summaries, using pharmaceutical care plans, providing patient counselling and re-engineering pharmacy systems. While this document acknowledges the problems of medicines management on admission to hospital, somewhat disappointingly, it focuses on discharge planning and provides little guidance on admission arrangements. However, admission was addressed a year later by joint guidance from the UK’s National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA). This was the first of a new type of guidance known as Patient Safety Guidance and was published in December 2007. This document mandated hospitals to undertake medication reconciliation for all new admissions to hospital and makes clear the important role pharmacy staff have in this process. Based on available published evidence at the time, it excluded children under 16 years from this requirement. As a consequence, funding estimations also excluded paediatric patients. Hospitals were given a year to implement this guidance and a great deal of work was done by hospital pharmacy departments to deliver this service, often based on model procedures prepared by NHS regions. How to perform medication reconciliation was not described in the original guidance but was addressed by another national body, the National Prescribing Centre, in March 2008. This document, ‘Medicines Reconciliation: A guide to implementation’, aims to support the delivery of medication reconciliation as a patient is admitted and discharged from hospital.3 A major benefit of this work was that it defined for the first time a nationally recognised minimum dataset for transfer of essential medication information between primary and secondary care. It also began to challenge existing responsibilities for who was responsible for information transfer. Prior to the publication of this document, the expectation was that hospital staff would have to obtain the information they needed themselves by contacting the patient’s primary care provider, usually their family doctor (general practitioner [GP]). In defining the data that is to be provided by GPs, this guidance suggested that the hospitals should receive the relevant information, rather than have to act themselves to obtain it. Unfortunately this is still not embedded in usual practice, especially for unplanned admissions.
Clinical pharmacy services in England now routinely undertake medication reconciliation for many new admissions to hospital. This typically involves collecting information from a number of sources, including: the patient’s description of the medicines they are using; examination of the patient’s own drugs (PODs); and obtaining GP-provided information. Access to the SCR is unlikely, as is direct access to the GP’s computer system. Therefore GP information is usually obtained by a telephone call to the GP practice. The information collected from these sources is then compared with the medication orders first prescribed for the patient after admission and any disparities identified and resolved. This process is resource intensive and may often take 20 minutes or more per patient. However, medicines-management pharmacy technicians, working under a standard operating procedure, may undertake most of the data collection. The resource investment to deliver medication reconciliation is usually considered to be good value for money based on readily identifiable clinical benefits. Published papers report that up to one in three patients have identifiable medication errors during admission and that one in three medication disparities identified during medication reconciliation have the potential for moderate or severe clinical consequences. In addition to the clinical benefits, there is growing evidence that the financial benefits of medication reconciliation outweigh the costs to provide the service, and is good use of limited national health service (NHS) resources. There are further benefits at the time of discharge from hospital, since the medication-reconciliation process concludes with providing the follow-on healthcare professional with details of the patient’s current medication and recent changes.
The importance of good communication
Successful seamless care must also involve patients or their carers in choices about prescribed medicines and support their role in passing on accurate and current information about the medicines they take. In January 2009, NICE published another document, ‘Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence.’4 This work acknowledges that patients may be under the care of healthcare professionals from different disciplines, specialties and sectors at the same time. Responsibility for patients’ care may also be transferred between healthcare professionals, with potential for medication errors. The document comments that: “Good communication between healthcare professionals is needed to ensure that fragmentation of care does not occur,” and encourages the development of robust processes for communicating between healthcare professionals involved in the patient’s care. In the absence of suitable electronic communication systems, patients may be a vital source of information about their medication. Patients receiving repeat prescriptions from their GP may be given a repeat medication list when their prescription is printed. However, the accuracy and usefulness of this list has been questioned. Providing a fit-for-purpose, paper-based, hand-held, up-to-date list of medicines, preferably in a language suitable for the patient, has been under consideration nationally and internationally for at least 12 years. A wallet-sized card presented by the patient at the point of transfer would be invaluable information when making clinical decisions but is not currently routinely available in the UK.
Specific needs of paediatric patients
Seamless care must also deliver service integration where there are ongoing collaborations between healthcare professionals, and in particular where cross-sector working is required to deliver the care the patient needs. Such collaboration is common for some patient cohorts and in particular is important for paediatric patients.
A patient treated under the NHS would not normally have self-determined access to a hospital specialist. In other healthcare systems, a parent with health concerns for their child may make an appointment with a hospital paediatrician. In the NHS, however, the gatekeeper to specialist services is the patient’s GP. Therefore, the parent must consult first with the GP and, if in agreement, they will then refer the patient for specialist opinion. Cross-sector collaboration is therefore common and some evidence suggests that long-term medicines for children may be provided by different healthcare sectors at the same time. During one study at our institution, it was found that approximately one in eight long-term medicines being taken by children on admission to hospital was not being provided by their GP, but rather was prescribed by a hospital consultant. In England, provision of long-term medicines for patients outside hospital is made by primary care services, usually prescribed by the patient’s GP and dispensed by their community pharmacist. Long-term medicines provided by another route may be unexpected and complicates seamless care. There may be clinical consequences if these medicines are not identified within medication reconciliation or other seamless care processes. While NICE-NPSA guidance excluded children from the requirement for medication reconciliation, there is growing evidence that this is at least as important clinically for children as it is for adults.
Problems after hospital discharge
There are further seamless care issues for patients when out of hospital. In October 2009, the Care Quality Commission (CQC) published results of an audit it conducted with 12 primary care trusts (PCTs). PCTs contract with GPs and community pharmacies to provide primary care services and commission hospitals to provide secondary care services for their patients. The CQC report, ‘Managing patients’ medicines after discharge from hospital’, comments on many aspects of seamless care, including managing both admission and discharge, and the introduction of the SCR, and highlights the responsibility of GPs and PCTs in these processes.5 The results of the audit demonstrated that communication was poor between hospitals and GPs following discharge and the consequential risks to patients were prominently reported in the media.
It is now becoming recognised that providing long-term medication for children after discharge or outside hospital introduces challenges for seamless care. These problems offer pharmacists in both primary care and in hospital the opportunity to work together to support patient care. One of the complications for children is that many who need long-term medicines will require unlicensed drugs. For example, they may need liquid formulations of existing licensed solid oral medicines. A typical example is menadiol oral syrup, which is not available as a licensed medicine in the UK.
While preparing a liquid formulation of menadiol may not be technically difficult, pharmacies in the UK are unlikely to prepare such preparations themselves. This is true for all pharmacies, including both hospital and community pharmacies. Instead, these items are made as ‘Specials’ by approved manufacturers. In general, Specials are high-cost medicines, often costing ten times or more the cost of the licensed formulation. They usually have short expiry dates and are unlikely to be held in stock by community pharmacies. A prescription for a Special may therefore take a few days to be provided to the patient. Our work shows that parents of children needing long-term medicines often turn to hospitals to obtain urgent supplies of medicines they cannot get quickly enough in primary care if they are to avoid missed doses. To circumvent these problems we have recently set up a new service in Birmingham to manage unlicensed medicines. In this process, the GP prescribes the unlicensed drug and sends the prescription to our hospital pharmacy. Hospital pharmacists clinically screen it and determine exactly what product should be provided and at what cost (to the NHS). We then support a community pharmacy partner to access the drug and dispense and deliver it to the patient. In this way, the patient is likely to get the medication more quickly, avoiding missed doses, and it probably costs the NHS less.
Pharmaceutical care in the NHS is far from seamless, especially for children needing long-term medicines. Pharmacists and other healthcare professionals must work together to support patients as they access care across the sectors.
1. Canadian Society of Hospital Pharmacists, Canadian Pharmacists’ Association. Seamless Care Workshop. A Joint Initiative of CSHP and CPhA. 1998 [cited 8th March 2011]; Available from: http://www.pharmacists.ca/content/hcp/resource_centre/practice_resources/pdf/seamless_care_1998.pdf
2. Moving patients, Moving Medicines, Moving Safely. Guidance on Discharge and Transfer Planning: The Royal Pharmaceutical Society of Great Britain, The Guild of Hospital Pharmacists, The Pharmaceutical Services Negotiating Committee, The Primary Care Pharmacists’ Association; 2005.
3. Medicines Reconciliation: A guide to implementation: National Prescribing Centre; 2008 March.
4. National Institute for Health and Clinical Excellence. Medicines Adherence: involving patients in decisions about prescribed medicines and supporting adherence. January 2009.
5. Managing patients’ medicines after discharge from hospital: Care Quality Commission; 2009 October.