Principles that ensure older people can use their medicines safely are vital across the NHS, say Theresa Rutter and Nina Barnett

Despite some examples of excellent practice, older people are still not consistently being enabled to take or use their medicines safely and appropriately, or consistently being supported in this.

Gaps are occurring in people's own homes, in care homes and particularly across interfaces in care, for example when they move from hospital back to their own home or to a care home or from home to hospital.

However, one of the milestones in the national service framework for older people is that 'all primary care trusts should have schemes in place so that older people get more help from pharmacists in using their medicines'.

In addition, primary care trusts are required to address issues around medicines from the white paper Our Health, Our Care, Our Say.

The steering group on medicines management and older people of London, Eastern and South East specialist pharmacy services has wrestled with the challenge of keeping older people and their medicines on the agenda to ensure that medicines management is optimised.

As a result, the group has written a set of six principles to provide solutions to some of the key challenges facing PCTs in their commissioning role, as they try to meet the requirements of the white paper and the national service framework milestone.

With each principle are suggestions for implementation and examples are included of good practice of integrated medicines management.

Principle 1

Every individual has the right to an assessment to identify their care needs and such support as is necessary for safe and appropriate use of his or her medicines.

Essex Rivers Healthcare trust has implemented a trust-wide self-administration of medicines procedure as its standard for medicines administration across all inpatient beds. Patients are expected to bring their own medication into hospital with them wherever possible. A medication review is conducted which includes the medicines brought into hospital and this is combined with an assessment of ability to self-administer medication. If a patient cannot self-administer and is unlikely to be able to at discharge, there is a discharge planning process that links to the single assessment process.

Principle 2

Every individual has access to their medicines to use them safely and appropriately.

Cambridgeshire community pharmacy domiciliary visiting scheme for housebound older people means that at-risk patients are referred to the scheme co-ordinator at the PCT. The co-ordinator contacts a suitably trained community pharmacist, who makes a home visit.

A care plan is written and sent to the patient's GP.

Principle 3

Every individual and/or carer has access to high-quality information from a healthcare professional about their medicines.

Around 10 per cent of callers to NHS Direct ask for advice about their medicines and up to 40 per cent of the 6.5 million calls provide some advice about medicines. Many of these enquiries can be dealt with directly by specially trained NHS Direct staff using a decision support algorithm.

However, in cases where more specialist knowledge is required the details of the caller are phoned through to a regional medicines information centre. A medicines information pharmacist then contacts the caller directly.

Principle 4

Health and social care organisations provide support for medicines use, in line with the principles of clinical governance and national minimum standards.

Norfolk PCT with Norfolk county council has implemented a service to facilitate the care of people in their homes by providing a patient-centred medicines management assessment by a pharmacist. This can be linked to single assessment process and to a referral for ongoing support, for example from the community pharmacist and/or .from social care, according to the assessed need.

Principle 5

Individuals are entitled to care when moving between different care settings.

The green bag initiative involves using specially designed plastic carrier bags to keep patients' own medicines together when they are moving between care settings.

This has been successfully demonstrated within the hospital medicines management collaborative at Nottingham City Hospital, where green bags have been shown to improve the discharge process, improve communications about medicines and increase patient safety.

Principle 6

Every health and social care economy has a robust referral system to a pharmacist to ensure a consistent point of contact, communications network and signposting.

This principle is fundamental to the successful implementation of the preceding five principles. At present, we are not aware of a comprehensive medicines referral system that operates across a whole health and social care economy.

One example of good practice was a service involving trained community pharmacists, working with other health and social care professionals, making domiciliary visits to any patient who had problems taking or managing their medicines.

The pharmacist reviewed medication regimens and assessed the patients' needs in discussion with the patient and/or carers to develop an individual, tailored pharmaceutical care plan.

The pharmaceutical care plan was then shared with the patient, referrer, dispensing pharmacist and GP.

Theresa Rutter is joint director of community health services for East and South East England specialist pharmacy services and chair of the steering group on medicines management and older people, London, Eastern and South East specialist pharmacy services. Nina Barnett is consultant pharmacist for older people, Northwick Park Hospital and East and South East Specialist Pharmacy Services, and a member of the steering group on medicines management and older people.

Click here for more on the principles