Pharmacists are ideally placed to take a central role in the care of patients with chronic conditions, delegates at the Clinical Pharmacy Congress heard. Varya Shaw reports
Pharmacists can extend their remit in the care of patients with chronic conditions beyond dispensing medicines
Imagine if there was a huge resource within the NHS: an army of highly trained staff who have regular contact with patients with long term conditions.
Imagine if this contact was usually brief and its potential largely untapped.
Imagine if the work of these staff was opened up so they could make an impact on how these patients took their medication and how often they were admitted to hospital.
‘Dispensing is usually a brief interaction focused on accurate, legal provision of medication. But it could be very different’
We are talking about pharmacists, of course - particularly those in community pharmacy. The NHS needs to grow its capacity without growing costs, and an elegant solution is to allow pharmacists to make the best use of their clinical skills to take on some of the duties of doctors and nurses.
To achieve this, a shift in mindset is needed across the NHS, and stronger leadership from within pharmacy.
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One starting point could be the management of chronic conditions. Through dispensing, pharmacists have more contact with patients than all other healthcare professionals put together, so their potential influence is huge.
Take diabetes, for example. Diabetes UK estimates this condition costs the NHS up to £1.5m an hour - or 10 per cent of the health budget. There are huge issues around non-compliance in people with diabetes, with a dire impact on health outcomes.
‘One thing that helps people control their disease is engagement with people with similar conditions’
Dispensing is usually a brief interaction focused on accurate, legal provision of medication. But it could be very different.
It is an opportunity to, for example, create a constructive dialogue about how best to manage hypoglycaemic episodes, and how to get the most from insulin.
It could even be an opportunity to touch on the real value to the patient of their health, such as avoiding the sheer unpleasantness of a “hypo”, or the ability to socialise and counteract loneliness.
Case study: Royal Wolverhampton’s integrated pharmacy service
Ray Fitzpatrick, clinical director of pharmacy at the Royal Wolverhampton Hospitals Trust, runs an integrated pharmacy service. The trust employs secondary and primary care pharmacists, and stations the latter in GP surgeries.
The goals are seamless medicines optimisation and tackling the patients with long term conditions who visit most often.
He says: “We are trying to develop a culture of the specialist and acute team working with the primary care pharmacy team. The hospital team can say to the primary care pharmacy team: ‘I’ve got a problem patient; I know they are coming home and I’m worried. We need you to engage with them.’”
His leadership is key to integrating the two cultures but it is not easy. “We are very good at doing what we do in silos but not so good at using the collective resource that is the pharmacy family. Even though secondary and primary care pharmacists are both part of my team we are still developing that culture - they still think of themselves in their traditional roles,” he says.
Two way process
David Terry, director of the Academic Practice Unit at Aston University, says: “Dispensing needs to be two way. It is not enough just to give the facts. We have to get back from a patient with diabetes what they intend to do. What’s the real position? As pharmacists we are as well placed as anyone to do that.”
Fostering patient communities can also have a huge impact.
Mark Robinson, a partner in the Medicines Management Partnership, says: “One thing that helps people control their disease is engagement with people with similar conditions.
‘If pharmacy was like driving a car, we would be very good at looking at the dashboard but not out of the window’
“Some of the solutions people come up with you wouldn’t think of in a hundred years, but they work for them. I would like to see community and hospital pharmacy engaging populations with diabetes to create a support programme.”
This vision is gathering force following the Now or Never: Shaping Pharmacy for the Future report by the Royal Pharmaceutical Society’s commission on future models of care delivered through pharmacy. Published in November, it says pharmacists need to embrace a broader role as care givers, and calls for stronger leadership within the profession.
So what are the barriers? The discipline itself lacks confidence, and there is a common concern among individual pharmacists that they do not have enough expertise in specific illnesses.
Pharmacy is thought by some to be inherently technical and geared towards detail, so the big picture thinking so vital to leadership may not come naturally to members of the profession.
Ray Fitzpatrick, clinical director of pharmacy at the Royal Wolverhampton Hospitals Trust, says: “A colleague of mine says if pharmacy was like driving a car, we would be very good at looking at the dashboard but not out of the window.”
Dr Terry adds: “Most of our lives we’ve spent learning to be clinical pharmacists. We’ve got the technical skills. What we lack are the softer skills: getting your team to accept change and selling the vision.”
‘We want the patient with diabetes to become the expert and gain confidence and competence in managing their own condition’
If pharmacists themselves need a change of attitude, then it is no surprise that NHS Alliance chief executive Rick Stern argues that the rest of the NHS does too. He says: “Managers in the NHS don’t tend to think automatically about pharmacy and its potential. Commissioners are probably not ready at the moment. It’s been quite a struggle in the last year to work in a new way with their own practices who make up clinical commissioning groups.”
But given the financial challenges facing the service, the case for overcoming the barriers is urgent. So what can be done?
Frontline pharmacists do not need to be experts, he says, but this new role is about skills rather than knowledge - forming relationships and employing the psychology of behaviour modification.
As Mr Robinson puts it: “We want the patient with diabetes to become the expert and gain confidence and competence in managing their own condition. There is nothing more powerful than an expert patient.”
The Centre for Pharmacy Postgraduate Education has launched a 90-day course in consultation skills for pharmacists, so help is at hand.
Pharmacists may not be groomed for leadership but they do have some natural advantages when it comes to influencing senior colleagues, Professor Fitzpatrick says.
“Pharmacists are in a very, very good position. While we are clinical, many of us also have a sense of business,” he adds. “Managers understand that medicines cost money. I know that’s the button to press if I want to get senior management engagement.”
‘Managers need to stand in a community pharmacy and survey their territory - that is a place they can commission services from’
The other big contribution of pharmacy to the business of the NHS is the mitigation of risk.
“We are the safety net when it comes to medicines. That gives us quite a strong voice and clinical pharmacy is the working out of that risk agenda,” he adds.
So once pharmacists have convinced their chief executive, where do they go next to flesh out this broader clinical role and deliver the seamless medicines optimisation that will keep people out of hospital?
Mr Robinson says: “Managers need to stand in a community pharmacy and survey their territory - that is a place they can commission services from. They then need to talk about what is possible and create a plan and a vision.”
In an ideal world, hospital pharmacists will communicate with community pharmacists to direct their effort towards the patients who need it most.
There are innovative pharmacy projects taking place all around the country, Mr Robinson says, including: pharmacists running minor injury and ailment clinics, being on GP out of hours teams and working with patients with long term conditions. But these are too fragmented. To achieve a tipping point and transform the profession, they need to happen simultaneously in one locality.
Mr Stern adds: “It will take a lot of time and new ways of working, and that is difficult. But over the next few years pharmacy is going to shift considerably. It won’t be making money on procuring and distributing medicines, it will be about how pharmacists can work with communities and improve their health. Managers and commissioners are not widely aware of the opportunity, but it wouldn’t be too hard to persuade them. There is a huge saving in this.”
- This article is based on a report of a session at the Clinical Pharmacy Congress, which took place on 24-25 April 2014 in London. Sanofi sponsored the session and contributed to the questions directed at the panel. HSJ attended the event, wrote an independent account of the discussion and retained editorial control of this special report.
NHS can scrimp and save on medicines
The medicines optimisation dashboard will help the NHS’s £13.8bn annual drugs bill to be used more effectively, as Clare Howard explains
Medicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. Prescribing a medicine to a patient remains the most common intervention made by the NHS.
Last year, NHS England spent £13.8bn on medicines. In an era of economic, demographic and technological challenges it is vital that patients, the NHS and the taxpayer get the best quality outcomes from these medicines.
But although we are using more medicines, their use could be described as “suboptimal” because:
- up to 50 per cent of medicines are not taken as intended;
- 5-8 per cent of all unplanned hospital admissions are the result of medication issues, rising to 17 per cent in over 65s;
- medicine waste is a significant and largely untackled issue;
- safety data indicates that we could do much better at reporting and preventing avoidable harm from medicines;
- multimorbidity and polypharmacy increase clinical workload, so doctors, nurses and pharmacists need to work coherently as a team with a balanced clinical skill mix; and
- a recent NHS England workshop with patients highlighted their desire for greater support.
NHS England has been working with patients, the Royal Pharmaceutical Society and other professional leadership bodies, and the pharmaceutical industry to develop medicines optimisation - guidance to change the way the NHS thinks about medicines. It aims to move us from a focus around cost and volume of drugs towards a much wider focus on supporting patients to get more from their medicines.
To support clinical commissioning groups with this and help them think about how their local populations are supported to use medicines, NHS England is developing a medicines optimisation dashboard. By looking at indicators such as medication safety, use of community pharmacy services and so on, CCGs can begin to develop their local approach. In time, the dashboard aims to include hospital admission data and patient experience indicators.
We know, for example, that where systematic programmes of support are developed to help patients use their inhalers properly, there is a positive impact on quality of life and hospital admissions.
CCGs have access to expert pharmaceutical support. Historically in some areas this support has concentrated on driving down drug spending. Now, leading CCGs are recognising that there are greater efficiencies in using their pharmacists to lead medicines optimisation programmes, which in the longer term aim to deliver far greater savings and value than simple drug switches. More importantly, this gives patients more of what they need to derive the greatest benefit from the medicines prescribed to them.
Clare Howard is deputy chief pharmaceutical officer at NHS England