Optimising the use of medicines
Optimising the use of medicines
Developing the community pharmacy medicines optimisation service
Notwithstanding the targeting of the MUR service towards priority groups of patients identified by the NHS, the two services do not currently fit firmly within locally or nationally agreed care pathways for patients with specific long-term conditions.
PSNC therefore believes that the development of the medicines optimisation services within the Community Pharmacy Contractual Framework (CPCF) could start by focussing the provision of MUR and NMS on one or more patient cohorts. For example, people with asthma and COPD could all be offered annual support via an MUR and additional support when a new medicine is added to their regimen, via the NMS. This would necessitate the provision of the two services by all pharmacies and registration of patients to an individual pharmacy may also be required to allow the management of the service by commissioners and appropriate funding flows to community pharmacy contractors. Patients would have a free and unfettered choice of pharmacy where there was a need for registration.
This approach to medicines optimisation would see community pharmacies taking responsibility for provision of specific support to a cohort of patients, which would allow, where appropriate, the community pharmacy support to be embedded within local or national disease management pathways and NICE quality standards. In this way, patients and other healthcare professionals involved in the care of the patient would have certainty about what support community pharmacies would provide to patients, thus supporting team working across primary care.
The choice of the initial patient cohorts would be a matter for agreement with commissioners and other stakeholders, in light of the clinical and economic priorities at the time.
With a registered patient cohort, it would be possible to implement patient outcome measures for the pharmacy services against which community pharmacies would be held to account and also rewarded where appropriate outcomes are achieved.
One of the failings of the current MUR service is that it generally can only be provided once a year to each patient. This episodic approach prevents the provision of longitudinal care to the patient over the course of the year, which is probably needed in order to have the maximum positive impact on optimising the patient’s use of their medicines. A second stage of development of medicines optimisation services may therefore be to encompass the support provided by MUR and NMS within a new service focussed on a specific patient cohort, which allows more frequent interventions with the patient over the course of their year of care.
The use of innovative smartphone apps could be incorporated into this service offering, for those patients with a smartphone. This could include provision of reminders to take medicines and support messages about other aspects of the patient’s condition.
Over time and assuming that this approach delivered positive patient outcomes, the range of conditions covered could be extended.
The development of the medicines optimisation services described above could take place alongside a move to support more active management of long-term conditions. Currently many long-term conditions are managed in general practice by practice nurses. Diseases such as asthma, hypertension and diabetes are managed in line with the structured guidelines provided by NICE and other institutions. There may be a need to release capacity in general practice to take on the management of more complex diseases, currently managed in secondary care, or to allow more active case management of high risk patients. This may therefore create the opportunity for community pharmacies, in collaboration with general practices, to manage specific patient cohorts, or at least to undertake specific elements of disease management detailed in care pathways and quality standards.
For example, the NICE quality standard for asthma requires patients to be offered an annual review of their condition. Traditionally this type of review has been undertaken in general practices by practice nurses. The review includes an assessment of the patient’s medicines and their use. With a small amount of extra training and with the availability of appropriate monitoring equipment, it is likely that the annual review described by NICE could be undertaken in community pharmacy. PSNC is currently exploring opportunities to test this concept within a discrete geographical area.
Other disease areas which may be similarly amenable to community pharmacy management include COPD, Parkinson’s disease, hypothyroidism, hypertension, type 2 diabetes and poorly managed pain.