Prescription for Excellence - the future of pharmaceutical care: vision and plan

Chapter 2 Person-centred Pharmaceutical Care and Medicines

In this Chapter we will set out our aims and proposed work programme to deliver person-centred pharmaceutical care.

This will focus on developing approaches to:

• Embed partnership working between the patient (and/or carer), their GP and pharmacist - therapeutic partnerships - and with other health and social care professionals.
• Further enhance the role of Pharmacist independent prescribers who will work with GP's to deliver medication/polypharmacy review, using telehealthcare and domiciliary visits where appropriate.
• Further develop the pharmacist's contribution to the management of common clinical conditions and develop new models of delivery of primary care services in partnership with GP's.
• Explore making better use of pharmacist prescribing post diagnosis.
• Introduce innovative pharmaceutical care to support the clinical application of translational genomics and stratified medicines.
• Enhance the role of pharmacists in pharmacovigilance (monitoring) within NHS secondary and primary care.
• Introduce and establish case loads to pharmacists to contribute to the clinical management of Long Term Conditions by developing the concept for registration with a 'named pharmacist' for all pharmaceutical care needs throughout the patient journey.
• Embed prevention, anticipatory care planning and early intervention into pharmaceutical care.
• Utilise the application of systems for the risk assessment of patients to prioritise care - e.g. tools such as Scottish Patients At Risk of Readmission (SPARRA).
• Develop new NHS standard specifications for services and innovative pharmaceutical care for specific patient groups developed with the professions.
• Improve and enhance pharmacists' role in working in partnership with patients and carers to improve co-production and support self-management using mobile technology.

Mutually beneficial partnerships between patients, their families and those delivering health and social care services ensure person centred pharmaceutical care is delivered to ensure appropriate treatment and interventions are delivered.

2.1 Introduction

2.1.1 Person-centred pharmaceutical care and medicines is pivotal in delivering our Vision over the next 10 years. In this Chapter, we will focus on our aims and objectives to deliver mutually beneficial partnerships between patients, their families, carers and those delivering health and social care services. Importantly, it will set out our approach to help ensure patients have appropriate treatment and interventions with medicines which respect individual needs and values demonstrating compassion, continuity of care, clear communication and shared decision-making.

2.2 Scotland's Population and Medicines Use

2.2.1 The changing demography of Scotland, the associated increase in people living with complex and long term conditions (multimorbidity) and the continuing health inequalities set major challenges for the provision of pharmaceutical care in the future. The proportion of over 75s, who are high users of health and care services and for whom prescribing can be particularly complex, will increase by over 25% in the next 10 years, and the number of over 75s is likely to have increased by almost 60% in the next 20 years. The pattern of disease will see a continuing shift towards long term conditions, with growing numbers who will have multimorbidities. In particular the combination of physical and mental health disorders can produce additionally complex needs.

2.2.2 In a recent Scottish study^[13] an analysis of a database of over one and three quarter million patients found that nearly a quarter had multimorbidity, that the onset of multimorbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent. Also, that the presence of a mental health disorder increased as the number of physical morbidities increased.

2.2.3 The study illustrates the challenges to the traditional single-disease framework to which most health care has been configured and underlines the importance of generalist clinicians providing personalised, comprehensive and continuous care.

2.3 Non-adherence to prescribed medicine regimens

2.3.1 Non-adherence (where medications are not taken as prescribed) has been estimated to be responsible for 48% of asthma deaths, an 80% increased risk of death in diabetes and a 3.8-fold increased risk of death following a heart attack^[14]. Another manifestation of non-adherence is failure to collect prescriptions. Two small studies show that 2.9 - 5.2% of items prescribed were not dispensed^[15], although they were conducted before the introduction of free prescriptions. It is estimated that one pound in every eight of NHS spending is on medicines, however up to half of all the medicines prescribed are not used as the prescriber intended^[16].

2.3.2 Waste medicines result predominantly from non-adherence, changes in prescribing and changes in the patient's condition. A study^[17] of waste medicines in England in 2010 found that medicines worth around £300 million were wasted per year and about £150 million could be saved in cost effective ways. The proportionate equivalent for Scotland would be wastage of £30 million and potential savings of £15 million. The study concludes that 'the greatest social and economic returns are to be gained when reducing medicines waste can be effectively linked to improving care quality and health outcomes' including patient safety.

2.3.3 Pharmacists are ideally placed to work with patients to support co production in managing their medications. The European Innovation Partnership in Active and Healthy Aging has an Action Group focused on improving both prescription and adherence of medicines regimens. One of its aims is to improve integrated care through better multi-professional working and with a particular work stream utilising the role of the pharmacist.

Scottish Government will explore development of a system to improve and enhance pharmacists' role in working in partnership with patients and carers to improve co-production and support self-management using mobile technology.

2.4 Therapeutic Partnerships & New Models of Working

2.4.1 Sir Professor Lewis Ritchie's report for Scottish Government on Establishing Effective Therapeutic Partnerships^[18] discussed the importance of partnership working between GPs and Pharmacists to deliver pharmaceutical care. Key themes identified in this report such as managing long term conditions and services to care homes, are all reflected in the Wilson and Barber report, the Vision and this Action Plan. As the number of other prescribers such as nurses, midwives and allied health professionals increases, it will be important to form collaborative working relationships with these professionals as well as GPs.

Scottish Government will seek to further enhance therapeutic partnerships which will be essential to embedding partnership working between the patient (or carer), their GP and pharmacist and other health and social care professionals.

2.4.2 A recent study for the General Medical Council (GMC)^[19] suggests that around one in eight patients have prescribing or monitoring errors, involving around one in 20 of all prescription items. As is common with errors, the vast majority had no effect, or only a mild or moderate, effect. However, one in 550 items was associated with a serious error. Some factors that increased the probability of an error were the patient's age (<15, >64) and the number of items prescribed. Monitoring errors (failure to monitor for the adverse effects of certain medicines) tended to have more serious consequences than prescribing errors. The most frequent forms of prescribing error were 'incomplete information on the prescription' and 'dose/strength errors'. The most common monitoring error was 'failure to request monitoring' (69%). In care homes^[20] errors were more frequent where 39% of residents had one or more prescribing errors.

2.4.3 Specific problems have also been identified with the transfer of information at the primary/secondary care interface.

2.4.4 Many of the problems associated with medicines can be addressed though effective therapeutic partnerships, including initiating medication, detecting prescribing and monitoring errors. Involving patients in decision making improves adherence and reduces waste. Pharmacists working directly with GPs can significantly contribute to addressing issues with prescribing^[21]. To be effective, pharmaceutical care requires good communication and shared understanding with patients and local prescribers. Being focussed on the outcome of interventions rather than the nature of them can equally be applied to self-care, and to health promotion and prevention. In the case of self-care and self-management, the pharmacist will distinguish the complaints that require referral to a doctor and those that can be dealt with by self-medication, and provide appropriate advice and follow up.

2.4.5 The Audit Scotland report^[22] on prescribing in general practice highlighted the beneficial effect of partnership working between GPs and pharmacists and among its recommendations was to increase the access of pharmacist support to GP practices. This would be facilitated by creating clinical practice models that would support this approach.

Collaborative working in 2013

"I have had the privilege of working closely with Colin, a pharmacist colleague for many years. Initially starting from a relationship where he was always available for prescribing support from within his community pharmacy, through support within the practice as a prescribing support pharmacist, to now where he is a non medical prescriber running clinics both within and out with the practice on a shared care programme, initially for patients with hypertension and more recently for chronic pain control. Over this time I have come to more fully appreciate the significant role that a pharmacist colleague can play in working with GPs practices to deliver an enhanced level of care. It feels at times that we have the benefit of an 'attached pharmacist' such that we now regard him as a fully paid up member of our primary care team."

GP, Deep End Practice, Greater Glasgow and Clyde

2.4.6 A particularly important role for pharmacists working with GPs to undertake is polypharmacy and medication reviews to improve patient outcomes and reduce harm through improving patient safety and effectiveness of prescribing. Last year, the Royal College of General Practitioners and the Royal Pharmaceutical Society published a joint statement on partnership working "Breaking down the barriers - how pharmacists and GPs can work together to improve patient care"^[23]. This emphasises the complementary roles of pharmacists and GPs in patient care, the value of collaborative partnership, and the importance of professional learning together.

Scottish Government will seek to further enhance the role of NHS accredited clinical pharmacist independent prescribers to work with GPs to deliver medication/polypharmacy review, using telehealthcare and domiciliary visits where appropriate.

2.4.7 In order to deliver closer ways of working between GPs and pharmacists and social care providers, new models and ways of working will be required. GPs and pharmacist will work in collaboration to allocate caseloads to pharmacists for management of patients with long term conditions.

2.4.8 The European Active and Healthy Ageing Innovation Partnership recognises the need to increase the pharmacist's role in improving the health of the older population through multi-disciplinary working.

2.5 Continuity of NHS Pharmaceutical Care and the 'Named Pharmacist'

2.5.1 Evidence gathered from the Wilson and Barber Review found that patients wanted to know that they could develop a relationship with their pharmacist and they expressed a preference to see the same pharmacist on a regular basis.

Scottish Government will explore the utilisation of caseloads to named pharmacists to contribute to the clinical management of Long Term Conditions by developing the concept for registration with a 'named pharmacist' for all pharmaceutical care needs throughout the patient journey.

2.6 Anticipatory Care and Public Health

2.6.1 An Audit Scotland report on Health inequalities^[24] found that there was a good distribution of pharmacies across deprived communities in Scotland. This will enable the further development of accessible services for substance misuse, including: drugs and alcohol, smoking cessation; sexual health as well as early intervention for prevention of cardiovascular diseases.

2.6.2 The Pharmore pilots^[25] offered a convenient access to a mix of primary care service such as pharmacist led minor illness clinic and nurse-led minor injury clinics available during normal pharmacy hours and in some cases extended to include out of hours periods such as evenings and weekends and the work undertaken in England by a collaborative of pharmacies demonstrated that up to 60% of pharmacist consultations saved patients contacting a GP. The pilots have also reduced the need to access out of hours service. Recent data from NHS 24 indicates that more people are accessing pharmacy services out of hours. Using pharmacist prescribers would allow treatment of common clinical conditions such as urinary tract infections and cystitis.

Scottish Government will consider further development of the pharmacist's contribution to the management of common clinical conditions and develop new models of delivery of primary care services in partnership with GPs.

2.6.3 Our work programme will place increased focus on prevention, anticipatory care and early intervention. It will develop pharmaceutical care for specific patient groups and specialist services: older people, mental health, children and substance misuse.

2.6.4 These arrangements are pivotal to the long term strategy to move pharmacists away from a focus purely on the dispensing of medicines to the provision of person- centred care as part of the wider healthcare team.

2.6.5 Together these services are an important part of the pharmacist's contribution in shifting the balance of care by:

• improving access for the public as they do not need an appointment to see their pharmacist for a consultation;
• decreasing unnecessary workload on the GP therefore freeing up their time to see patients with more serious complaints;
• improving health outcomes and minimising adverse events from medicines;
• helping to address health inequalities; and
• making better use of the workforce by more fully utilising the skills of pharmacists.

2.7 National NHS Specifications and Standards for Pharmaceutical Care Services

2.7.1 As services are developed, standards and specifications will need to be developed to ensure consistency of service for patients and delivery of outcomes that are person-centred.

Scottish Government will develop with the professions new NHS standard specifications for services and innovative pharmaceutical care for specific patient groups.

2.7.2 Areas that will be considered as a priority are the pharmaceutical care that is delivered to people who are residents in care homes and those that are being supported by social work or family to live at home. A report from Reshaping care for older people^[26] and the Royal Pharmaceutical Society's report on Improving Pharmaceutical care for patients in care homes^[27] highlight areas of good practice for work in care homes across Scotland and also collaborative working with social care.

2.7.3 The polypharmacy guidance^[28] published last year provides guidance on undertaking reviews and outcome data for reviews that have been undertaken for people taking medicines that are high risk. National tools for monitoring improvement and facilitating multi-disciplinary working will be further explored with NES, Health Improvement Scotland (HIS) and Information Services Division (ISD).

2.7.4 Hospital at home is where some medicines which previously were only able to be administered in the hospital setting are now given to patients in their own home due to advances in technology and medicine design. These are prescribed by hospital consultants and supported by hospital pharmacists. Hospital clinical pharmacists who are recognised as experts in medicines and are an integral part of the multidisciplinary ward clinical team in hospital. These hospital pharmacists would be required to deliver pharmaceutical care in the hospital at home setting to ensure continuity of pharmaceutical care.

Scottish Government will develop new pharmaceutical care service models for hospital at home with medical, pharmaceutical professions and the pharmaceutical industry.

2.7.5 Some other areas where national specifications and NHS standards will be explored include smoking cessation, sexual health and drug and alcohol services. It is also well documented that people that abuse alcohol and drugs are a high risk population. They are well served in the provision of medicines to treat their problems, but expansion of pharmacist prescribing skills to review these medications is recommended.

The Expert Group Review of Opiate Replacement Therapies^[29] (and substance misuse services) will be used to inform development of further services building on existing work already taking place in some NHS Boards.

2.8 Stratified Medicine

2.8.1 The landscape of therapeutics is presently undergoing revolutionary change through the introduction of biopharmaceuticals and genomic research. This rapidly developing field is producing new healthcare interventions through translational genomics. This in turn will create better drugs, improved insight into the disease process and better diagnostic methods. This whole new area of therapeutics will place new demands on pharmaceutical care. The healthcare professions and academia need to quickly become more familiar with this if patients are to fully benefit from this aspect of therapeutics. This is starting to be addressed in Scotland with the Scottish Government's Chief Scientist's Office and the contribution of innovative pharmaceutical care will need to be developed as will the education and skills of clinical pharmacists in this area.

2.8.2 Stratified medicine is a developing concept where genetic phenotype modelling using genetic analysis of patients' likelihood of benefiting from particular drugs will allow for more specific targeting of drug treatment.

Scottish Government will develop innovative pharmaceutical care to support the clinical application of translational genomics and stratified medicine.

Our work programme to deliver PERSON CENTRED pharmaceutical care will explore options to:	Years 1-3	Years 3-5	Years 5-10
1. Create a model to facilitate NHS accredited clinical pharmacist independent prescribers working in partnership with patients, GPs and other prescribers
2. Introduce the utilisation of clinical case load for review and management of Long Term Conditions and prescribing through Therapeutic Partnerships e.g. polypharmacy and medication review
3. Develop models to ensure all patients have pharmaceutical care including polypharmacy/ medication reviews where appropriate
4. Work with the rural practitioners to scope and develop the use of domiciliary visits/ telehealth/ mobile apps to respond to needs of different age groups, and different settings
5. Work with patients, professions to develop a NHS framework for registration with a 'named pharmacist' and implement the legislative and contractual framework to underpin this innovative approach
6. Establish a framework for anticipatory pharmaceutical care planning
7. Develop service models for those receiving high risk and high tech medicines building on risk assessment tools developed for polypharmacy and anticipatory care planning
8. Scottish Government will develop innovative pharmaceutical care to support the clinical application of translational genomics and stratified medicine
9. Develop national service with the professions new standard specifications for services and innovative Pharmaceutical care and pharmaceutical public health for specific patient groups of:
Cardiovascular health
Older People - in care homes and in their own home
Alcohol and Substance Misuse
Mental Health
Sexual health
Children
10. Further develop the pharmacists contribution to the management of common clinical conditions and develop new models of delivery of primary care services in partnership with GPs