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

Chapter 4 Effectiveness of pharmaceutical care and medicines

In this Chapter we will set out our aims and related work programme to deliver effectiveness of pharmaceutical care and medicines. This will focus on developing approaches to:

• Define and implement a robust framework of NHS Board Pharmaceutical Care Services Plans informed by a local needs assessment.
• NHS Boards identifying clusters of pharmacists that could work as a group.
• Introduce general practice clinical pharmacists working in primary care who are pharmacists delivering pharmaceutical care in the community.
• Redesign the dispensing process to be effective and efficient, releasing pharmacists' time for clinical care through workforce planning and improved use of pharmacy team and automation using robotics.
• Further development of models to reduce harmful and wasteful variation in prescribing.
• Implement contracts, models and/ or service frameworks to prevent perverse incentives that compromise professionalism.
• Ensure clinical and cost effective use of existing, new medicines and technologies by implementing evidence based guidance through Area Drug and Therapeutics Committees.
• Design models for provision of hospital Homecare medicines co-ordinated through integrated working between hospital and community pharmacists and pharmaceutical industry.
• Seek to review the use of technology such as telehealthcare to enhance the patient journey.

Effective appropriate treatment, interventions, support and services is evidence based, provided at the right time reducing waste, harm and variation and ensuring clinical and cost effective use of both existing and new medicines and technologies

4.1 Introduction

4.1.1 There are a number of workforce issues including the fact that, currently, the skills of a pharmacist are underutilised in the community setting. More effective pharmaceutical care can be delivered by allowing the pharmacist to develop their professional clinical skills. Medicines arrive at the pharmacy mostly pre-packed. With the exception of the clinical check being undertaken by the pharmacist, the dispensing process could be managed by appropriately qualified technicians, thereby releasing pharmacists' time to undertake pharmaceutical care in the most appropriate setting, which may be the GP practice or the person's home.

4.1.2 NHS Board Pharmaceutical Care Services Plans will identify the pharmaceutical needs for their populations, and also the clusters of pharmacists that could work collaboratively together to deliver clinical care as a group practice.

In order to deliver effective pharmaceutical care, it is essential that the most appropriate treatments, interventions, support and services will be provided at the right time to reduce wasteful or harmful variation.

4.2 NHS Board Pharmaceutical Care Services Plans

4.2.1 This will be central to how NHS Scotland plans, provides and delivers pharmaceutical care and medicines to its communities. In the longer term it has implications for existing arrangements for service provision, where and how it is provided. These plans will need to consider population needs, which include public health and health inequalities.

4.2.2 NHS Boards are responsible and accountable for the provision of pharmaceutical services in secondary and primary care sectors. Currently in primary care, NHS Boards make arrangements with pharmacy owners for the delivery of pharmaceutical services. The pharmacist delivering these services needs to ensure that their priorities are focused on the patient above all else. Perverse incentives such as targets and bonuses based on commercial retail priorities should not be allowed to adversely affect patient care.

4.2.3 More importantly, NHS Board Pharmaceutical care planning will facilitate the clustering of pharmacists to deliver pharmaceutical care for patients without decreasing the accessibility of a pharmacy services to a community. In addition, it may be appropriate for secondary care pharmacists and those working in primary care to work collaboratively together to deliver homecare medicines or hospital at home clinical pharmacy services where complex or specialised medicines are being taken. It is recognised that this is a fundamental shift in approach which we will consult on as appropriate.

4.2.4 The provision of pharmaceutical care out of hours will be reviewed with NHS 24.

Scottish Government will explore defining and implementing a robust framework of NHS Board Pharmaceutical Care Delivery Plans informed by a local needs assessment, and work with NHS Boards to identify clusters of pharmacists that could work as a group, and introduce contracts or service frameworks which prevent perverse incentives.

4.2.5 In some parts of rural Scotland, the NHS relies on dispensing doctors to provide dispensing services to their own patients who (through geography and demographics) are unable to secure the dispensing services of a community pharmacy. In these cases we will need to explore how these patients can be supported in terms of pharmaceutical care.

Scottish Government will work with patients, dispensing doctors and appropriate stakeholders to explore how rural communities can be further supported in terms of pharmaceutical care.

4.3 The General Practice Clinical Pharmacist

4.3.1 The vision of all patients having access to NHS pharmaceutical care from clinical pharmacist independent prescribers in all settings will be achieved though extending and developing the clinical pharmacy services currently provided by pharmacist prescribers in both community and secondary care. In order to rapidly expand the provision of pharmaceutical care in the community, the concept of the "general practice clinical pharmacist" will be considered. The skills of appropriately qualified hospital, primary care and community pharmacists can be harnessed to form the foundation of the general practice clinical pharmacist. This will begin to plug identified gaps in the provision of pharmaceutical care, and to target the most vulnerable and high risk patient groups. We will consider the advancement of pharmacists' skills that will also be required to be developed. Examples include prescribing in clinics and polypharmacy review for the frail elderly and those in care homes, and monitoring outcomes with medicines.

Scottish Government will establish with NHS, NES and professional bodies the framework for development of general practice clinical pharmacists.

4.4 Release Time for Pharmacists to Deliver Pharmaceutical Care

4.4.1 In order for pharmacists to deliver the effective pharmaceutical care required, work force planning and redesign will be required to use the available skills of the workforce. In particular, the use of pharmacy technicians and pharmacy assistants should help to facilitate this.

4.4.2 Consideration would also need to be given to the automation of the supply of medicines using robotics and routine repeat dispensing transferred to serial dispensing. It is important to build in here a patient information system that would allow sharing of electronic data across primary and secondary care and implement a paperless integrated electronic prescribing system.

Scottish Government will consider redesign of the dispensing process to release time for clinical care using workforce planning, improved use of pharmacy team and robotics.

4.5 Reduce Harmful and Wasteful Variation in Prescribing

4.5.1 The prescribing work stream of the NHS Scotland Efficiency & Productivity Framework has started to develop tools for clinicians to address harmful and wasteful variation in prescribing. The York University report into waste^[34] identified that medication review was an appropriate way to address waste. Development of indicators to illustrate variation in prescribing with appropriate clinical guidelines is an effective way to change behaviour. The PINCER trial was a randomised controlled trial that demonstrated that pharmacists working with GPs provided better outcomes than just sharing electronic data.

Scottish government will explore extending joint working of pharmacist with all other prescribers to ensure all patients have appropriate pharmaceutical care

4.6 Integration of Primary and Secondary Care Pharmaceutical Care and Medicines

4.6.1 In order to deliver effective person-centred care, pharmaceutical care will need to be delivered across the interfaces of health and social care. Pharmacists will have a role in facilitating better integration of advice and use of medicines across sectors and disciplines.

4.6.2 Hospital at home is a developing concept where patients needing hospital care are facilitated to live at home by providing hospital care in their own homes and to be treated with medicines that would normally be given in a hospital setting. In order to deliver this effectively, pharmacists working in hospital and primary care will need to work as a team, ensuring effective sharing of information to improve patient safety.

4.6.3 Pharmacy Homecare is where medicines prescribed by the hospital specialists are delivered to patients in their own homes. It is proposed these medicines should be delivered through NHS pharmaceutical care services to allow capture of prescribing information for the patient and to assess suitability and compatibility with other medications. This would allow for appropriate governance and monitoring. By having a complete record of all medications that a patient is taking adequate monitoring can be provided.

Scottish Government will consider models for provision of hospital homecare medicines co-ordinated through integrated working between hospital and community pharmacists and pharmaceutical industry.

4.7 Technology- Telehealthcare and Mobile Apps

4.7.1 Effectiveness of delivery of pharmaceutical care may be enhanced by the use of technology and mobile apps. The national delivery plan for telehealth and telecare considers technology as a tool to drive improvement and to facilitate greater integration, skill mix, choice and control. Use of technology would allow pharmacists to effectively manage their case load of patients.

4.7.2 The European Innovation Partnership in active and healthy ageing promotes the use of mobile applications to enable people to self-manage, improve adherence to treatment and to provide decision making support for professionals. These applications for mobile technologies are best developed through collaboration between healthcare, and technology companies and patient groups so that their effectiveness can be assessed.

Scottish Government will introduce a framework to promote and increase the use mobile technology to support people manage their medications and improve adherence

4.7.3 The Scottish Government Health and Innovation Partnership Board would also provide strategic support for this development.

Our work programme to deliver EFFECTIVE pharmaceutical care will explore options to :	Years 1-3	Years 3-5	Years 5-10
1. Consult on the powers of NHS Board Pharmaceutical Care Plans and its impact on existing planning arrangements including dispensing doctors
2. Establishing with NHS, NES and professional bodies the framework for development of general practice clinical pharmacist
3. Develop new models to enhance role of pharmacist by better use of pharmacy workforce such as pharmacy technicians and pharmacy assistants
4. Establish a framework of joint working and information sharing between primary and secondary care pharmacist and other members of the multidisciplinary team
5. Redesign the dispensing process to release pharmacists time or clinical care through workforce planning and improved use of pharmacy team and automation using robotics
6. Establish a public/private partnership framework to promote and increase the use of robotics
7. Build on the work being taking forward through NHS Scotland Efficiency & Productivity programme
8. Respond to Audit Scotland report into prescribing in general practice - in particular to extend joint working of pharmacist with all other prescribers to ensure all patients have appropriate pharmaceutical care
9. Introduce a framework to promote and increase the use mobile technology to support people manage their medications and improve adherence