Review of NHS Pharmaceutical Care of Patients in the Community in Scotland

Care Homes

36. We were specifically asked to consider the needs of residents in care homes and how these might best be met. As demonstrated in an earlier section of this review, on any one day seven out of ten residents in care homes will suffer at least one form of medication error²⁵ , most of these being caused by the actions of doctors or pharmacists. The concerns about the variation in the quality of care generally and, in particular, of pharmaceutical care in some care homes have been well documented and the need to address these clearly demonstrated in the recent report by RPS Scotland²⁶ and in the RCGP Scotland and RPS Scotland Joint Statement²⁷ . The increasing dependency and multimorbidity of residents, many with dementia, requires high quality pharmaceutical care, to meet the clinical and hence medication needs of individual residents.

37. Fundamental to any improved and effective system of pharmaceutical care is a consistent clinical input from a suitably trained pharmacist, working in partnership with general medical practice, nursing, social work and care staff, and any other professionals involved, together with the care home owner. It is our view that the local NHS Board, in partnership with the local authority, should take responsibility for making this happen on behalf of the care home residents, by entering into and monitoring contractual arrangements with pharmacists and general practitioners, and by arranging for the provision of specialist support (staff or services) where needed. While we recognise the principle of patient choice, there is substantial evidence from local examples (such as in Tayside) and clear support from our review work that the arrangements for each care home should be with one pharmacy team and, preferably, one general medical practice to ensure consistency of care and appropriate clinical governance.

38. We consider that the following principles should apply:

• pharmaceutical care and associated supply delivered through local not distant providers
• nationally agreed standards of service and contractual terms
• nationally agreed standards of documentation and recording systems
• integrated information exchange, including medicines reconciliation at admission, transfer and discharge
• all care providers having access to current medication details and to the sharing of other information appropriate to their particular responsibilities
• standards for the safe administration of medicines that meet the needs of individual residents
• encouragement of patients with the capacity to self care
• quality assured training and support for care home staff in medicines administration
• regular multi-disciplinary review of medication

39. The aim should, therefore, be to have a pharmaceutical care service which:

• is person centred
• improves quality of prescribing, monitoring and review of medication
• encourages accurate record keeping in homes
• reduces administration errors by carers
• supports patient self medication where appropriate
• improves adherence in self medicating patients
• addresses polypharmacy
• reduces inappropriate prescribing of psychoactive medication
• reduces high risk medicines
• reduces falls and hip fractures
• improves dementia care
• improves pain management
• improves palliative and end of life care

40. The NHS Board should ensure that the supply of medicines complements the clinical service, and also monitor supply arrangements to ensure that they are cost effective and not subject to perverse incentives. We support a move towards more original packs and away from MDS, unless assessed as required for an individual. We also recommend that Scottish Government should consider whether it should debar the ownership of care homes by pharmacists or pharmacy bodies which are in contract to supply medicines or a clinical service to care homes and how it might also restrict ownership of pharmacies by care home proprietors.

41. A number of submissions to our review contained suggestions as to how a system such as that outlined above might work in practice, including the more integrated use of information technology. We recommend that, as a matter of some urgency, Scottish Government should bring together all the relevant interested parties (including professional health and social care bodies, care home providers, Care Inspectorate, patient and carer representatives), and, building on the national reports and local experience, design and promote a coherent system of pharmaceutical care for care homes in Scotland.