Summer 2004 Focusing on pharmacy in the new NHS
CHRONIC DISEASE MANAGEMENT
This edition of the Pharmacy Flyer focuses on describe how community pharmacy can be involved
chronic disease management (CDM) and discusses and give you some examples of the numerous
how primary care organisations (PCOs) can fully schemes that already exist.
utilise the community pharmacy network to help We also highlight the latest resources available to
Community pharmacy improve CDM. We focus on the numerous positive PCOs to encourage community pharmacy service
network gives UK messages about community pharmacy in the development.
a head start on Government’s policy papers on CDM. We also
COMMUNITY PHARMACY NETWORK GIVES
UK A HEAD START ON CHRONIC DISEASE
Both Kaiser and EverCare have the same overall goal
Why it is important you read of keeping patients out of hospital, but their models
this article of care to deliver this goal are slightly different 3,4.
• Chronic disease management (CDM) is currently
a top priority for the NHS. What’s happening in the NHS?
• This article explains why it is essential that The American experience has given renewed
community pharmacy is involved in this agenda.
impetus to the DH’s efforts to bring its chronic
disease-related programmes together and develop
them under the ‘chronic disease management’
Background umbrella. Several DH work streams dovetail into
The increased incidence of chronic conditions CDM policy and practice. These are described in
presents a considerable challenge to the NHS. In figure 1.
Britain, 17.5 million adults may be living with a
Stop Press chronic condition1, ranging from asthma and diabetes Figure 1: What’s happening
through to arthritis and dementia. Their care in the NHS?
consumes a large proportion of health and social care
resources, with 60% of hospital bed days devoted to • A number of PCTs are piloting aspects of care
chronic disease and its related complications1. practiced by Kaiser and EverCare. There are
The Department of Health (DH) is exploring other learning groups, such as Pursuing
models of CDM to try to stave off what has been Perfection communities, that are developing
dubbed the “chronic disease timebomb”. The DH care pathways for people with chronic
believes that essential components of good CDM conditions.
include: • Modernisation Agency-sponsored case-
management masterclasses are taking place
• Identifying people with chronic disease. throughout England.
• Stratifying patients by risk (i.e. risk of a patient’s • The National Primary Care Collaborative is
condition deteriorating which could ultimately lead sharing CDM learning among health economies
to a hospital admission). as part of its ‘third wave’ programme.
• Involving patients in their own care. • The King’s Fund has brought together a
• Co-ordinating care (using case managers). ‘stakeholder coalition’ of health groups to
• Using multidisciplinary teams. establish a generic model of CDM.
• Integrating specialist and generalist expertise. • The Quality and Outcomes Framework of the
• Aiming to minimise unnecessary hospital admissions. new GMS contract marks a sizable financial
• Providing care in the least intensive setting incentive to tackle chronic disease in primary
possible, all underpinned by the use of evidence- care.
based care pathways1. • Self-care projects such as the Expert Patients
Programme are being rolled out.
This approach has become increasingly prominent • Extending the use of patient group directions,
within UK policy and practice, most notably manifest and independent and supplementary prescribing,
in the National Service Frameworks (NSFs). will increase the number of practitioners with
American models of CDM, as pursued by the responsibility for managing patients with long
health maintenance organisations (HMOs) Kaiser term conditions1. Pharmacist supplementary
Permanente and United Healthcare (parent company prescribing will allow pharmacists to prescribe
The National Pharmaceutical of EverCare), have attracted the particular admiration within clinical guidelines for specific patients, and
Association of DH policy makers in large part because they appear this is likely to be useful in dealing with long-term
to have successfully reduced hospital admission rates medical conditions and with long term health
Mallinson House, 38-42 St. Peter’s and, by extension, costs2. A key feature of both needs such as anti-coagulation. The first cohort
Street, St Albans, Herts. AL1 3NP.
systems is the effort to prevent deterioration in of pharmacist supplementary prescribers has
Telephone 01727 832161 condition through early alert processes, proactive already begun prescribing for chronic conditions.
Fax 01727 832326 intervention and, for those experiencing complex, • The NHS Improvement Plan contains a
significant focus on developing chronic disease
www.npa.co.uk multiple difficulties, case-management by a
firstname.lastname@example.org designated healthcare professional 3,4.
2 PHARMACY FLYER
It is difficult to predict with precision the 3. 27% had dose-related side effects relationship, provide a regular platform for
endpoint of these workstreams. Although 4. 55% were prescribed medication which chronic disease interventions and formalise
CDM is a ‘whole systems’ challenge, it is highlighted a potential drug interaction communication with other members of the
likely that the initial focus will be on those, 5. 47% did not know the purpose of at least primary care team, especially GPs.
usually older, people with multiple chronic one of their drugs Consequently, community pharmacists are
conditions that frequently occupy hospital 6. 33% were taking at least one drug well placed to detect early changes in
beds as a result of difficulties coping in the incorrectly condition, identify at-risk patients and
community. Over time, we are likely to see 7. 48% of all patients needed a change in initiate action to avoid unnecessary hospital
a proliferation of integrated care pathways their medication, or to stop their admission or simply to re-establish control.
and more attention being paid by service medication, or needed a dose adjustment. The DH has already recognised community
commissioners to their application. One pharmacy as a suitable location for chronic
certainty is that PCTs will be heavily Against this background, it is clear that disease monitoring14. Kaiser Permanente in
incentivised to minimise the use of hospital effective CDM must involve a pronounced Northern California uses pharmacy data to
beds by people with long term conditions. effort to improve medicines use. designate people to receive additional
Recognising this, the American HMOs give support – for example patients with asthma
Community pharmacys’ pharmacists a central role in their disease whose data reveals two oral steroid boosts or
management processes; Kaiser pharmacists an excess of asthma inhalers are referred to
contribution are charged with a wide range of an asthma care manager. This care manager
The key written resource published by the responsibilities and routinely initiate changes may, in turn, be a pharmacist15.
DH describes how “the NHS is fortunate in to therapy within prescribing protocols. Self care within a CDM framework
having a number of things in place that gives Meanwhile, one of EverCare’s five core involves a substantial investment in patient
it a head start with managing chronic principles is to “avoid adverse effects of education and information provision. This
disease…these include strong community medication and polypharmacy”13. With their links to community pharmacy’s public
nursing teams, strong general practice, medicines expertise and accessible location, health/health promotion remit, as set out in
patients on registered lists and a network of the UK’s community pharmacists are in an the essential service domain of the new
community pharmacists”5. excellent position to help limit inappropriate pharmacy contract.
hospital admissions and to provide There are numerous examples of
medicines support for vulnerable people community pharmacy-based CDM services,
The DH has also recognised the living in the community. Medicines under Local Pharmaceutical Service
important contribution that community management services are already contracts and elsewhere, covering a range of
pharmacy can make to the CDM established in numerous community conditions – some examples are described in
agenda by publishing an aide memoir pharmacies and such services are likely to figure 2.
entitled Integrating community become widespread in England, with the In fact, all community pharmacists already
pharmacy into CDM. This is available at inclusion of medicines use review as an provide support to people with long–term
www.natpact.nhs.uk/cms/331.php and advanced service in the new pharmacy conditions, as part of their core day-to-day
describes how pharmacy fits into the CDM contract providing a catalyst. service of supplying appropriate medication
‘pyramid of care’. People with chronic conditions managed and advising on its use. Many people with
by medication have more contact with long term conditions visit pharmacies to self-
Active disease management points to community pharmacists than any other medicate, often without reference to their
more services being delivered away from healthcare professional. Pharmacy repeat doctor. Pharmacy input therefore needs to
secondary care and an emphasis on dispensing (an essential service in the new be integrated within care pathways, in order
supported self-management, which tallies pharmacy contract) could further intensify to maximise continuity of care, even where
with community pharmacy’s ‘mission the patient-community pharmacist no bespoke CDM service is in place.
statement’ of helping people to live
independently and healthily in the
community. Indeed, an intrinsic CDM
equation is that increased investment in
pharmaceutical care offsets hospitalisation
and medical procedure costs6. Figure 2: Examples of community pharmacy chronic
23% of nursing home admissions and disease management services
10% of hospitalisations may be due to older
patients’ inability to manage or follow drug Cambridgeshire
therapy, or the result of adverse drug Community pharmacy domiciliary visiting scheme
reactions, or contraindications in relation to This is a domiciliary visiting scheme for housebound older people.
the recorded clinical diagnosis7. And, as It is a joint scheme between South Cambridgeshire PCT, Cambridge City PCT,
many as 50% of all patients with chronic Cambridgeshire County Council and Cambridgeshire LPC.
conditions end up using their medicines in a ‘At risk’ patients are referred into the scheme co-ordinator at the PCT by GPs, district
way that is not fully effective8. Up to 75% of nurses, health visitors, social services, care workers and hospital discharge teams.
older patients fail to comply with prescribed The scheme co-ordinator contacts a suitable trained community pharmacist who then
medication9. Impaired dexterity and poor undertakes a home visit.
memory impact on older patients’ ability to The trained community pharmacist writes a care plan and communicates with the
take their medicines10. Studies have shown patients GP and community pharmacist as appropriate.
that as many as 40% of older people have For further information contact Jennifer Peel, Prescribing Adviser, South
problems accessing their medicines from the Cambridgeshire PCT. Email Jennifer.email@example.com.
containers or packaging in which they are
supplied11. Rowlands Pharmacy, Salford
It is also clear from research that older LPS medicines management service
people receive inappropriate therapy or This LPS service is focused on providing patient medication review. The patient stays
unnecessarily prescribed medication. A with the service only until all their medication problems are resolved at which point they
study of domiciliary visits by pharmacists to
are then “discharged” back to normal pharmacy care.
86 elderly housebound patients prescribed
For further information see ‘Pharmacy at the heart of a scheme to
four or more drugs revealed that12:
integrate health and social services’ at www.pharmj.com/noticeboard/
1. 36% had unrelieved symptoms series/vision.html.
2. 35% had difficulty remembering the dose
of one or more of their drugs
PHARMACY FLYER 3
Eastern Riding and Hull
Pharmaceutical care for the vulnerable elderly scheme Faced with a persistent trend towards
Patient hospital discharge information is faxed to community pharmacists for ‘high increased prevalence of chronic illness, the
risk’ patients (e.g. aged 75 or over on complicated dosage regimens, if admission to DH is accelerating its policy work on active
hospital was due to medication problems). The community pharmacist visits the patient management of long term medical
at home for a medication review, liaises with the GP and produces a care plan, and conditions. The DH has begun to transmit
continues to monitor the patient. the message to PCTs that the community
For further information contact Graham Hill, Professional Development pharmacist network is a necessary part of
Pharmacist, East Riding and Hull LPC. Email firstname.lastname@example.org. the CDM jigsaw. Managing chronic
conditions is foremostly a self-management
and community-based activity, aimed at
reducing the need for expensive secondary
Diabetes management in primary care
care interventions that deal with the
This service is delivered through community pharmacies in Hillingdon PCT. The
consequences of poorly controlled chronic
service is available to all adults, taking medication for their diabetes, residing within
conditions - and the experience of CDM in
Hillingdon PCT. Each patient has a consultation with the pharmacist on at least 6 the United States has been that increased
occasions in a 12-month period. Pharmacists measure each patient’s blood glucose, investment in pharmaceutical care leads to
blood pressure, HbA1c and cholesterol levels; and offer an obesity management service. savings in hospitalisation costs and medical
Pharmacists agree referral criteria with GPs and refer patients to them when monitoring procedure costs. To make the most of
parameters fall outside the target range, or there are other problems (e.g. intolerable side- community pharmacy’s contribution in the
effects) that cannot be resolved in the pharmacy. UK, the NHS must recognise the unique
Further information at www.medicines-partnership.org/projects/current- potential afforded by the sector’s regular
projects/diabetes-programme. contact with patients and integrate
pharmacy services into CDM care
Sutton and Merton pathways.
Merton Horizon Health Living Centre
Specially trained and accredited community pharmacists in Merton run a holistic
lifestyle health care management programme for individual clients who attend three References
community centres as part of the Merton Horizons HLC. Many of these clients, who are
1. Belfield and Colin-Thome. Improving
residents of the estates surrounding the three community centres, have complex and
chronic disease management.
multiple health needs as well as social problems. The objectives of the service include
DH 2004. Available at
improving the knowledge of and compliance with medication.
Services available include screening for diabetes, cholesterol and blood pressure, 2. Feachem. Getting More For Their
smoking cessation, pharmaceutical advice sessions, the provision of information and Dollar: a comparison of the NHS with
advice and referral back to the GP when appropriate. A referral system has also been California’s Kaiser Permanente. BMJ
developed from social services, the acute sector and other agencies. 2002 324 135-143. Available at
For further information contact Dinesh Patel, LPC Secretary, Merton www.bmj.com.
Sutton and Wandsworth LPC. Email email@example.com. 3. United Health Group. PEC Paper,
NatPaCT 2004 4. Available at
South Derbyshire www.natpact.nhs.uk/cms/70.php.
The Southern Derbyshire Medicines Support Service 4. Learning from Kaiser Permanente. PEC
Trained community pharmacists (who have completed an MSc module on Paper, NatPaCT 2004 2. Available at
‘Therapeutics for Older People’) across 5 PCTs in Southern Derbyshire make domiciliary www.natpact.nhs.uk/cms/70.php.
visits to any patient who has problems taking or managing their medication. It involves 5. Chronic disease management: a
multi-disciplinary working and joint visits are made with the key workers for mental health compendium of information.
patients, and with learning disability nurses for their patients. DH 2004. Available at
The pharmacist reviews medication regimes, assesses the patients’ needs and www.natpact.nhs.uk/cms/288.php#pa
discusses the medicines with patients and/or carers based upon the principles of ck.
concordance, in order to develop an individual, tailored pharmaceutical care plan. Any 6. Wendy. Economic evaluation of
clinical interventions are suggested and compliance issues are addressed (examples pharmacist involvement in disease
include reminder/tick charts or compliance aids). A copy of the care plan is given to the management in a community pharmacy
patient or carer, referrer, dispensing pharmacist and a letter is sent to the GP. This is a setting. Clinical Therapeutics 1997
busy service and over 1,700 referrals have been received to date. 19(1) 113-123.
For further information contact Diane Harris, Community Pharmacy 7. Oxley. Providing a pharmacy service to
Adviser, Amber Valley PCT. Email diane.harris@amberValley-PCT.nhs.uk. the over 75s. PJ 1999 262 888-890.
Available at www.pharmj.com.
8. Anon. Medicines and older people:
London Older Peoples Development Programme implementing medicines-related aspects
Incorporating pharmaceutical care into the single assessment process of the NSF for older people. DH 2001.
The London Older Peoples Development Programme ran several pilots in 2003 to Available at
determine how pharmaceutical care could become an integral part of the single www.dh.gov.uk/PolicyAndGuidance/
assessment process (SAP). Within the pilots, vulnerable older people were identified and HealthAndSocialCareTopics/Older
then referred to trained assessors for an overview assessment as part of the SAP. The PeoplesServices/fs/en.
overview assessments incorporated four trigger questions to identify older people with 9. Hughes. Compliance with drug
unmet medicines management needs. Older people who were found to have unmet treatment in the elderly. Prescriber Jan
medicines management needs were then referred to a trained pharmacist to conduct an 1998. 45-49.
in-depth medicines management review. The pharmacist then developed a 10. Hudson. Pharmaceutical care of the
pharmaceutical care plan in conjunction with the patient and where appropriate their elderly. PJ 1997 259 686-688.
carer, based on the needs identified. In line with the care plan, a care package that met 11. Medication management: strategies to
the older people’s needs was then developed in conjunction with the patient’s chosen meet the needs of vulnerable
community pharmacist. The patient’s community pharmacist had responsibility to people. NPA 1998. Available at
deliver, monitor and review the care package. They were also expected to initiate and www.npa.co.uk.
maintain contact with the patient’s carer and other relevant members of the care team. 12. Naylor. Assessing the need for a
domiciliary pharmaceutical service for
4 PHARMACY FLYER
elderly patients. PJ 1997 258 NHS. DH 2003. Available at • How community pharmacists can be
479-484. www.dh.gov.uk/PolicyAndGuidance/P better used to help general practice
13. Adapting the Evercare model for atientChoice/fs/en. meet the GMS quality framework.
the National Health Service. 15. Wagner. Improving primary care for • How to start planning for the
Evercare 2003. Available at patients with chronic illness. Journal of implementation of the new community
www.natpact.nhs.uk/cms.php?pid=2. the American Medical Association 2002 pharmacy contract.
14. Building on the Best: choice 288 1775.
• How to manage the workload arising
responsiveness and equity in the
from the numerous policy developments
impacting on community pharmacy. For
example it will be difficult for PCTs to
deliver on the growing pharmacy
Further examples of extended community agenda without the advice of a
pharmacy services community pharmacist at PEC level.
• How to start to implement the
National Collaborative Medicines Management Services Programme schemes recommendations in The Vision for
www.npc.co.uk/ Pharmacy document, which stresses the
The Medicines Management Services Programme is funded by the DH, and based at importance of having a pharmacist on
the National Prescribing Centre. It was established in 2001 to help PCTs to achieve the PEC.
sustainable improvements in prescribing and in the use of medicines. This initiative was
• How to think and plan more strategically
part of the Pharmacy in the Future target, which stated that by 2004 every PCT should
about the location of, and the service
have a medicines management scheme in place.
mix within pharmacies, by including
There have been four waves of MMS pilot sites involving a total of 146 PCTs. A
pharmacy in the Strategic Service
significant number of these sites involve extended community pharmacy services. Details
are available on the MMS database at
The PEC paper is available at
The Community Pharmacy Medicines Management Project
The Community Pharmacy Medicines Management Project is a national randomised Care homes training
controlled trial that is seeking to evaluate if community pharmacists can contribute to
health outcomes in cardiovascular disease through medicines management services in a pack
community pharmacy setting. Results of this trial are expected later this year.
The NPA has launched a new resource
for community pharmacists who wish to
RESPECT trial provide training on medicines to care
www.managingmedicines.com/trials.php home staff.
RESPECT is an ongoing Medical Research Council supported randomised trial of This is a flexible training pack which
pharmaceutical care for older people delivered through community pharmacies in East can be adapted to meet the requirements
Yorkshire and Hull. A detailed description of the trial can also be found at of all types of care homes. It has been
www.biomedcentral.com/1472-6963/4/11. written to meet the requirements set by
the Commission for Social Care Inspection
Prescribing and Medicines Management journal and the Royal Pharmaceutical Society, and
www.pharmj.com/ consists of a pharmacist’s manual and
This is an extremely useful bulletin that is designed for the exchange of ideas on individual workbooks for the care home
developments in medicines management in all parts of the UK. staff.
For more information email Sukhjit
Pharmaceutical Journal Vision for Pharmacy articles Grewal, Assistant Head of Education and
www.pharmj.com/noticeboard/series/vision.html Training at firstname.lastname@example.org.
This is very useful website to access articles on extended pharmacy services.
University of Keele report Public health resource
Blenkinsopp and Stuttle. Chronic disease management: making the most of nurses’
and pharmacists’ skills in primary care. Public health is currently a top priority
A report to the NHS Confederation. University of Keele, 2003. for the NHS.
The NPA, PharmacyHealthLink, PSNC
and the Royal Pharmaceutical Society have
launched a major new resource pack
entitled Public health: a practical guide
for community pharmacists. This
STOP PRESS! The briefing describes how community
pharmacy can be utilised to help PCTs resource explains the broader concept of
meet some of their key priorities, what public health in more detail, outlines the
potential contribution that community
LATEST RESOURCES opportunities currently exist to develop
pharmacists can make to this agenda, and
community pharmacy, and what the
future holds for community pharmacy describes what steps community
Understanding community development. pharmacists can take to increase their
involvement and contribution to public
pharmacy in the future The paper asks PCTs to consider: health at a local level.
The latest PEC briefing paper from • How to make the best use of community This resource is available on the
NatPaCT Understanding community pharmacy to help the PCT to meet respective organisations websites (for
pharmacy in the future describes why its targets, and how this should be example, on the NPA website at
PCTs should actively engage with incorporated into the Local www.npa.co.uk then ‘Publications’ then
community pharmacy now. Development Plan. ‘NHS Service Development’).