Document Sample
					Issue Number

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
  chronic disease
                                     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                multiple difficulties, case-management by a
                                                                                                  management services.            designated healthcare professional 3,4.

   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 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
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
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                              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                       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                   
Sutton and Wandsworth LPC. Email                                          3. United Health Group. PEC Paper,
                                                                                                    NatPaCT 2004 4. Available at
South Derbyshire                                                                          
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    
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           
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                               the over 75s. PJ 1999 262 888-890.
                                                                                                    Available at
                                                                                                 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             
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     
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

    elderly patients. PJ 1997 258                 NHS. DH 2003. Available at                   • How community pharmacists can be
    479-484.                                          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             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                                                                                  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
                                                                                                 Delivery Plan.
 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                                                         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                                                        written to meet the requirements set by
                                                                                              the Commission for Social Care Inspection
 Prescribing and Medicines Management journal                                                 and the Royal Pharmaceutical Society, and                                                                              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                                                Training at
   This is very useful website to access articles on extended pharmacy services.

 University of Keele report                                                                      Public health resource                                                       pack
   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 then ‘Publications’ then
community pharmacy now.                         Development Plan.                             ‘NHS Service Development’).