Pharmacist-led care of people with long term. conditions

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1 Pharmacist-led care of people with long term conditions The Royal Pharmaceutical Society believes that utilising pharmacist led care of people with long term conditions will deliver cost-effective services that will bring significant results to patients and the NHS. Introduction Primary care has come under greater pressure in recent years, with higher demands on General Practitioners (GPs) and patient waiting times increasing 1. The number of people with three or more long term conditions (LTCs) was 1.9 million in 2008 and expected to rise to 2.9 million in People waiting one week or more to see their GP will rise from 26.2 million in 2013 to 27 million in Alongside this, demands on urgent and emergency care are rising, with 10am on Mondays being the peak hour for attendances in a typical week 4. The Royal College of General Practitioners (RCGP) is calling for increased numbers of GPs and additional funding for GP services to manage the increased demand and expectations of patients 5. The Royal Pharmaceutical Society (RPS) is proposing that in addition, pharmacist led care of people with long term conditions will enable resources to be utilised more efficiently to deliver the standard and level of care expected by patients. Pharmacists are an unused resource that can make an immediate difference by freeing up GPs to manage more complex or demanding cases. Recommendations The RPS believes that utilising pharmacist led care of people with long term conditions will deliver cost-effective services that will bring significant results to patients and the NHS: Waiting lists in urgent and emergency care, and GP surgeries will be reduced by utilising the skills of pharmacists to provide care to people with long term conditions People are kept healthier for longer, reducing hospital admissions Medicine waste and over prescribing is reduced and savings realised. 1 Royal College of General Practitioners: wait-week-or-more-to-see-gp-in-2014.aspx 2 Department of Health (2012). Report. Long-term conditions compendium of Information: 3rd edition 3 Royal College of General Practitioners: 4 Hospital Episode Statistics Accident and Emergency Attendances in England , Health and Social Care Information Centre published 28th January Pharmacist-led care of people with long term conditions 1

2 Background There is a body of evidence demonstrating that pharmacist-led care for people with LTCs delivers significant results. Pharmacist-led services are used in areas spread across England but there is no consistency. Innovative commissioning is required locally to enable pharmacists to demonstrate their full potential. In some Clinical Commissioning Groups (CCGs) pharmacists run clinics for people with LTCs either in a pharmacy or working alongside GPs in a practice; taking on patient caseloads and providing care for people with stable LTCs. It has been demonstrated that people using pharmacist-led services are more likely to take their medicine and achieve the associated health benefits. It is also known that patient satisfaction is high amongst those who receive care from pharmacists. The recent evaluation of the New Medicine Service 6, which focuses on supporting patients with asthma, COPD, hypertension, type II diabetes and those on antiplatelet / anticoagulation medicines who are prescribed a new medicine, demonstrates that this service carried out by community pharmacists significantly increased medicines adherence by around 10%. Asthma According to Asthma UK 7 there are 5.4 million people in the UK that are receiving treatment for asthma. The NHS spends around 1 billion a year treating and caring for people with this long-term condition. In the UK every day 200 people are hospitalised with asthma and 3 of these will die. In 2010 there were 1,143 deaths from asthma in the UK. It is estimated that 75 per cent of hospital admissions and 90 per cent of the deaths that may follow are preventable. According to NICE guidelines 8 people with asthma should receive an annual review and have a written action plan from their doctor or asthma nurse. Those without an action plan are four times more likely to need emergency care in hospital. Despite this, according to Asthma UK only 12 per cent of people with asthma have an action plan 9. In addition, it is reported that only two-thirds of patients with asthma have a routine asthma review each year. The recent National Review of Asthma Deaths (NRAD) 10 identified prescribing errors in nearly half (47%) of asthma deaths and room for improvement in the care received by 83% of those who died. The NRAD also highlighted that only 57% of those who died had an annual review in the last 12 months of their life and, of those who did have one, many people s reviews didn t even include the key components Pharmacist-led care of people with long term conditions

3 Asthma patients are a particularly hard to reach group often not engaging with their GP services but they are seen regularly by their community pharmacist for repeat prescriptions. An average pharmacy has around 450 asthma patients and 400 of them are probably not getting the best from their treatment. It is thought that approximately 50% of asthma patients have poor inhaler technique resulting in poor control of their disease. The case study below clearly illustrates the benefits of fully integrating the pharmacists into the healthcare team, utilising the pharmacist clinical skills to improve patient outcomes, reduce hospital admissions and GP appointments. Case Study 1 In collaboration with other health professionals, community pharmacists were given extra training to deliver structured asthma reviews including reviewing inhaler technique. 13 pharmacists carried out reviews in Leicester city centre on 165 patients with follow-up appointments at 3 and 6 months: 42% of patients had not had an asthma review at their GP practice in the last 12 months 56% had not had their inhaler technique checked in the last year. Using the validated Asthma Control Test (ACT) the results showed most improvement in those patients who had not had an asthma review from their GP in the last 12 months; showing patients receiving significant clinical and quality of life improvement. It is known that people only take their medicines as prescribed 50% of the time which leads to poor outcomes and wasted resources. The study found considerable improvement in patients compliance with their medicines, resulting in better overall asthma control. The study demonstrated a 32% decrease in GP appointments and a 40% reduction in hospital admissions. The authors concluded that to improve patient outcomes and thus decrease hospital admissions, pharmacist asthma reviews should be targeted at patients who have not had a review from the GP recently, capitalising on the accessibility and approachability of the community pharmacist. Pharmacist-led care of people with long term conditions 3

4 Hypertension Hypertension is one of the most prevalent cardiovascular (CV) risk factors in England and one of the most important preventable causes of premature morbidity and mortality. The risk associated with increasing blood pressure (BP) is continuous - each 2mmHg rise in systolic BP is associated with a 7% increased risk of mortality from ischaemic heart disease and a 10% increased risk of mortality from stroke 11. Lowering BP reduces the risk of CV events in people with established hypertension. Case Study 2 Analysis of the effectiveness of utilising prescribing pharmacists to deliver BP management services across South London demonstrated significant positive outcomes for patients, when measured against the Quality and Outcomes Framework BP audit standard (150/90mmHg) and the clinical BP target ( 140/90mmHg). In addition, data were collected relating to assessment of CV risk, prescribing interventions made, adherence counselling offered and lifestyle advice given. The costs of this service were significantly more cost-effective than the traditional use of medical staff. Of those referred with uncontrolled BP at the commencement of the study, 79% (181/229) achieved the QOF BP target ( 150/90mmHg) at 6 months; while 58% (128/229) had achieved the clinical BP target ( 140/90mmHg) at 6 months. This outcome alone represents a substantial potential benefit in terms of health gains and excellent value for money. The estimated cost of the pharmacist service was approximately 70 per BP controlled, which compares favourably with a first referral to specialist care at 200 or more and with follow visits costing at least Pharmacist-led care of people with long term conditions

5 Polypharmacy At least 25% of people over 60 years old have two or more LTCs which means that there a number of patients on a multitude of medicines. Such multiple medicines use (polypharmacy) is widespread and increasingly common, occurring in both primary and secondary care. It is driven by an ageing, increasingly frail and multimorbid population, coupled to a single-disease health service framework supported by numerous poorly-connected clinical guidelines. Polypharmacy may be clinically appropriate, but can increase clinical workload and clinical complexity. Polypharmacy can also be problematic, where multiple medicines are prescribed inappropriately or where the intended benefit of the medicine is not realised. Harms associated with polypharmacy include risk of errors associated with medicines (including prescription, monitoring, dispensing and administration errors), adverse drug reactions, impaired medicines adherence and compromised quality of life for patients. There are costs not only in terms of morbidity and mortality, but also of pharmaceutical products (including waste) and health service utilisation. Growing concerns around polypharmacy led to the publication of Polypharmacy and medicines optimisation: Making it safe and sound by the Kings Fund in This report highlights the implications of multi-morbidity and polypharmacy for clinical practice, services and policy, and calls for actions to facilitate the management of complex multimorbidity and systems to optimise medicines use. This report states that Multi-morbidity and polypharmacy increase clinical workload. Doctors, nurses and pharmacists need to work coherently as a team, with a carefully balanced clinical skill-mix. Pharmacists, as experts in medicines use, can play a significant role in the reduction of problematic polypharmacy. Summary There is a body of evidence demonstrating that pharmacist-led care for people with LTCs delivers results. Such services are available in pockets across England but there is no consistency. We are in a period where funding levels cannot increase and health care professionals must become more efficient. GPs are also clear: they cannot maintain existing levels of service let alone increase levels of service to meet patient demand and expectations. The effective use of pharmacists would increase efficiency, improve quality, reduce cost per patient and potentially provide services nearer to the patient. The examples demonstrate some of the types of pharmacist-led care available to the public, where integrating the pharmacist into the healthcare team and collaborative work across primary and secondary care can improve patient outcomes significantly and make better use of NHS resources. All of these services could be provided at a national level, across every CCG Pharmacist-led care of people with long term conditions 5

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