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Medicines Optimisation Strategy
Forward
Medicines are the most common intervention in healthcare with half of all adults prescribed at least one medicine (NHS, 2014). When medicines are taken correctly they can be lifesaving, however all too often medicines use is suboptimal. With a drug spend in England of circa £17.4 billion in 2016/17 (Ewbank, 2018), getting the best outcomes from the use of medicines is best for both patients and the health economy.
“Medicines optimisation is about ensuring that the right patients receive the right choice of medicine, at the right time” (RPS, 2016). The four principles of medicines optimisation are summarised in the diagram below however the central theme of this is involving our patients in the prescribing decisions associated with their care. Doing so can aid concordance and compliance with treatment which in turn can improve outcomes.
Figure 1 : Four Principles of Medicines Optimisation (RPS, 2016)
At Royal Papworth our pharmacy staff are passionate about medicines optimisation. The safe use of medicines is at the heart of everything we do from the procuring of stock and topping up of wards to the screening of prescriptions and prescribing for our patients. With over 50 members of staff from all different backgrounds the pharmacy department exists to
ensure that medicines are available wherever and whenever they are needed and that they are used in the safest way possible.
This Strategy builds on the previous one (2014) and details five key ambitions:
Support a safety culture surrounding the use of medicines Delivery of excellent pharmaceutical care Improve patient outcomes associated with the use of medicines Maximising the management of medicines Pharmacy workforce development
The opportunities that moving to our new, purpose built hospital brings are crucial to fulfilling our ambitions. The installation of the robot allows us opportunities to change processes surrounding the storage and distribution of medicines that have previously not been possible. Our location on the Cambridge Biomedical Campus enables us to consider collaborating with our Campus partners and exploring new clinical and education opportunities. All of which will allow us to continue developing a safe, high quality, forward thinking pharmacy service that puts our patients first.
Jennifer Harrison (Chief Pharmacist)
Empower all staff to report concerns regarding medication use without fear of prejudice. Lead by example. Senior staff to demonstrate adherence to medicines safety principles to provide an example to junior staff. Regular patient safety rounds by senior staff and execs to provide a check and challenge on practice. Listen to staff through formal and informal channels. Act on the “soft intelligence” quickly. Use of Laudix to praise good practice. Scanning technology will be introduced as and when it becomes available to augment the safe administration of medicines Electronic prescribing is in place across the hospital. Pharmacy will continue to work with the EPMA team to ensure that this system is as safe as possible and that its benefits are maximised.
2. Delivery of Excellent Pharmaceutical Care
Introduction “The delivery of hospital pharmacy services and the optimisation of medicines are intrinsically woven and, from a value perspective, can’t be separated” (Lord Carter, 2016). The ethos of the Carter report is that at least 80% of pharmacy staff time should be spent on direct medicines optimisation (MO) activities. In the 2017 NHS pharmacy benchmarking exercise pharmacists at Royal Papworth spent 76% of time on MO activities and pharmacy technicians 43%. Since that time the staffing model has changed and those figures are likely to have increased further. However it is worth noting that both were above the national average. The seven day clinical standards require that pharmacy is available seven days a week in order to support treatment decisions and transfer of care (NHS England, 2017). In October 2018 Royal Papworth pharmacy began opening all day on a Saturday and Sunday. Although staffing levels at weekends are lower than during the week, they are able to meet the demand for discharge medication and urgent inpatient items as well as increasing the percentage of medicines reconciliation carried out.
Ambition: We aim to provide excellent pharmaceutical care to all Royal Papworth patients seven days a week. All patients who are admitted for 24 hours or more and require medical intervention will have medicines reconciliation provided by a member of pharmacy staff. Pharmacists will be actively involved in prescribing decisions and be valued members of the multi-disciplinary team. Patients’ wait for medication will be kept to a minimum.
This means: Pharmacy services are available seven days a week to ensure that patients’ medication is optimised in a timely manner.
To achieve this we will: Provide a pharmacy service seven days a week. Weekend services will focus on the efficient and accurate provision of discharge medicines, urgently required medicines for inpatients and medicines reconciliation. Discharge medicines will be provided within 90 minutes of receiving a completed prescription. Near patient dispensing of discharge prescriptions (dispensing from the ward) will be the preferred model. Medicines reconciliation training will be provided for pharmacy technicians to support the pharmacists in achieving this in a timely manner.
3. Improve Patient Outcomes Associated with the use of Medicines
Introduction One of the goals of medicines optimisation is to improve patient outcomes (NICE, 2015). Medicines prevent, treat or manage many illnesses or conditions and are the most common intervention in healthcare. However, it has been estimated that between 30% and 50% of medicines prescribed for long-term conditions are not taken as intended (World Health Organization, 2003; NICE, 2015) Many of Royal Papworth’s patients will be on appropriate polypharmacy, meaning that they are intentionally prescribed multiple medicines and that each one is necessary. However appropriate polypharmacy can all too easily become problematic when care is not taken to ensure that each medicine is still required and still working as it should do. The more medicines a patient is on the less likely they are to take them as instructed and the more likely it is that they will experience side effects. Many documents exist that advocate the importance of involving a patient in the decision making about their medication (NICE, 2009; RPS, 2016) and there is evidence to show that by doing so their adherence to their medication regimens is improved (NICE, 2009)
Ambition: We aim to support patients with their adherence to their prescribed medication regimen, enabling them to take their medication correctly thereby maximising the benefits they get from their treatment. Patients’ best interests will be at the heart of every decision and the patient will be involved in those decisions wherever possible. We aim to provide accurate information to patients and other healthcare providers when a patient is transferred between care settings. We aim to avoid the prescription or continuation of unnecessary medication and at all times ensure there is a robust evidence base for all prescribing decisions.
This means: Clinicians will actively involve patients in decisions concerning their medication. Medicine changes should be explained in clear terms to the patient. Prescribing decisions should be evidence based and outcomes of treatment monitored for efficacy to inform the choice of therapy.
To achieve this we will:
Pharmacy and nursing staff will ensure that every patient discharged from hospital has their medication explained to them so that they understand how to take it and why it is being prescribed. Pharmacy will provide a written list of medication to the patient on discharge. An accurate list of the medication prescribed on discharge will be provided to the relevant healthcare provider on transfer of care (e.g. GP on discharge). Patients ,where adherence to a medication regimen is critical, will be supported to self-medicate whilst in hospital e.g. transplant and CF. Prescriptions will be reviewed and unnecessary medicines discontinued in order to reduce polypharmacy and to improve patient compliance. The efficacy outcomes of therapy will be monitored to inform choice of therapy, medicines that are not proven to be efficacious will be discontinued. Medicine use will be evidence based. Only medicines that have been approved for use by the Drug and Therapeutics Committee and added to the formulary will be initiated.
Consideration will be given to supplies of patients’ own medicines at home when dispensing for discharge (as per NHSE and CCG commissioning contract) in order to prevent stock piling by patients. Stock rotation will be standard practice to enable medicines to be used prior to their expiry dates and thus minimise wastage. The Trust has a biosimilar/generics policy that states that where a biosimilar or generic exists this will be used in preference to a branded product where it is safe to do so. The robot will be used as the primary store for medicines to maximise the use of space within the dispensary and to ensure an accurate stock holding is available.
5. Pharmacy Workforce Development
Introduction National recruitment of certain bands of registered pharmacy staff is a known problem. Current and proposed Health Education England funding cuts to both pharmacy pre-registration technicians and pharmacists is compounding the issues with less training places available. Retention of existing staff is even more important given these constraints to recruitment. We have introduced a band 4 to 5 progression programme for our pharmacy technicians. It is our ambition to develop this further by looking at pharmacy supply assistant to technician training programmes and to look at career opportunities for pharmacists that enable them to be recognised for their expertise. We believe that strong leadership is essential at all levels of pharmacy. We want to develop leaders who can nurture and develop other staff in order to achieve their full potential and to continue to provide the best possible care for our patients.
Ambition: We aim to equip our workforce with the skills and knowledge required to undertake their role in medicines optimisation to the highest possible standard. We aim to develop a pharmacy team that is well led, forward thinking and dynamic. We aim to invest in growing our own staff and to provide career pathways for all staff groups within pharmacy to enable them to develop and reach their full potential. We aim to introduce consultant pharmacist posts that recognise the expertise and national presence that our highly specialist pharmacists already have.
This means: We want to provide attractive career opportunities that will appeal to those staff who want to develop themselves further, in order to retain their excellence and expertise within the department.
To achieve this we will:
Invest in the leadership of the pharmacy department. Ensure that all staff with line management responsibilities have appropriate and up to date leadership training. Provide opportunities for staff not already in line manager roles to gain experience with key skills such as interviewing and project management. Introduce consultant pharmacist posts to ensure that the expertise of these highly specialist pharmacists is not lost from the department due to lack of career development opportunities.
Roles and responsibilities
Board of Directors Ratify the strategy and support delivery.
Chief Pharmacist Accountable for the delivery of the strategy.
Deputy Chief Pharmacist Responsible for supporting senior pharmacy staff to deliver the strategy.
Drug and Therapeutics Committee (DTC) To monitor the delivery by receiving reports and challenging where required. DTC will sign off annual reporting and agree changes in application of the strategy.
Senior Pharmacy Staff To lead on the delivery of the ambitions. Provide the updates to Pharmacy Business Unit and CADs Meetings.
All Pharmacy Staff To understand how they can contribute to the overall strategy and maintain professional pharmacy standards at Royal Papworth Hospital.
Monitoring
Quarterly
- DTC and CADs
- Update on progress in written report
- Deputy Chief Pharmacist
Annually
- Q&R
- Board Annual Report
- Director of Chief Pharmacist
Ways to achieve this:
- Optimising our Prescription Tracking System Fully utilise the recording of near misses and errors functionality Explore the reporting functionality to aid design of work flow to streamline dispensary processes
- Lorenzo Digital Exemplars (LDE)
Ensure that all electronic and technological advances at Royal Papworth Hospital are in line with enhancing patient care and improving access to appropriate patient directed information Engage with IT to develop Lorenzo to realise full system potential Utilise the reporting functionality to aid with key medicines optimisation audits and research in order that we develop our services according to current statistics within the system Work with ICT to implement bar code drug administration technology in line with GS
- Medicines Safety Officer Ensure all pharmacy staff receive training on the reporting of incidents as part of local induction Regular contributions to lessons learnt and to patient safety rounds from pharmacy staff Work with the regional and national medicines safety teams to maximise the learning from incidents
- Staff development Invest in the senior leaders within the pharmacy. Ensure all receive training appropriate to their role that promotes effective and inspiring leadership Work with PSS to promote the expertise of specialist pharmacists and AHPs and to create consultant positions in these areas
