Introduction

This quality standard covers the safe and effective use of medicines for all people who take medicines, including people who are receiving suboptimal benefit from medicines.

It does not cover aspects of managing medicines specific to care home settings because this is covered by the NICE quality standard on medicines management in care homes (QS85). For more information see the medicines optimisation topic overview.

Why this quality standard is needed

Medicines optimisation is defined as 'a person‑centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines'. Medicines optimisation applies to people who may or may not take their medicines effectively.

Getting the most from medicines for both patients and the NHS is becoming increasingly important because more people are taking more medicines. 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). This issue is affected by the increasing number of people with long‑term conditions.

In 2012, the Department of Health published Long-term conditions compendium of information: third edition, which defines a long‑term condition as 'a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies'. The report suggested that about 15 million people in England have a long‑term condition and the number of long‑term conditions a person has increases with age: 14% of people under 40 and 58% of people over 60 have at least 1 long‑term condition. The presence of 2 or more long‑term conditions in a person is called 'multimorbidity'. In 2008, the number of people with multimorbidity was 1.9 million, but this is expected to rise to 2.9 million by 2018. Twenty‑five per cent of people aged over 60 report having 2 or more long‑term conditions.

Data from the Health and Social Care Information Centre shows that between 2003 and 2013, the average number of prescription items a year for every person in England increased from 13 to 19. With an ageing population, the use of multiple medicines (polypharmacy) is increasing.

In 2013, the Royal Pharmaceutical Society produced 4 guiding principles to describe medicines optimisation in practice and the outcomes it is intended to affect. The 4 principles are:

  • Aim to understand the patient's experience.

  • Evidence-based choice of medicines.

  • Ensure medicines use is as safe as possible.

  • Make medicines optimisation part of routine practice.

The quality standard is expected to contribute to improvements in the following outcomes:

  • harm attributable to errors in medication

  • patient satisfaction with outcomes from the use of medicines

  • quality of life for people with long‑term conditions

  • preventable mortality

  • preventable morbidity

  • life expectancy for people with long‑term conditions.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults ii Children and young people

1b Life expectancy at 75

i Males ii Females

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long‑term conditions

2.2 Employment of people with long‑term conditions*, **

Reducing time spent in hospital by people with long‑term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions

ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

Enhancing quality of life for people with mental illness

2.5 i Employment of people with mental illness**

ii Health-related quality of life for people with mental illness**

Improving quality of life for people with multiple long‑term conditions

2.7 Health-related quality of life for people with three or more long‑term conditions**

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP Out-of-hours services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i Primary care

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving access to primary care services

4.4 Access to i GP

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving children and young people's experience of healthcare

4.8 Children and young people's experience of inpatient services

Improving people's experience of integrated care

4.9 People's experience of integrated care**

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Improvement areas

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life*

Outcome measures

People manage their own support as much as they wish, so that are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

Carers can balance their caring roles and maintain their desired quality of life.

1D Carer‑reported quality of life*

Aligning across the health and care system

* Indicator complementary

Table 3 Public Health Outcomes Framework for England, 2013–16

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable**

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.13 Health-related quality of life for older people

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to medicines optimisation.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to people using services. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect patient experience and are specific to the topic are considered during quality statement development. For this quality standard on medicines optimisation, statement 1 relates to patient involvement in making decisions about the use of medicines.

Patient safety is an explicit component of statements 2 and 3 of this quality standard on medicines optimisation, as well as being one of the overarching aims of the whole quality standard.

Coordinated services

The quality standard on medicines optimisation specifies that services should be commissioned from and coordinated across relevant agencies encompassing the use of medicines. A person‑centred, integrated approach to providing services is fundamental to delivering high-quality care to people who take medicines in health and social care settings.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality medicines optimisation service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care professionals involved in caring for people who take medicines, or who could benefit from medicines, should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting people who are taking medicines in health and social care settings. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.