The NICE medicines optimisation guideline section 1.3 contains recommendations about medicines reconciliation and section 1.4 contains recommendations about medication review. Medication review is recommended when there is a clear purpose (see recommendation 1.4.1) and it is recommended that organisations should determine locally the most appropriate health professional to carry out the review (see recommendation 1.4.2).
Wyre Forest Clinical Commissioning Group (CCG) commissions a medicines optimisation service from practices, and most have employed a pharmacist to deliver review of medicines post discharge or clinic attendance and medication review. The latter is targeted to those patients taking medicines likely to cause a hospital admission. The service requires recording of interventions made and surveys to patients and staff.
This example was highly commended in the 2016 NICE Shared Learning Awards.
Aims and objectives
The aims of the service were to:
- Improve management of medicines after discharge and reduce the risk of medication errors.
- Maximise clinical outcomes for patients by focusing on patient engagement
- Improve management of medicines to help reduce adverse effects to medicines.
- Reduce potential waste medicines by medicine synchronisation and patient engagement to reduce the risk of intentional non-adherence.
- Improve support for practice staff e.g. repeat prescription and reception staff.
Practices were asked to:
• Undertake reviews of discharge medication, recording any intervention made, to ensure all changes are accurately recorded on the clinical system and patients contacted where changes to medication have occurred.
• Undertake medication reviews with direct patient contact for patients taking medicines likely to cause a hospital admission.
Recognising that the pharmacist is the expert in medicines the majority of practices have employed a pharmacist working with staff across the practice to optimise the use of medicines.
Reasons for implementing your project
The service was developed as a result of a pilot in one practice who used innovation funding to employ a pharmacist to improve their management of medicines. The idea came from the GPs who felt they were always rushed when looking at discharge medicines and this task would be more efficiently and effectively undertaken by a pharmacist. They also wanted the pharmacist to undertake medication reviews for patients on multiple medicines.
This pilot was evaluated and data on the numbers and types of interventions made during one month was collected. This highlighted many interventions made that if they were missed could have resulted in a hospital admission. The pharmacist contacted patients following discharge where they had medication change to ensure they understood this change and establish stock levels before prescriptions were generated unnecessarily.
This information was used to develop a business case to provide this model of medicines management in all practices in the CCG. For the CCG to be able to extend the pilot to all practices it was necessary to develop a commissioned service. The CCG is unable to fund staff directly for practices but are able to commission a service for activities which are outside of the standard contract. Although GPs do review discharge medicines it was felt that the level of intervention was more than would be expected in the core contract.
How did you implement the project
A business case was developed and funding requested to commission a Medicines Optimisation Service. Funding required was an initial set up cost of 50p per patient and an ongoing running cost of £1.75 per patient. A service specification was developed which included the following key performance indicators:
• Number of discharge summaries and clinical letters received and percentage of reviews undertaken of those letters and discharges
• Total number of medication reviews undertaken in previous quarter
• Number of A&E pharmacist referrals reviewed
• Details of interventions made for discharge or medication reviews and A&E referrals
• Number of patients taking medication likely to cause a hospital admission and percentage who have a patient contact review within the previous 12 months. See 5.1.4 below
• Number of challenges made to requests from outside the practice to prescribe when requests are not in line with policy/guidance.
• Results and action plan from medicines related audits, agreed mutually between the practice(s) and the CCG.
• Patient satisfaction survey - 10 completed surveys per 5000 patients
• Practice staff survey
The CCG worked with practices to set up the service, helping them to recruit appropriate staff and developing a template for the clinical system EMIS Web to record the medication reviews. Since the service started in June 2014 the CCG has met regularly with staff delivering the service to provide ongoing support. Our biggest challenge was persuading the commissioners that this was a good investment of quite a large sum of money. We overcame this using the in depth intervention data to give a best estimate of potential savings including admissions saved. Please see the attached document for details of some of the information used to make the argument in the business case.
In July- September 2014, 1309 discharge summaries and 1132 clinical letters were reviewed, and 472 medication reviews were undertaken across 11 practices. Practices reported that they had reviewed 100% of discharge summaries (in line with NICE recommendation 1.3.3) During November 2014 a detailed analysis of the interventions were made. A full evaluation of these interventions is provided in the supporting document with this submission. A patient and staff survey was undertaken and full results are also given in the supporting document.
Nearly 2000 interventions were recorded during November with 38% of them being for medication being commenced, changed or stopped. Specific examples were highlighted where patients had been inadvertently ordering medicines that they should have stopped. Dose alteration accounted for another 12% which were often as a result of adverse effects or changes to renal function. There were also examples of interventions picked up where a GP had previously missed or misread letters and discharge summaries. Examples include phenytoin removed from repeat when it should not have been, doses increases missed, capsules added not oro-dispersible after bariatric surgery, reduced dose of PPI compared to discharge summary added for a patient with two admissions with GI bleed.
A number of the interventions in the view of the clinician had avoided a hospital admission such as stopping medication that was causing Q-T prolongation and risk of lactic acidosis with metformin in renal impairment.
Patients and staff were positive about the service. 67% of patients agreed it was useful to have the opportunity to discuss their medicines. 32% learnt something about their medicines that they didn’t know before and 38% have changed the way they take their medicines as a result of the discussions.
Improved safety and efficiency around medicines as well as support for practice staff were the key themes of comments from the staff survey.
Financial Impact of the Service:
The annual cost of the service was £253,920. Based on the data for one month’s direct savings from interventions the total annual savings are in the region of £450,000. The CCG spend on prescribing is growing at a lower rate than surrounding CCGs. Their spend per ASTRO-PU (age- sex adjusted patient population) has reduced by 1.4% when comparing April-October 14 to the same time period in 2013 prior to the introduction of the full service.
Key learning points
If possible use the information and evidence from any trials or pilots to support your business case. Please see the attached document for details of some of the information used in the business case. Potential patient numbers for medication review was huge. We’re revising the service spec for the next financial year for the practice to agree with the CCG a cohort of patients that will equate to approximately 6-7% of their list size.
What worked well was working with the practices to develop a template for EMIS web to record and getting all practices to use the same read codes etc. Data collection has been encouraged to continue as this data is beneficial for a number of reasons including being able to provide the ongoing reassurance of benefit and value for money of the service.
When we issued the initial service spec we had copied in practices to get their views. We also met with the practices to discuss how to set it up, developed recording templates for EMIS web along with searches for producing the reporting data. The WF locality pharmacist now also meets regularly with the person delivering the service to provide ongoing support and training.