Shared learning database

Croydon Clinical Commissioning Group
Published date:
February 2019

The Croydon Integrated Community Network Medicines Optimisation Service (ICN MOS) is part of a whole system approach designed to transform the delivery of health and social care.

This includes implementation of the following standards:

Assess and review a person's medicines support needs. Optimise the pharmaceutical care plan and ensure medicines support needs are met. (NG67). 

Undertake joint working with the wider health and social care team primarily providing ongoing advice and support about a person's medicines and checking if any changes or extra support is required, such as simplifying a regimen to improve adherence (NG67).

Medicines reconciliation and reviews are carried to ensure safe and appropriate medicines use. This provides an opportunity to ascertain what medication patient is taking, help reduce risk of medications errors especially if patient has recently been discharged from hospital (NG5).  

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of the ICN Medicines Optimisation Service is to support patients with long term conditions to use their medicines appropriately and to manage independently for as long as possible.

In addition, the service also aims to achieve the following:

  • Reduce medicines-related incidents, harm, and hospital admissions.
  • Reduce medication waste and improve adherence.
  • Support patients and their families to make informed decisions about medicines use and to optimise the use of medicines in each individual.
  • Reduce the risks associated with medicines use in domiciliary care settings and during transfers of care.
  • Improve collaborative work across health and social care boundaries. By regularly attending and contributing to ICN huddles and other multidisciplinary meetings to facilitate proactive care planning to help reduce admissions and refer patients that may need support from other members of the ICN.
  • Identify medicines related support needs for health and social care professionals within the community and provide professional advice on the safe prescribing, handling and administration of medicines.

ICN pharmacists work with vulnerable and housebound patients that have complex needs and who often have difficulty accessing services.  These patients typically have several long-term conditions that are being managed with multiple medicines. It is recognised that polypharmacy increases the chance of adverse effects and interactions, and can also make adherence more difficult.  As such, polypharmacy is a major issue in health and social care and there is evidence suggesting that it increases an individual’s risk of harm and contributes to hospital admissions (WHO, 2017).

Medication related admissions are a national concern.  A report commissioned by the Department of Health, ‘Exploring the costs of unsafe care in the NHS’, found that 5% to 8% of unplanned hospital admissions are due to medication issues. 

ICN pharmacists undertake shared decision making with patients to rationalise prescribing, reduce wastage and promote adherence. Within the MDT, ICN pharmacists use their expert clinical knowledge of medicines and understanding of local systems to co-ordinate services with the aim of reducing the risks associated with multiple care providers all trying to support with medicines

Reasons for implementing your project

In Croydon, Health and Social Care providers and commissioners have agreed a whole system approach to transform the delivery of health and social care. An external review in 2017 revealed that Croydon had a higher than expected non-elective admission rate and poor integration of services compared to peer CCGs. This led to the development of Integrated Community Networks (ICNs) to address this, and a successful case was made for a new integrated care clinical pharmacy service.

The ICN Medicines Optimisation Service (ICN MOS) is a group of six specialist clinical pharmacists working across six clinical networks in Croydon. The ICN pharmacists support vulnerable and housebound patients with long term conditions, to use their medicines safely and appropriately and to manage their medications independently for as long as possible.

The service aims to reduce medicines-related hospital admissions and medication incidents and errors. By promoting better use of medicines in an at-risk population, the service also supports a reduction in inappropriate polypharmacy and medicines waste.

ICN core team members include GPs, pharmacists, community nurses, social workers and personal independence coordinators. ICN core teams attend weekly multi-disciplinary “huddles” at each GP practice to identify high risk patients and develop care plans. 

How did you implement the project

The ICN MOS accepts referrals from professionals across health and social care including via huddles, falls MDTs and via a hospital discharge pathway. All patients must consent to the referral or have a documented lack of capacity to do so.

Each ICN pharmacist attends fortnightly huddles at the GP practices in their network. This provides opportunity to identify new patients, to provide feedback and advice on open cases from all referral sources, and to refer on to other professionals where appropriate.

The hospital discharge pathway enables hospital pharmacy staff to refer direct into the service any patient upon discharge from hospital.

ICN pharmacists also attend a monthly falls MDT within the community falls service to provide advice and accept referrals where medication-related falls are a particular concern.

Patients are initially contacted by phone to arrange a domiciliary visit where a detailed consultation is conducted to identify any medication related problems. If a patient does not consent to a home visit then a telephone consultation is offered.

For every problem identified, a plan to address it is agreed with the patient, family members, and all relevant people involved in their care.

Each intervention is given a score, using an adapted RiO score which looks at how likely that intervention was at preventing an admission:

  • Level 1 – Unlikely to have prevented an admission.
  • Level 2 – Possible that an admission was prevented.
  • Level 3 – Likely to have prevented an admission.

The pharmacist will then follow up the patient following any changes being made to ensure that no further intervention is required.

Key findings

In the 6 months from April to September 2018 a total of 544 new cases were referred to the ICN MOS, and a total of 329 cases management episodes were completed.

60% of referrals (n=322) were received directly from huddle meetings and 27% (n=146) via the hospital pharmacy discharge pathway. The remainder came from sources including the falls and acute elderly care services and direct from individual members of the health and social care MDT.

For the 329 completed cases, a total of 580 medication related problems were identified equating to an average of 1.8 per patient.

Using the adapted RiO scoring tool, an estimated total of 49 admissions were avoided equating to an estimated saving of £153,135. An additional £15,116 of saving was made following recommended changes to medication regimes to address clinical problems or waste.

In addition, ICN Pharmacists recorded 470 episodes of patient or carer education, recommended 222 changes to medication regimes, and made 71 referrals to other services or professionals.

Following the implementation of integrated community networks as part of a wider set of new models of care initiatives in Croydon, the non-elective admission rate has decreased by 12% from April - August 2017 compared to April - August 2018. The ICN Medicines Optimisation Service is recognised as a key element of this achievement.

Key learning points

One of the key critical success factors for the success of the ICN MOS is its place within the wider Integrated Community Network model. This has enabled the team to develop key relationships with the wider MDT and to develop a deeper understanding of local systems, their limitations, and the consequences these have for patients.

The weekly huddle enables the pharmacists to both action solutions to problems in an efficient and timely manner, but also an opportunity to be involved with a wider multi-professional team providing holistic support to patients in order to influence health outcomes.

Contact details

Lucy Galloway
Principal Pharmacist
Croydon Clinical Commissioning Group

Primary care
Is the example industry-sponsored in any way?