Shared learning database

Guys & St Thomas NHS Foundation Trust (Community Health Services) NHS Specialist Pharmacy services
Published date:
September 2015

The Guys and St Thomas’ "@home service" (GSTT@home service) provides an alternative to hospital admissions and facilitates early discharge by delivering a range of advanced nursing interventions to patients within the comfort of their own homes. The Integrated Care Clinical Pharmacists (ICCP’s) working within the GSTT@home service have driven forward the medicines optimisation agenda by developing and delivering a clinical pharmacy service to improve patient outcomes, and have enabled a range of multidisciplinary practitioners within the team to optimise the use of medicines within their scope of practice.

This service is an example of the implementation of a number of recommendations within NICE guideline 5 but in particular those recommendations in section 1.3, 1.4, and 1.8 around medicines reconciliation, medicines review and medicines-related models of organisational and cross-sector working.

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 GSTT@home service is part of a wider program from Southwark and Lambeth Integrated Care (SLIC), who aim to ‘drive the delivery of pro-active and preventative care and ensure local people have access to the right care, in the right place, at the right time’. The GSTT@home service aim is to reduce hospital admissions and facilitate the early discharge of patients by providing integrated case management of individuals with complex needs. The service is aimed at adults most at risk of being admitted to hospital (often vulnerable older people), or those that can safely be discharged home early from hospital when provided with extra medical and nursing support in the community.

Care is coordinated by the GSTT@home service Matrons with intensive support from a range of health professionals. The Integrated Care Clinical Pharmacists (ICCP’s) were recruited to:

• Develop and deliver a clinical pharmacy service to the patients within the @home service

• Provide professional advice and support to other health and social care professionals on the safe prescribing, handling and administration of medicines

• Lead on the medicines aspects of patient care to optimise medicines, reduce medicines related risks and improve adherence to taking medicines by o Carrying out domiciliary medication assessments and reviews in identified patients o Providing professional advice and support o Co-ordinating and leading interventions to reduce medicine related problems by developing care plans in agreement with patients and other health and social care professionals o Developing partnerships and facilitating collaborative working between multidisciplinary teams/agencies

• Develop best practice guidelines and medicines processes that are efficient, consistent, practical and sustainable within the constraints of the existing systems and takes into account the values of patients and their carers

• Identify areas of risk relating to medicines use in primary care and facilitate compliance with medicines legislation to deliver safe standards in the prescribing and handling of medicines in the community across health and social care

• Support the development of care pathways to support frail older people identified as having a medicines management need

• Identify medicines related training needs for health and social care professionals within the Community Health Services and provide appropriate professional advice and support in response to this

Reasons for implementing your project

The @home is a new service developed by Guy’s and St Thomas’ NHS Foundation Trust in collaboration with King’s College Hospital operating within Lambeth and Southwark.

The Consultant Pharmacist was involved at the very early stages of commissioning and development of the service specification and operational policy and was crucial to the development the pharmacist’s role. It was recognised that medicines optimisation support would be required at various stages of the care pathway as the service was new, and there were clinical, governance, procurement and other practical issues to deal with. In addition, prescribing and timely administration of medicines are two key interventions provided to the patients within the service. So there was a need for individualised medicines optimisation, as well as the implementation of safe administration and handling processes for the various staff involved at all stages. These issues were flagged up to the service governance group and addressed via a medicines work stream which highlighted the need to recruit a dedicated and integrated pharmacist post (6 months) within the team.

The first ICCP was recruited to post in June 2013 (working 0.5wte) The pilot phase (one site) allowed the testing of this model of working, and once established, a business case was put together. This business case included the addition of a 1.0WTE ICCP in recognition of the increase in workload since the inception of the project. Currently the service has expanded to two @home sites with 1.5wte pharmacists working across both.

Working with the Specialist and Consultant Pharmacists and the Medical Consultant for Infectious Diseases (amongst others), the Home Ward Pharmacist led the development of an intravenous antibiotics guideline fit for purpose for the types of patients presenting to the Home Ward service. Previously there was confusion as to which guideline should be followed by the Home Ward service as patients are mainly admitted from two different trusts and Clinical Commissioning Groups.

How did you implement the project

Direct patient care

This involves proactive screening for medicines related risks, medicines reconciliation and undertaking domiciliary medication reviews. GSTT@home service staff identify and refer patients at the highest risk of medicines related morbidity and/or hospital readmission that need pharmacy input. The ICCP’s prioritise patients for a domiciliary visit according to their needs and undertake a holistic domiciliary medication review. A care plan is then jointly agreed with the patient and the pharmacist makes recommendations to various health and social care practitioners to optimise the use of medicines. The pharmacist is able to carry out simple practical interventions to support the patient to take their medicines as prescribed.

Medicines optimisation leadership

The ICCP’s provide expert advice and support on all aspects of prescribing and medicines handling (e.g. procurement, prescribing, medicines reconciliation, administration, storage, record keeping) within the GSTT@home service to ensure that the use of medicines is optimised and meets safety, statutory and governance requirements. In addition to this, there is also the collating and analysis of prescribing data which enables the monitoring and improvement of clinical and cost effectiveness. Another important aspect of this role involves nurturing partnerships and facilitating collaborative working between multidisciplinary teams especially during the transfer of care. Identifying and providing support to meet medicines related training needs for clinical and non-clinical staff to reduce medicines related adverse incidents and improve outcomes is also a crucial aspect of the ICCP’s role.

The service is constantly evolving to cater for the increasing pressure of patients who present within A&E settings and aims to deliver care in domiciliary settings as much as it possible. As a result there are constant challenges for the pharmacists to meet the demands and challenges of procuring, supplying, prescribing medicines and delivering a “virtual ward” clinical pharmacy service in the community in a safe, way as well as meeting statutory requirements.

The ICCPs worked hard to become integrated members of the GSTT@home service team, and kept abreast of developments to the team which enabled them to ensure that medicines optimisation stayed high on the agenda.

All resources required were paid for from the GSTT@home service budget (e.g. Lone worker devices, mobile phones, laptops etc).

Key findings

The details of the in depth domiciliary assessment/review and interventions were recorded using a Microsoft Infopath template. Medicines related problems (MRPs) were identified in 3 areas (access, adherence and therapeutic) and an intervention was made for each problem. The data obtained was then exported to a Microsoft Excel spreadsheet for analysis. Analysis of 207 patients who had their medicines reviewed identified 467 medicines related problems (2.3 problems per patient).

Area of medicines related need

Total MRPs










Patients are most vulnerable and at higher risk of medicines related errors at the point of transfer of care between services or settings. Many errors are picked up by the ICCPs and potentially adverse events are averted e.g. wrong dosage, omitted drugs, inappropriate prescribing, duplication of therapy, non-adherence etc. There are many examples of individual patient benefits:

• Better access to medicines through liaison with local community pharmacies.

• Adequate supplies of emergency stock.

• Improved adherence (particularly with inhalers).

• Resolution of conflicts between health and social care to facilitate safe administration of medicines.

• Liaison with GPs to discontinue long term prescribed medicines that are no longer indicated

• Monitoring to improve therapeutic effects and reduce adverse effects of prescribed medicines.

• Supporting and empowering patients to self-administer medicines.

Historically, patients usually come into contact with pharmacists during their stay at hospital or in community pharmacy settings in primary care. Many of the GSTT@home service patients have multiple long term conditions or are housebound and do not receive the appropriate level pharmacy expertise, input or support that could reduce the risks of medicines related hospital admissions. For these patients, the ICCPs reviewing medication and co-ordinating the medicines related aspects of their care is a bonus which many patients and health care professionals find beneficial. The ICCPs have also reduced medicines waste through tighter stock control and monitoring of prescribing data, and have implemented a ‘Doctors Bag’ system to enable speedy access to medicines in an emergency situation.

Key learning points

The ICCPs have made a significant impact in the overall quality of care that the GSTT @home service patients have received, and have also had a positive effect on the overall medicines optimisation of the service in general. The ICCPs are now well recognised as key medicines specialists within GSTT community health services and are involved in all decision making around the use of medicines.

Early identification of the needs of the service helped in making this a successful initiative; engagement of key pharmacy stakeholders at every stage of implementation of change within the teams is essential.

When commissioning clinical pharmacists input to innovative services such as this in the community, provision should also be made for appropriate senior pharmacy input for clinical supervision, to oversee and provide clear strategic direction for medicines optimisation. This senior role will ensure that appropriate governance and quality is maintained with regards to medicines use at directorate level. Also to deal with complex issues and help to unblock the inter professional and organisational barriers, that usually arise as a result of multi-agency working around medicines.

Contact details

Lelly Oboh
Consultant Pharmacist, Care of Older People
Guys & St Thomas NHS Foundation Trust (Community Health Services) NHS Specialist Pharmacy services

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