I’m just going to go out and say it. Community pharmacists are a very under utilised useful resource we have for commissioning care in the local area. I actually see them fit a similar position to Information Technology (IT), medication is ubiquitous and infiltrates into all aspects of services which we provide and needs to be given appropriate focus to make an important impact just like IT. Pharmacists have this paid service called MURs (Medicines Use Review) and it kind of goes like this
Pharmacist: “Hello sir, here are your meds”
Patient: “<dry cough> Thank you”
Pharmacist: “I noticed you are on a blood pressure drug which can cause dry coughs, have you had that cough since you started the medication”
Pharmacist: “Oh let me recommend to the GPs for you to have a drug which won’t give you this side effect”.<Pharmacist writes a note to the GP to explain this in the form of a MUR and gets their remuneration for it>.
I’m not belittling pharmacists with the above example, but the model stinks. You end up with haphazard checks with not much use for the commissioning of care, as pharmacists need to meet that quota of checks regardless of content. However it’s not the pharmacists fault, I blame GPs for this. In my opinion
GPs should be starting Medicines Use Reviews not Pharmacists
When GPs choose patients everything changes and the pharmacist then becomes a service the GP can refer to in order to improve the quality of care without additional costs. An analogy is similar to a GP referring a patient to the Heart Failure Nurse who is appropriate rather than the Heart Failure Nurse just choosing a patient at random to do a review on which is what is going on at the moment with Pharmacists and their MURs. I did a bit of work last year on this with Romy Kalsi, Sarah Taylor and Niel Kenny from the pharmacy team in my local area and we came up with a Target MUR, that is a focused MUR done by pharmacists based on a population who has a real health care commissioning need. I’m sure other CCGs are doing something similar but in a different guise. I really need to plan and revisit this process from next year (my bad).
The Pharmacy Integration Form
The cornerstone of integration is the following form which we use when interfacing with pharmacists the context of which I’ll explain below. It could form the basis of a dynamic document with sections pull in and push out based on agreed areas of focus. At the moment the sections are
– COPD Check
– Asthma Check
– Statin Review
– NHS Health Checks
Step 1- Choose your Patients
This is probably the most important step and in my opinion should be the focus of how we can improve health care locally within the constrains of our budgets. As I’ve said before the sweet spot for commissioners, GPs and patients is keeping them out of hospital. It’s a win win but is complex as in order for this model to succeed we need to identify the patient before they are admitted. I’ve written about this in a previous blog The Answer is 42. So what is the question?
Whatever population is chosen it’s important to have a practical process with an identifiable population and aligned with local commissioning intentions for example COPD attendances to A&E and discharges from hospital within the last week (if you have the data!).
Naturally you also have to make sure the type of focus involves drugs which are amenable to intervention for example inhaler technique and compliance is a good one.
Step 2 – GP contacts Patient
Once the patients have been identified, it’s the GPs responsibility to contact the patient, ask them which Pharmacist they usually attend and get their consent for the Pharmacist to do the MUR.
Step 3 – Fill in the form
The GP simply puts the patient details in and ticks the section they want the Pharmacist to go over. eg Basic Information and COPD MUR Checks.
The form is then placed in the box for the Pharmacist the patient has a preference for.
Step 4 – The Pharmacist’s turn
The Pharmacist contacts the patient and does the MUR check based on the form’s requirements. They normally have to fill in their own form too, but in the future it would be nice to have a unified one.
Step 5 – Back to the GP
The GP reads the form and actions any suggested points from the Pharmacist, read codes the associated sections in the computer and calls the patient in for a further review if required.
What’s in it for me?
We ran this scheme last year with interesting feedback. Pharmacists seemed to really like the form and the processes as finally they felt they are linking in appropriately and making good use of the MURs rather than opportunistically viewing patient’s medications to look at interactions which have variable outcomes. It also helps GPs get their QOFs but most of the time they need to see the patients anyway after their MUR and quite frankly GPs don’t focus much on commissioning of care but more on the provision of care. ie as a provider a patient with COPD looks the same whether they go into hospital several times or once. This might form a section of a LES other groups could find useful to improve GP buy in or be integrated into the upcoming emergency DES..
The pdf version of the form is here.
The docx version of the form is here here.