BY 2004, EVERY PRIMARY CARE TRUST (PCT) must have medicines management schemes in place. But what is medicines management and why do we need it? What are the key drivers for this agenda? What medicines management initiatives are currently underway? At the end of this article you should have a better understanding of MM and know where to look for further information.
What is Medicines Management?
Medicines management means different things to different people and covers a range of activities and tasks associated with the use of medicines. Think of the chain of events from when it is decided to prescribe a medicine, through supply and review to ensure it is effective and remains optimum treatment. Every person or process involved at each link in this chain is delivering a medicines management service - any break or weakness in the link may mean that the patient or the NHS will not get the best use from their medicine. In medicines management patients are partners in the use of their medicines and are empowered to take a far more active role in the management of their medication.
‘Medicines management aims to prevent, detect and address medicines-related problems and to achieve optimum use of medicines.’
‘Medicines management (MM) is a system of processes and behaviours that determines how medicines are used by patients and the NHS. Effective MM will place the patient as the primary focus, thus delivering better targeted care and better-informed individuals.
Why do we need Medicines Management?
The most common therapeutic intervention in the NHS is the use of medicines. An average PCT spends £18 million on medicines, which represents approximately 16% of its total expenditure.3 Most patients will benefit from appropriately prescribed medicines. However, evidence shows that not all patients benefit from medicines and some patients are caused harm or put at risk through inappropriate use or prescribing of medicines. The most expensive medicine is the one that the patient does not use! Evidence also shows that there is a huge amount of wasted medicines largely due to adverse effects from medicines but also through patient’s not understanding how to use their medicines or being prescribed medicines in a form that that they are unable to use. Some statistics relating to problems associated with poor medicines management are summarised below:
• As many as half of all patients with chronic conditions do not use their medicines appropriately
• Medication problems are implicated in 5-17% of hospital admissions.
• In hospital, 6-17% of older inpatients experience adverse drug reactions.
• Medication errors have been estimated to cost the NHS £500 million year in additional days spent in hospital.
• Some patients are not receiving medicines from which they would benefit and others are taking unnecessary medication (e.g. appropriate use of statins for patients with or at high-risk of heart disease).
• Each year approximately £100 million worth of unused medicines are returned to pharmacies.
What are the key drivers for Medicines Management?
There are four key drivers for medicines management:
• Value for money from medicines prescribing
• Medicines Partnerships
•Getting the right drug to the right patient at the right time
• Delivering measurable healthgain to the patient
1. Value for money from medicines prescribing
National Service Frameworks (NSFs) aim to drive up standards, improve health and reduce inequality of services and outcomes through medicines management and the appropriate use of health professionals to provide targeted advice and support. In addition the National Institute of Clinical Excellence (NICE) provides patients, health care professionals and the public with authoritative, robust and reliable guidance on the use of some medicines and treatments.
As a result of NSFs and NICE guidance, annual growth in prescribing is faster than the general increases in health spending. In 2002/03 the forecast increase in drugs spending was 11-13% compared to the planned increase in NHS spending for the same period of only 8.8%.3 The implementation of the Coronary Heart Disease NSF is the most significant factor driving increases in drugs spending – for example evidence in support of using statins to reduce mortality and morbidity in patients at high risk of heart disease or with existing heart disease is overwhelming and spending on statins increased by 33% in 2001/02.
Primary Care Trusts are finding it very difficult to control the growth in prescribing spending and need to ensure that prescribing is appropriately targeted and represents good value for money. The Audit Commission Report on Primary Care Prescribing3 found that a significant proportion of those taking statins were not in the high risk group (as defined in the NSF for Coronary Heart Disease), while large numbers of patients (up to 75% of men who have suffered angina, and 66% of men who have had heart attacks) who should be taking statins were not. The same audit also showed that review in some other areas ofprescribing could release funds to help manage the increase in prescribing required for the NSF Coronary Heart Disease.
Prescribing support at PCT and practice level is now commonplace and most if not all PCTs have a Prescribing Adviser or Head of Medicines Management who manages a multidisciplinary prescribing support team. Such teams will develop medicines management services that promote good management of prescribing and ensure that prescribing is appropriately targeted.
Examples of MM services that achieve value for money in medicines prescribing:
• Disease management guidelines
• Care pathways
2. Patient partnerships
For the individual patient, medicines management is about working to achieve concordance. Concordance is a partnership between patient (and/or their carer/family) and health professional in which an agreement is reached about whether and how medicines are to be taken/used1. Concordance in medicines for patients can be achieved by:
• Informing patients about the drug and non-drug options available to treat their condition or disease.
• Involving patients in the choice of treatment and respecting their views and priorities
• Providing lifestyle advice to support any treatment
• Explaining how long they may need to take the medicine for explaining to patients how and when to take their medicine and how long the course of treatment is likely to be.
• Explaining the benefits of the drug treatment and any potential harms
• Informing patients of the benefits of regular review and the necessity of any monitoring
• Providing patients with an opportunity to comment on their medicines and their effectiveness
Examples of medicines management services that achieve patient partnerships:
• Patient information
• Patient support groups
• Disease management clinics
• Medication reviews
3. Getting the right drug to the right patient at the right time
The majority of health care is well intentioned but can be let down by inefficient or ineffective systems of delivery. Much work has been done following the ‘patient journey’ from the first consultation with a health care professional through to the delivery of a medical intervention. (It is important to remember that medicines management is only part of the care pathway or journey of the patient and that there will be number of other healthcare and social care professionals involved in the patient’s care.) Making sure that people can get medicines or pharmaceutical advice easily and, as far as possible, in a way, at a timeand at a place of their choosing is an essential component of medicines management and this will be best achieved by ensuring that as well as efficient systems there is effective communication between all professionals carers.
Some medicines management services may be developed around improving existing systems in the GP practice so that patients can have easier access to medical services. For example changing the appointments system so that all patients can see a doctor within 48 hours or improving the repeat prescribing system so that patients can collect a repeat prescription within 72 hours of ordering it.
Pharmacy in the Future5 and A Vision for Pharmacy in the new NHS6 describe how pharmacy systems and structures will provide patients with fast and convenient care that is tailored to individual patient needs and delivered to a consistently high standard. For example by 2004, electronic prescribing will reduce the scope for incomplete and illegible prescriptions and also by 2004, repeat dispensing will mean that patients will be able to get repeat prescriptions from a pharmacy, without having to contact their surgery each time. Evidence from pilots has shown that repeat dispensing reduces the amount of waste of medicines. Other models that are being developed will move the delivery focus of a particular type of care into another area, freeing up GP time. Examples of this are Patient Group Directions and Supplementary prescribing. Patient Group Directions (PGDs) are an alternative way of authorising the supply of medicines. PGDs can be used by pharmacistsor nurses to manage prescribing for some conditions or chronic diseases, for example emergency hormonal contraception, nicotine replacement therapy, asthma management. PGDs are normally drawn up by a doctor and counter signed by a pharmacist. Supplementary prescribing, allows professionals such as pharmacists to be responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. By the end of 2003, the first pharmacists will be acting as supplementary prescribers.
Examples of medicines management services that get the right drug to the right patient at the right time:
• NHS Direct
• Out of hours services
• Patient Group Directions
• Managing repeat prescribing systems
• Repeat dispensing services
• Electronic transmission of prescriptions
4. Delivering measurable healthgain to the patient
All medicines management services should show a measurable healthgain for both the patient and the NHS. Separate outcome mon-itoring and review processes will be required for different types of medicines management service. For example clinical audit or ePACT analysis would be used to measure how well a disease management guideline or NICE guideline had been implemented whereas patient feedback would be more useful to assess a new system for collecting repeat prescriptions, particularly patients perception of whether the service has made a difference to them.
Examples of medicines management services that measure healthgain for patients
• Clinical audit
• Medication review
• EPACT analysis
• Patient satisfaction surveys
What Medicines Management initiatives are currently underway?
This last section looks at some of the nationally funded initiatives around medicines management. In addition to the national initiatives there are numerous medicines management initiatives that are being funded locally by PCTs from the unified budget. It is beyond the scope of this article to look at the detail of these.
1. National Collaborative Medicines Management Services (MMS) Programme
The National Collaborative Medicines Management Services (MMS) programme is funded by the Department of Health and hosted by the National Prescribing Centre (NPC) in Liverpool
The programme uses a collaborative approach to achieve the overall goal of the MMS collaborative - ’to help optimise prescribing, plus the experience and health outcomes, for each patient, where medicines are involved’. The programme encourages team working and sharing of best practice and will help ensure that all PCTs have access to a range of appropriate medicines management services by 2004. It is delivered through four planned waves, where a wave is made up of a number of collaborative sites drawn from applications from PCTs. Each wave last approximately two years. To date 106 PCTs across England have participated in three waves. Medicines Management services developed through the programme have included use of GP clinical systems for medicines management, repeat prescribing systems, medication review, prescribing expenditure, clinical governance and making better use of the skills of local pharmacists. Applications are currently being considered for the fourth wave which will be made up of a further 40 sites. This wave will focus on repeat dispensing and closer co-operation with local hospitals.
2. Medicines Partnership
Medicines Partnership is a two-year Department of Health funded programme designed to involve patients as partners in prescribing decisions and support them in medicine taking, to improve health outcomes and satisfaction with care. To date the Medicines Partnership has been involved in a number of projects that aim to put patient partnerships into practice that have involved policy makers, professionals, patients and the public.
An example of the work that the Medicines Partnership is doing is its joint work with the National Medicines Management Collaborative Programme to produce a succinct, practical guide to medication review called ‘Room for Review.’9 The aim of the guide is to assist local organisations to improve the quality and patient-focus of their medication review, recognising that they are starting from very different points. Other areas that the Medicines Partnership has been involved in are supplementary prescribing and the NSFs for Diabetes and Renal Disease.
3. The Community Pharmacy Medicines Management Project
The Community Pharmacy Medicines Management Project is being sponsored by the Department of Health and five pharmacy organisations – The Pharmaceutical Services Negotiating Committee, the Royal Pharmaceutical Society of Great Britain, the Company Chemists Association and the Co-Operative Pharmacy Technician Panel. The project, which involves patient with coronary heart disease, is being conducted in nine pilot sites. Once patients have agreed to participate in the project, core base-line data is extracted from their medical records and sent to the pharmacy. The pharmacist then makes an appointment to see the patient and follows up any recommendations with the GP.
Medicines Management is now an accepted and important area of PCT activity. It means different things to different people but is principally involved in ensuring that patients and the NHS get the most benefit and the least harm from their medicines. There are a number of initiatives already underway with more to follow. Importantly the implementation of the Quality Outcomes Framework of the new GMS Contract for General Practice will ensure that good medicines management services are delivered. So too, the proposed new contract for community pharmacy will also encourage pharmacists to provide medicines management services.