When the healthcare service embraces new ways of working that address clinical need and changing demands, patients can benefit, particularly when high risk medicines are involved. But for some healthcare providers it can be difficult to know where to start.
Our pharmacy team at Buckinghamshire Healthcare NHS Trust decided to set up a service to manage the entry of novel oral anticoagulants (NOACs) to maximise safety and access for patients.
When NOACs were first introduced, there was a risk that some clinicians would over-prescribe the medicines and others would be reluctant to prescribe drugs they were unfamiliar with. We established the service to accept referrals from both GPs and acute trust doctors and, since its inception in 2012, it has accepted approximately 200 referrals per month. We are now expanding and applying our NOAC service model to other areas of prescribing.
Pharmacists are well placed to find opportunities for new and innovative clinical services, and establishing this type of service helps to demonstrate the value pharmacists can have. The recent call for pharmacists to be working in GP practices also presents an opportunity for pharmacists to take on more clinical roles, and secondary care pharmacists may be able to provide support with more complex patients or conditions. So how can pharmacists identify where services are needed and how can they implement them?
The idea for our NOAC service began when we became aware of the technology appraisal for dabigatran in atrial fibrillation from the National Institute for Health and Care Excellence
. We identified this as an area where we could add value for our patients by making sure they were involved in the decision about the choice of anticoagulant. This meant carrying out a thorough risk assessment and providing intensive counselling before prescribing the right anticoagulant for the patient at the correct dose.
The following types of medicines are often good targets for a beneficial service, especially those meeting more than one criterion:
- High cost medicines;
- Medicines with complex prescribing regimens;
- Medicines that require dosage individualisation;
- Medicines with narrow therapeutic indices;
- Medicines where full consultation with patients and adherence support is particularly important;
- Combination prescribing for new patients naÃ¯ve to medicines.
Develop important skills
In order to lead a service, a pharmacist requires specific clinical expertise. This will usually include being an independent prescriber, having an expert knowledge of the relevant condition and therapies and, ideally, having existing relationships with important local stakeholders, such as consultants in hospital or GP prescribing leads in primary care. Additionally, the individual should be confident and proactive.
These skills match well with the advanced pharmacy framework from the Royal Pharmaceutical Society (RPS)
, particularly those competency clusters related to expert professional practice, collaborative working relationships and leadership. As such, RPS Faculty membership is something we would recommend when appointing a candidate to develop a service because this provides assurance that the individual has developed professionally in these areas.
Find a champion
Engagement from chief pharmacists in acute trusts and clinical commissioning groups (CCGs) is vital to ensure that new ideas can be implemented in a timely fashion. This may involve making quick decisions, such as hiring a locum to backfill an existing member of staff.
Chief pharmacists can build prescribing capacity into their teams by sending appropriate staff on prescribing courses in order to take advantage of new opportunities as soon as they arise. Additionally, because they have relationships with those sitting at board level, chief pharmacists are in a position to secure the support of senior clinicians and managers, which is essential for a successful outcome. They will also be able to engage with CCG senior pharmacists who can influence their own primary care stakeholders.
For our NOAC initiative, we first met informally with CCG lead pharmacists to outline the proposal, where ‘buy-in’ was secured. We then invited key stakeholders, including GP prescribing leads, lead consultants for cardiology, stroke, and haematology, and senior acute and primary care pharmacists. Our discussions allowed us to explore and gain a mutual understanding of the issues and barriers, which included acknowledging the challenges the local healthcare economy was facing. Following this, an extraordinary meeting of our Joint Formulary Management Group was held, dedicated to the NOACs in atrial fibrillation, and the formal decision was made to commission a specialist NOAC service.
Develop a business case
Once you have secured support from those who can influence the decision in your favour, you will need to write a business case for the service. This should be planned carefully, and should be written by either the chief pharmacist or a senior member of the pharmacy team. Find out if there is a preferred standard format within your organisation by obtaining a copy of a successful business case, for example.
You will not need to write each section of the case yourself. Once you have provided some basic information, a local finance lead can help with the financial section. In addition to the business case, shared care guidelines, or documentation that defines who will be involved and what their responsibilities will be, need to be written and approved. A care pathway will also need to be developed — interface pharmacists, who are based in CCGs or acute trusts but work across primary and secondary care, can provide valuable support with this.
Set realistic costs
Although you can access a lot of support when working out the financial aspects of your service, there is certain information that you will need to decide yourself. It is a good idea to ask colleagues who have set up similar services in other organisations for advice.
When budgeting for the service you will need to allow for annual leave and sickness. In addition, you will need to account for administrative support, including equipment, stationery, printing and computers. There is a fine line between pricing your service so highly that it appears prohibitive and under-selling it.
Once successful, you will need to write a service specification for a newly commissioned service. Much of this will be taken care of by commissioners who will draft the document for you. However, you will be asked some questions, such as how long your service is being commissioned for, what tariff has been agreed, who can provide the service and what qualifications or training they should have. Your chief pharmacist will probably have service specifications that already exist for other aspects of the pharmacy service.
Engage your stakeholders
Internal and external marketing is also essential for your stakeholders. Those backing the service should be briefed on your business case fully and prepared for likely resistance. Securing support from local opinion leaders, such as consultants or appropriate GPs, will help with the establishment of your service and providing regular audit data to service commissioners will help you demonstrate value for money. You should also develop a robust set of performance indicators to allow you to measure your service impact and patient outcomes, such as the number of patients who have a stroke — this is likely to be a prerequisite to services being commissioned.
It is also important to consider how you will evaluate the success of your service before you begin. We provide monthly data for our NOAC service, including the number of patients we have seen and what anticoagulant, if any, they have been prescribed at what dose. We have also evaluated the service using patient questionnaires and the ‘friends and family test’, which asks patients if they would recommend the service to their friends and family. The service was initially commissioned for 15 months but it has been extended and there are now no plans to decommission the service.
Account for administration
Running clinics is not just about seeing patients. It is easy to underestimate the time needed for following up after appointments by writing, checking and sending clinic letters. It is critical to manage information governance requirements fully. Time to write guidelines and develop shared care processes must be built in from the start.
Acute trusts have appropriate systems for processes such as booking appointments and checking patients in, and you should liaise with the relevant managers to ensure that you establish a clinic in a way that your organisation collects data for activity and income capture purposes.
If you have electronic medical records in your trust then you will need to ensure you have a level of access to allow you to add to them, as well as read other clinician’s entries. If paper records exist instead, you will need to decide who is going to obtain the records for your clinic. In addition, you will need to find out what software packages are used for producing clinic letters for GPs or other hospital clinicians and determine who is going to type them. The cost of this administrative support will need to have been accounted for in your business case.
Once your clinic is running properly, you may benefit from using standard clinic pro formas in your consultations. These will speed up your record keeping and ensure that you are systematic in your work. It is important not to delay starting your service until you have perfected every clinic pro forma and any patient information leaflets that you develop. If possible, use or adapt one that already exists or obtain one used elsewhere.
Resist the temptation to develop documents for the sake of producing them. If the pharmaceutical industry already produces patient support materials that are acceptable, use those rather than spend precious time producing your own. There may be an opportunity to develop documents alongside patient representatives but, again, this should not be a priority when setting up the service.
If your service is successful, employing more staff is a logical next step. Fixed term contracts may be preferable because of the length of commissioning but, where possible, posts should be permanent as this will make it easier to recruit people with the right skills. Flexible working often helps new service models because clinics can fit around this if necessary.
Important tips for setting up your service
- Constantly look for opportunities and think big — consider future problems as well as current ones;
- Identify members of your team who have or could develop competencies within the Royal Pharmaceutical Society advanced pharmacy framework, particularly if you do not have these skills yourself;
- Find stakeholders to advocate for you to help build momentum and remember that some will be cautious and need convincing;
- Write a robust business case with help from financial advisers, commissioners, administrators, IT and like-minded colleagues;
- Do persist and do not give up if your service does not get off the ground. You will need to be determined and work hard.
We are grateful to Barry Jubraj at the Chelsea & Westminster Hospital for his help developing the manuscript for this article. Our thanks also go to the members of the joint formulary management members, especially Piers Clifford (chairman), Jane Butterworth (head of medicines management), Aylesbury Vale and Chiltern CCGs, Raj Bajwa (GP prescribing lead of Chiltern CCG), Maire Stapleton (formulary pharmacist), Sarah Crotty (interface pharmacist) and Jonathan Pattinson (consultant haematologist).
 Royal Pharmaceutical Society Advanced Pharmacy Framework. Available at: http://www.rpharms.com/faculty-resources/advanced-pharmacy-framework.asp (login required).