NHS England is currently in the process of recruiting more pharmacy professionals to work with care homes to improve both the safety and effectiveness of medicines and residents’ quality of life.
There is a need for better medicines optimisation in the nation’s 20,000-plus care homes (source: Oscar Research). Three-quarters of 75-year-olds in the UK have more than one long-term condition and, as a result, more than half of this age group are taking five or more drugs.
Yet one pharmacist describes care homes as a ‘healthcare black hole’ because they can be seen as low priority, even among GPs. Residents have professional in-house care rather than being looked after in their own home by untrained family members. However, a lack of medicines knowledge among care home staff can lead to over prescribing and hospital admissions.
Increased funding, increased opportunities
The Pharmacy Integration Fund, set up in 2016 to help integrate clinical pharmacy practice into a wider range of primary care settings, will pay for 180 pharmacists and 60 pharmacy technicians to go into care homes.
Two-thirds of medicines-related hospital admissions could be avoided if more use was made of pharmacists’ expertise. Simon Stevens, chief executive of NHS England, wants to end the “a pill for every ill” view still held by some care homes.
The scheme will help GPs whose visits to care homes have become more acute driven and less proactive, while the British Medical Association is asking GPs not to overstretch themselves when working with care homes.
In February 2018, the Royal Pharmaceutical Society (RPS) published its
‘The Right Medicine: Improving Care in Care homes’
report. This examined how care home residents should only be taking medicines that are actually effective for their personal needs. It also reiterated how residents should be more involved in deciding what medicines they take so they feel more confident about self-medicating. There were also calls to end outdated concepts such as medicines rounds.
Pharmacy-led medicines optimisation services can deliver impressive results. When the idea was piloted across six sites, emergency hospital admissions fell by 21%, ambulance calls were reduced by 30% and the savings on drugs costs per resident were between £125 and £305.
But there are challenges when a pharmacist decides that he or she wants to work more closely with local care homes. It can be difficult to get a resident’s relative and a care home nurse to attend the medicines review at an agreed time, and setting up the service initially with GPs and individual care homes can be time consuming.
Pharmacist, Wasim Baqir is national pharmacy lead (care homes) for NHS England and previously lead pharmacist at Northumberland Vanguard Northumbria Healthcare NHS Trust. Baqir has been working with care homes for many years and says when pharmacists set up a medicines optimisation service in a care home in a local area via a local clinical commissioning group (CCG) initiative, they must initially earn the trust of care home owners and managers who are effectively allowing a third party to come into their private businesses and tell them they might not be doing something well.
My advice would be to not assume that what you want to give a care home as a medicines service is what they want or need
Local clinical commissioning groups (CCGs) can help to plan and pilot a service, but the local GP surgery should always be the first port of call. It can provide general information relating to the types of medicines that residents are taking and for how long. The next step is to make contact with specific care homes and to offer support by demonstrating the value that a pharmacist could add to their business in terms of improving care and saving money. Time must also be allocated to ensure governance and standards procedures are in place and that IT and data collection systems are up and running. It is important that a pharmacist sees this as a long-term service that adds value to care and not just a project.
Source: Courtesy of Wasim Baqir
According to Baqir, a major challenge for pharmacists is how they measure the improvement in medicines use once a service has been launched.
“My two bits of advice would be to not assume that what you want to give a care home as a medicines service is what they want or need,” he says. “Also, start with some joint reviews with GPs to build that trust and confidence,”
He adds that specific targets or tasks should be set and robust data collected that can be analysed. This will enable other people, including other care homes, to see the positive impact that a pharmacy-led service can have. “There is a lot of relationship building involved with care homes as well as with GPs before a service like this can be launched.”
Baqir emphasises that pharmacists should stress to care homes the added value they can bring in terms of reducing medicines supply, medicines waste and in helping care home nurses and other staff to improve their own medicines knowledge by working closely with a pharmacist on-site.
The pharmacists at Northumbria Healthcare NHS Trust recall a number of examples where resident care has been improved.
For example, one resident was taking flavoxate to reduce bladder spasms associated with catheter use. However, a review by the care home showed she had been managing without a catheter but the drug had not been stopped. The pharmacist stopped it and removed it from the GP repeat prescription system.
Baqir says best practice occurs when a medicines optimisation service is embedded into the care home and the adult social care system locally with GPs, community pharmacies and hospitals all working together and not in silos. “In Northumbria we also have a very good relationship with the local mental health trust which offers additional help and advice to the care homes,” he says.
The role of the pharmacy technician
The traditional model for most pharmacists was to review patients one by one and then move on to the next care home. There are many cases today where a pharmacy technician will assess a new resident to ensure effective medication reconciliation and the pharmacist will only get involved if there are complications.
The role of the pharmacy technician can be crucial to the success of this kind of service. They can quickly demonstrate real improvements to a busy and under pressure care home manager who may worry they are just going to be issued with yet another action plan.
Kayt Blythin, principal clinical pharmacist medicines optimisation for care homes at Sussex Community NHS Foundation Trust, says that the role of the pharmacy technician has grown on the back of the initial work carried out by pharmacists.
Source: Courtesy of Kayt Blythin
Taking the time to get it right
Blythin urges pharmacists who do see opportunities to work in care homes not to rush into launching a medicines optimisation service. She says they need to take their time to get it right and this includes researching how local care groups do work together. “The most successful services are based on a good relationship with GPs, but they are busy and do not always think about how a stronger relationship with pharmacists can benefit care home residents,” says Blythin.
The most successful services are based on a good relationship with GPs
“We put a pharmacist in first to get the medicines right for each resident and our involvement is welcomed by care homes that can struggle to get GPs to attend face-to-face reviews. They see us as an asset to help with individual care plans,” she says.
The Sussex Community NHS Foundation Trust covers 165 care homes and so far only three homes have declined a pharmacy-led medicines optimisation service after being approached.
“One was owned by a pharmacist so it did not need it, while the other homes resisted in a more passive way by, for example, cancelling appointments. Often it is just a case of helping a care home to understand the value a pharmacist can bring. They can wrongly see such a service as creating more work for them.”
Another barrier to these services being successful is poor communication.
Changes to a resident’s medication must be communicated to the care home manager, for example. Was he or she involved in the review conversation from the start? Also, once the pharmacist has identified that changes to someone’s medication are needed, these alterations have to be communicated to the GP and back to the care home. This is where delays can occur and such hold-ups can have a negative impact on the perceived value and success of the service.
When pharmacists and pharmacy technicians engage with care homes they become a driving force for change. They can relate with the resident and their loved ones while also interacting with GPs to help under-pressure care homes ultimately improve the care they provide.
Challenges do exist but so do opportunities to improve patient care and quality of life.
Box: Pharmacist roles in care homes
Below is a summary of pharmacist care home roles posted on NHS Jobs at the end of July 2018. All offered training according to the Medicines Optimisation in Care Homes Training Pathway, including support in obtaining an independent prescribing qualification if required.
Generally two years, fixed term
Between 18.75 hours and 37.5 hours per week
Agenda for Change salary banding:
Band 7–8a (£33,222–49,969 per annum)
- Support care home staff and care home residents (nursing and residential) through patient-centred clinical medication reviews and medicines optimisation;
- Provide clinical advice, appropriate on-site assessment, advanced care planning/care planning, chronic disease management, post discharge reviews and GP/nurse care home rounds;
- Work closely with service users, providers, residential and nursing homes and community services, as well as medicines management and quality team members and GP surgeries.
Prerequisites for Band 8a positions:
- Previous implementation of medicines optimisation projects;
- General practice and/or primary care experience desirable;
- At least five years post-registration experience, a postgraduate pharmacy qualification (minimum two-year university Diploma level) or equivalent demonstrable experience.