Missed opportunities: the patients falling through the cracks after discharge

The Discharge Medicines Service (DMS) is an NHS service that is so obviously beneficial, patients thought it was already happening before it had even begun.

First announced in February 2020, the service pays community pharmacy teams in England to receive information from hospital trusts that allows them to check if any medicines awaiting collection by a patient recently discharged are still appropriate. Pharmacists can then set up a consultation if the patient needs any help with understanding their new medicines regimen (see Box 1).

In the same way as the ‘Transfer of Care Around Medicines’ (TCAM) service before it, the aim at its launch was to help meet the World Health Organization’s (WHO) goal of reducing severe avoidable harm from medicines by 50% by 2022 and minimise the number of hospital readmissions.

“When you talk to any group of patients about anything, that’s one of the biggest things they get concerned about — that services sometimes operate in silos,” says Clare Howard, medicines optimisation lead at Wessex Academic Health Science Network (AHSN), adding that patients on a programme board to facilitate the TCAM service “were very clear that their expectation was that we talk to one another about what we were doing with their medicines — they think it’s already happening.”

But, in parts of England, it still isn’t.

Responses to freedom of information (FOI) requests submitted by The Pharmaceutical Journal from NHS trusts reveal that more than a quarter have yet to implement the DMS, despite advice from NHS England to do so by February 2021.

Even among trusts that have a DMS in place, the types of patients being offered a referral vary widely, with some trusts offering post-discharge support from community pharmacy teams to every discharged patient, while others limit the offer to one patient group.

The result is a service with proven benefits to both patients and the NHS that lacks equitable access.

Proven benefits

A hospital-to-community pharmacy referral service has been running in parts of England and Wales for years. In Wales, pharmacists have been able to review patients’ discharge advice letters since November 2011 to ensure that changes to patients’ medicines made in hospital are enacted as intended in the community.

The service was then launched for the first time in England in 2014 at Newcastle-upon-Tyne Hospitals NHS Foundation Trust, with the help of the AHSN ‘Transfers of Care Around Medicine’ project. A 2016 evaluation of the service found that it significantly reduced rates of readmissions at 30 days, 60 days and 90 days after referral, as well as shortening hospital stays for those who were readmitted.

Further evaluations of the service also showed the type of care offered by pharmacy teams through the service. Half of patients referred to community pharmacy through the TCAM service from the Royal Cornwall Hospitals NHS Trust between 1 April 2018 and 31 March 2019 received a medicines use review, with pharmacists most commonly saying that they offered “education and information” as part of their follow-up consultation.

But pharmacists working in this service also recorded instances of adverse drug reactions (ADRs) in 5% of the patients they saw. While most (46 out of 69) of the ADRs were categorised as non-harmful, with the patient able to continue taking the medicine, in 23 cases, the patient had stopped taking the medicine and was referred to their GP.

The proven benefits of the TCAM service to reduce medication-related harm in patients after discharge directly led to the commissioning of the DMS in every community pharmacy in England from February 2021, with acute, community and mental health trusts also expected to start referring into the service by the same deadline to “enable equitable access to the NHS DMS for their patients”.

In April 2022, NHS England also began to incentivise acute trusts to refer 1.5% of patients through the DMS “within 48 hours following discharge” during 2022/2023, as part of its Commissioning for Quality and Innovation (CQUIN) framework.

An inconsistent service

Despite this, roll out of the DMS has not been uniform across England and there are still parts of the country where patients are missing out on the benefits of a pharmacist consultation after discharge.

Responses to freedom of information (FOI) requests submitted by The Pharmaceutical Journal from 147 hospital trusts in England reveal that 39 trusts (27%) have not yet implemented the DMS, with 14 of these trusts saying that plans to set up the service were in the pipeline and due to start in late 2022.

Some 102 trusts said that they had set up a DMS service, while 6 trusts said the DMS did not apply to them as community providers or specialist hospitals. A further two trusts told The Pharmaceutical Journal that they refer patients to community pharmacy after discharge “through other means”.

“With continued pressure on the health service, there is a clear benefit for both patients and the NHS to reduce the potential harm from medicines at transfers of care and reduce the number of avoidable hospital admissions,” says Thorrun Govind, chair of the Royal Pharmaceutical Society’s English Pharmacy Board.

“The DMS highlights the key role of pharmacists working across the system to help patients with their medicines, but if we are to help reduce health inequalities, it is vital that new services are rolled out consistently across the country.”

Alistair Gray, clinical services lead pharmacist at East Lancashire Hospitals NHS Trust, which has referred at least 7,557 patients through the DMS since February 2021, says that where the DMS is not in place, when referring patients from secondary to primary care, “there’s a risk that the information might not be fully transcribed and that can finish up with an inappropriate prescription, which could then finish up with the patient taking it and having an [adverse] event … or they may not get the full health benefits if they’re missing new medicines”.

“It doesn’t happen all the time,” he says. “But that’s one of the reasons why the DMS was commissioned; to try to close that loop.”

Ade Williams, superintendent pharmacist at Bedminster Pharmacy in Bristol, says the service should be a “prime priority project” but adds that referrals “seem to trickle down very poorly from acute [trusts] and I don’t know why”.

“We know that for many patients, the most traumatic thing that can happen to you is to get admitted in hospital.

“Then when you come out, you have so much to deal with, and that hand-holding, supporting you, navigating you through the system, also ensuring that unintentional harm does not happen because medicines that should be stopped, are stopped. We know that these are the benefits that flow from that [service].”

Reasons for not having a DMS in place varied between trusts, but many responded that they were still waiting for suitable IT systems before moving forward with the service, despite receiving a total of £1.2m from NHS England in March 2022 to support either the purchase of IT licences, development of IT solutions or integrating third party systems specifically for transferring patients through the DMS.

According to a response from University Hospitals of Morecambe Bay NHS Foundation Trust, trusts “across Lancashire and South Cumbria are in the process of jointly developing a DMS service,” which it says will be implemented before March 2023.

“Refer-to-Pharmacy is going to be spreading to all of the trusts in the Lancashire and South Cumbria Integrated Care System (ICS) over the next two quarters,” confirms Gray. “So hopefully by the spring of next year, all the trusts in Lancashire and South Cumbria will have Refer-to-Pharmacy.” From this rollout, Gray expects “a four-to-five-fold increase in referral numbers”.

The Refer-to-Pharmacy system was created specifically for East Lancashire Hospitals NHS Trust by the healthcare IT company Cegedim Rx and launched in October 2015.

An audit published in June 2019 showed that the system prevented at least 1,200 prescriptions from being dispensed unnecessarily in the two years from March 2017 at East Lancashire Hospitals NHS Trust, with more than 250 incidents of harm prevention reported after community pharmacists spotted prescribing errors on the first prescription after discharge.

“My philosophy is that every eligible patient is referred,” says Gray. “The Refer-to-Pharmacy application makes it easy to do that. It adds a few seconds onto the patient’s care, but those few seconds can save a life.”

Broader the better

However, the FOI responses from trusts also revealed that even where the DMS is running, eligibility criteria that patients need to meet in order to be offered a referral vary widely between trusts.

NHS England’s ‘DMS toolkit’ offers a suggested list of patient groups (see Box 2) for which a DMS referral should be considered, but adds that “actual referral criteria should consider local population needs and the NHS trust’s capability to refer patients”.

When asked to provide a list of eligibility criteria for DMS referrals, 19 trusts said they did not have criteria, with some — including Avon and Wiltshire Mental Health Partnership NHS Trust and Alder Hey Children’s Hospital — specifying that this was because all patients are offered a referral at discharge.

Meanwhile, 14 trusts said they were currently limiting DMS referrals to one patient group, such as those on monitored dosage systems, with some planning to expand to further groups in the future.

Hull University Teaching Hospitals NHS Trust, for example, which has referred 318 patients through the DMS since June 2021, said it had previously “been referring patients to community pharmacies through the PharmOutcomes platform for more than four years”.

A spokesperson said that the trust initially “targeted patients being discharged from the cardiology wards … because it was felt they would receive significant benefit from the service, given that most patients were initiated on more than one new medicine during their admission”.

“In line with the introduction of the CQUIN, the service has been rolled out to other clinical areas, including neurology and respiratory wards,” they said, adding that “there is a plan to extend the service further to other clinical areas”.

Howard says that from her experience with implementing TCAM, “the message would be the broader, the better”.

“What we’ve learned is that the trusts that broadened out their criteria had a much better chance of making [the service] ‘business as usual’,” she explains. “So, places that just started with monitor dosage systems, for example, it tended to just get stuck a bit there.”

“It’s about sitting down and thinking, what have we got going on in our patch, who do we absolutely want to make sure has got access to this service, rather than keeping it narrow to monitored dosage system patients, because you could miss some high-risk patients that could really benefit,” she continues.

NHS England did not respond to requests for comment on whether it is concerned that some patients are able to access help with their medicines more readily after discharge than others. But until the NHS DMS is rolled out equitably across the country, that will continue to happen, with missed opportunities extending well beyond the service.

“The benefits of this service are not just about the service,” says Howard. “When you bring people together, you realise that, actually, there aren’t huge numbers of conversations that have gone on in the past between trusts and LPCs, for example, and bringing those people together means there’s bigger benefits than just the DMS.”

Additional reporting by Emma Wilkinson