Community health services are at the heart of the integrated care system (ICS) and provide diagnostic, therapeutic and preventative health services closer to the patient. Community health services also provide step-down community hospital-bedded units to support early patient discharge from acute hospitals, as well as step-up beds via referral from a GP. There are more than 140 community hospital services delivered by private providers across England; this includes Caterham Dene Hospital (CDH), Surrey.
The discharge medicines service (DMS) is one of several initiatives being implemented as part of the second year of the ‘NHS long-term plan’ to relieve the load on hospital A&E departments. NHS England and NHS Improvement made £1.2m available to ensure NHS trusts have appropriate software and functionality to send referrals to community pharmacies, but the funding is not available to private providers responsible for community hospital services. However, for the DMS service to strengthen and improve medicine safety across the NHS, there is a need to involve community hospital services run by private providers.
Following national guidance and support from Surrey Heartlands ICS releasing funding to First Community Health and Care — which provides NHS community healthcare services to people living in east Surrey and parts of West Sussex — the DMS service was implemented at Caterham Dene Hospital, a 28-bed community hospital, in mid-June 2022.
The use of PharmOutcomes enables a safe means of electronic transfer of information about medications between CDH and community pharmacies. During the medication reconciliation process at the point of admission, pharmacy staff explain to patients how they may benefit from a follow-up consultation with a community pharmacist using a bespoke DMS leaflet.
The suggested list of patients for referral to the DMS Service by NHS England are those that:
- Are taking high-risk medications;
- Have been initiated on respiratory medications (e.g. inhaler);
- Are on medication that requires monitoring or dose adjustment;
- Have been prescribed drugs with the potential to lead to dependence;
- Are using medications of which doses are altered or fluctuate over time;
- Are taking more than five medicines;
- Have started a new medication during hospital admission;
- Have had changes in medicines during hospital admission;
- Have had a new diagnosis of stroke or myocardial infarction;
- Need medicines support after discharge from the hospital.
- Have a learning disability.
Patients are informed that their community pharmacist will be notified of their medication information and contact details at discharge and will get in touch with them via telephone after they leave the hospital. Patient discharge summaries are reviewed by the pharmacist to determine whether there were changes in the patient’s medication prior to being discharged from East Surrey Hospital (ESH) to CDH and then to their home. The discharge summaries of 143 patients who were admitted to CDH from ESH and then discharged home between 15 June 2022 and 30 November 2022 were reviewed. Patients are prompted to choose their preferred pharmacy as the recipient of this electronic communication and this information is entered onto PharmOutcomes. After that, an electronic notification is sent to the preferred pharmacy at discharge. These referrals can be accepted or rejected, and when they are declined, the community pharmacist must complete or specify the reason. The referral status stays as “referred” if the patient’s preferred pharmacy does not accept the referral or take any further action.
Over the course of 6 months (June 2022 to November 2022), there were a total of 68 discharge referrals (48%), higher than the figure obtained during a previous research project published in the International Journal of Pharmacy Practice. In total, 31 of these referrals (45.6%) have been completed, 4 were accepted but not completed, and 31 referrals are outstanding. Most patients (n=61; 89.7%) referred were aged 75 years and above, 44 patients (64.7%) were female and 24 patients (35.3%) were male. All patients were asked to consent to their information being shared with their nominated pharmacy. When a patient is unable to provide consent, the patient’s next of kin was contacted to provide consent. Consent for referral was a mixture of patients (88.2%) and next of kin (11.8%), and 66 patients (97.1%) were referred owing to a change to medicines. Five referrals were rejected because they were either sent to the wrong pharmacy or the patient moved to another pharmacy; three were successfully re-referred to the correct patient’s nominated pharmacy. The outstanding referrals that are yet to be completed by the nominated pharmacy are mainly a result of the staffing level at the community pharmacy.
The limitation of this study is that most referrals are based on changes in medicines; however, it did not examine each referral to present data based on NHS England’s suggested list of patients for referral to the DMS. This is because most of the referrals were uploaded to PharmOutcomes by the pharmacy assistant after they are reviewed by the pharmacist.
The results support the findings of the study completed by First Community Health and Care that examined the need for DMS referral to be extended to private providers delivering a community hospital service. At present, high-risk patients may be missing out on vital assistance from their local pharmacy because more than 140 private providers operating community hospitals in England are not funded to deliver the DMS service.
Temitope Odetunde, head of medicines management, First Community Health and Care, Surrey
- 1The NHS Long Term Plan. NHS. 2019.https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ (accessed Dec 2022).
- 2NHS Discharge Medicines Service – Essential Service: Toolkit for pharmacy staff in community, primary and secondary care. NHS England. 2021.https://www.england.nhs.uk/publication/nhs-discharge-medicines-service-essential-service-toolkit-for-pharmacy-staff-in-community-primary-and-secondary-care/ (accessed Dec 2022).
- 3Odetunde T, Sunny O, Scott R. Introduction of the Discharge Medicines Service (DMS) at acute NHS trust, does this go far enough? International Journal of Pharmacy Practice. 2022.https://academic.oup.com/ijpp/article/30/Supplement_2/ii38/6854487 (accessed Dec 2022).