Think outside the box: replacing multicompartment compliance aids

In January 2019, Boots announced that it was changing the way it dispenses medicines to care homes — from multicompartment compliance aids (MCAs) to original packs.

The decision follows a similar move from LloydsPharmacy, and the news triggered a hugely positive response from The Pharmaceutical Journal readers — both on our website and Twitter. According to Boots, the change follows guidance from the National Institute for Health and Care Excellence and the Royal Pharmaceutical Society (RPS), which states that original packs should be used as standard. 

Further RPS guidance on MCAs says that the use of original packs of medicines with appropriate support is the preferred option and that each patient identified as having medicines adherence issues should have a “robust individual assessment” to identify the best intervention for them.

But this simply isn’t happening. Estimated figures seen by The
Pharmaceutical Journal suggest that millions of MCAs are being handed out each year in England, and that the majority of these are given to patients without an assessment taking place. In addition, putting together MCAs is a huge burden on pharmacy time. Studies suggest some pharmacies have reported having to prepare MCAs weeks in advance just to keep up, which can cause huge logistical problems when a patient’s medicines change. 

It is time that pharmacists and other healthcare providers look into safer and more effective alternatives to multicompartment compliance aids

Pharmacists are under constant pressure from GPs, carers and patients to continue to provide MCAs and they can be helpful for those whose adherence is hindered by cognitive impairment, forgetfulness or difficulties with managing multiple medicines. Care home resources are stretched and perhaps it is easier for nurses and care providers to rely on MCAs to dispense vast quantities of medicines every day.

But, in truth, the evidence of direct benefit from MCAs is scant. These devices may be adding to polypharmacy in older people; the evidence that MCAs can help improve medicine taking is poor and an investigation by The Pharmaceutical Journal has uncovered evidence that they are linked to errors and, in some cases, harm.

Our figures show in the first six months of 2018 alone, 507 patient safety instances involving the term ‘monitored dosage’ or ‘dosette box’ were reported to the NHS’s National Reporting and Learning System. Of these, 56 cases caused harm to some degree, although this is likely to be an underestimate.

We are still awaiting the final plan for NHS Improvement’s medicines safety programme, due to launch in April 2019, but medicines administration and care homes have been identified as priority areas. This could provide a crucial opportunity to look at why we continue to provide MCAs to patients in such vast quantities, despite a paucity of evidence for their benefit.

Given that the tide is starting to turn against MCAs, it is time that pharmacists and other healthcare providers look into safer and more effective alternatives. The placement of more pharmacists in care homes should help to improve the management of medicines in care homes and educate staff about the importance of optimising treatment. Schemes involving GP or community pharmacists working with patients in their own homes to improve adherence should also be considered as a solution.

Even the use of the word ‘compliance’ is old fashioned; it is time for a more holistic and patient-centred solution.