The role of a primary care pharmacist

Question 1

What is Medicine Optimisation

Answer 1

• Medicines optimisation looks at the value which medicines deliver
• Making sure they are clinically effective and cost-effective
• It is about ensuring people get the right choice of medicines, at the right time and are engaged in the process by their clinical team

Question 2

Medicines optimisation in real life

Answer 2

• Right drug
• Right dose
• Right patient
• Right time
• Everytime

Question 3

Why do medicines need managing

Answer 3

• Prescribing is the most common therapeutic intervention in the NHS
• The complexity, volume and cost of medicines are all increasing
• Medicines have the potential to do harm as well as be beneficial

Question 4

Medicines optimisation

Answer 4

• Patient safety is at the heart
• Cost-effectiveness
• Patient safety
• Greater choice for patients
• Better patient information
• Promote self-care
• Better access to services
• Improve health

Question 5

What is clinical governance

Answer 5

• A clinical governance is
  
  • A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical care will flourish

Question 6

Clinical governance foundation

Answer 6

• The foundations of clinical governance are
  
  • The setting of realistic and evidence-based standards of care
  • The monitoring of performance against these standards
  • The implementation of change to ensure that these standards are reached and if possible, exceeded

Question 7

The tools to achieve clinical governance in a healthcare setting

Answer 7

• Multidisciplinary clinical audit
• Clinical effectiveness
• Research & development
• Lifelong learning
• Risk management & critical incident reporting
• Evidence-based medicine/ practice
• Guidelines, pathways and protocols
• Service accreditation
• Individual appraisal and assessment
• Information management

Question 8

INSIGHT- CG in action (Community)

Answer 8

• Audit
• Chaperone policy
• Complaints procedures
• Confidentiality
• CPPQ (patient satisfaction survey)
• Patient safety incident reporting
• Practice leaflets
• Rasing concerns (whistle-blowing)

Question 9

INSIGHT- MI department

Answer 9

• Standards
• Audit programmes
• User satisfaction surveys
• Benchmarking schemes
• Evidence-based practice
• CPD
• Training programmes
• UKMi standards
• QA Visits
• MI user survey
• Workload survey
• Enquiry answering
• Personal CPD
• Advanced MI training

Question 10

What are the benefits

Answer 10

• Clinical governance improves not only the quality of patient care, but also efficiency and procedures
• It can therefore both enhance patient satisfaction and reduce costs
• Reduce risk to patient and the organisation

Question 11

When CG fails

Answer 11

Question 12

The mid Staffordshire NHS Foundation Trust Inquiry

Answer 12

• Concerns about mortality and the standard of care provided at the Mid Staffordshire NHS Foundation Trust resulted in an investigation by the Healthcare Commission (HCC) in 2007
• HCC report: poor standards of care
• Inquiry launched by government
• Francis report published on 5th Feb 2013
• Made a number of key recommendations

Question 13

The Mid Staffordshire NHS Foundation Trust Inquiry

Answer 13

• Implications for pharmacy
• Discharge management
• Governance

Question 14

What Influences GP decisions

Answer 14

• Clinical effectiveness of a drug
• Prescribers experience and knowledge
• Pharmaceutical industry
• Consultants and other GPs
• Patients
• Practice nurses
• Awareness of local and national guidlines/framework
• Formularies and choice of drug
• QIPP
• Prescribing Advisor

Question 15

Audit

Report on the prescribing of anti-psychotic drugs to people with dementia

Answer 15

• 11 recommednations suggested by Prof Banarjee
• Recommendations for PCTs and SHAs to review prescribing
• Major finding was a increase in number of patients with dementia dying whilst on anti-psychotic
• DoH response
  
  • All clinical decisions to prescribe anti-psychotic drugs to people with dementia should be taken on the best evidence available, with proprt regard to the existing NICE guidance
  • This guidance makes clear that people with dementia should only be offered anti-psychotics if they are severely distressed or there is an immediate risk of harm to the person or others

Question 16

Audit criteria for Prof Banarjee Report

Answer 16

• The records show that dementia patients have been prescribed an anti-psychotic for indications in accordance with NICE recommendations
• The records show that the patients indetified have an appropriate read code documented and are included on the practices dementia register
• The records show that dementia patients prescribed an anti-psychotic have had it reviewed in the last 3 months

Question 17

NHS response to Prof Banarjee report- In Practice

Answer 17

• Review of all patients on the dementia register or taking dementia medication
• Review of CV/Stroke risk
• Use of anti-psychotic in patients with dementia

1. Who initiated anti-psychotic? is it in line with licensed indication
2. Has patient/patient career been involved in discussion about pharmacotherapy
3. Referral to appropriate agencies

Question 18

Audit

Answer 18

• Step 1- Identification of potential patients for audit
• Step 2- Exclude patients who have a psychiatric diagnosis
• Step 3- Record total number of dementia patients to be audited
• Step 4- Identify whether patients are being prescribed antipsychotic medication
• Step 5- Record total number of dementia patients being prescribed antipsychotic medication
• Step 6- Elimination patients not being prescribed anti-psychotic medication and carry out a full review for dementia patients on antipsychotic medication

Question 19

The catalyst for change in practice

Answer 19

Question 20

Preliminary results

Answer 20

• Patient not listed on dementia register
• Patients have not had a CV/Cerebrovascular risk profile
• Patients have been prescribed antipsychotic outside licensed indications
• Patients have not been reviewed in line with a time frame
• GP response: dementia patients where the domain of secondary care and the assumption was that they would undertake a complete review

Question 21

Independent prescribing

Answer 21

• Many pharmacists undertake postgraduate study to qualify as an independent prescriber
• They can prescribe any medication legally
• Usually, adhere to their specialist area and scope of practice
• Patient facing role
• Clinical Examination and diagnosis
• Management of Long Term Conditions (LTC)
• E.g. Asthma/Diabetic/CKD/HTN

Question 22

Clinical pharmacists in general practice pilot

Answer 22

• Clinical pharmacists work as part of the general practice team to improve value and outcomes from medicnies
• This included providing eextra help to manage long-term conditions advice for those on multiple medicines and better access to health checks
• The role is pivotal to improving the quality of care and ensuring patients safety
• Having clinical pharmacists in GP practices means that GPs can focus their skills where they are most needed e.g. diagnosing and treating patients with more complex conditions

Question 23

PINCER

Answer 23

• Developed by the University of Nottingham
• The result of a trial, published in the Lancet, showed that the PINCER intervention is an effective method of reducing a range of clinically important and commonly made medication errors in primary care
• DoH has mandated that it is implemented by all health economies
• The aim of the PINCER quality improvement tool is to identify at risk patients who are being prescribed drugs that are commonly and consistenyl aassociated with medication errors

Question 24

additional prescribing roles

Answer 24

• Polypharmacy/Deprescribing reviews- these form part of a detailed medication review reviews
• Use a variety of tools to review patients on multiple medicines
• Target elderly patients
• Save money
• Better quality of life for patients

Question 25

What logistical function are there

Answer 25

• Implementation of safety alerts from MRHA e.g. Valproate in pregnancy
• Supply issues- shortages/interupted supply
• Prescribing dashboards- A measure to compare primary care organisations with each other in defined areas of prescribing
• Prescribing indicators- DoH produced an updated provider checklist of 50 efficiency measures to help NHS trusts, SHA’s and PCTs to deliver safer, more cost-effective prescribing
• CIP/Cost-effectiveness- cost improvement programmes

Question 26

Interface Issues and Roles

Answer 26

• HARMS- Hospital Admission Related to Medicines
• Medicines Reconciliation post discharge
• Formulary Adherence
• Guideline Development
• Area Prescribing Committees
• Interface issues e.g. Essential care agreements (ESCA’s)