Professor of the Practice of Pharmacy, Keele University School of Pharmacy, UK
Alan Hassey MSc MB BS DRCOG FRCGP
General Practitioner, Fisher Medical Centre, Skipton, UK
Patient Representative and Advocate for Explicit Standards in Health Care, UK.
Received date: 3 April 2007; Accepted date: 19 April 2007
Access to, and use of, medicines were key areas identified for improvement in the NHS Plan in 2000. In this discussion paper and in relation to the primary care setting we:consider the problems that patients have in accessing and using medicines review relevant initiatives in NHS policy and practice, and their effects propose standards for patient-centred medicines management
Every day 2.8 million prescription items on 1.3 million prescriptions are dispensed in primary care. Seventy percent of these are ‘repeat prescriptions’, which are repeated long-term prescriptions where the doctor does not necessarily review the patient. Recent years have seen concerted efforts to improve the quality of medicines management. (‘Medicines management is a system of processes and behaviours that determines how medicines are used by patients and by the NHS.’) The NHS Plan promised changes that would improve access to medicines and convenience in obtaining repeat prescriptions for patients. More recently, changes in NHS contracts for general practice and community pharmacists have increased the emphasis on good medicines management. Finally, the concept of information as therapy and the development of NHS information prescriptions offer the opportunity for better patient access to information about medi-cines. Taken together, these changes have considerable potential to improve healthcare quality. But looked at from a patient’s perspective how does the quality of the service measure up in 2007?
Problems with repeat medicines
The lack of research on the problems that patients experience in relation to repeat prescriptions is note-worthy. However, in 2002 the local teams of clinicians and managers participating in the national Medicines Management Services Collaborative (MMSC) ident-ified the following areas for improvement based on analysis of their own practices and patients:
improvement of general practitioner (GP) com-puter and repeat prescribing systems
better prescription collection and delivery services
development of concordance between patients and healthcare professionals.
Patients also experience more basic practical prob-lems; these are summarised in Box 1, with some examples in patients’ own words in Box 2.
The prevalence of these problems is difficult to estab-lish. Some practitioners argue that the low level of complaints from their patients about these issues must mean that they are not perceived as a real problem by patients. However, patients may have low expectations of the system based on their previous experience and assume that is just ‘how things are’. The ‘cost’ in terms of time and inconvenience to patients is not always recognised or thought about as a cost by clinicians.
One study found that there was misalignment in repeat intervals for prescriptions of one in five older people. Unintentional changes to medicines follow-ing hospital discharge for a substantial proportion of patients have been reported in several studies. There is widespread acknowledgement that patients might not be taking the medicines the clinician thinks they are taking. In one area a nurse has been seeing patients identified as being at risk of avoidable hospital ad-missions during 2007. When she talked with patients in their own homes she compared the medicines and doses they were actually taking with what the practice records showed they should be taking (often eight, nine or ten medicines). There was not a single case where the two lists were the same.
Patients’ understanding of their condition and the medicines used to treat it may not be as complete as clinicians sometimes think, exemplified by a study in diabetes which showed a lack of understanding about treatment in type 2 diabetes. One in five patients thought it was not very important to take their medicines and was unaware of the complications of diabetes. For many patients the manufacturer’s leaf-let in the medicines pack may be the only piece of information received. A recent review has shown that many patients do not value these leaflets and want information more tailored to their needs, including information about their condition as well as the treat-ment. The same review found consistent evidence that patients want to know more about the side-effects of medicines, but many side-effects are never discussed with the GP and only 1% are aware that patients can report them on a yellow card. Patients’ wishes to know more about their condition and treatment are well illustrated in the findings of the 2006 national survey of people with diabetes. Almost a quarter said they had not received sufficient information at the time their diabetes was diagnosed. When a medicine is prescribed for the first time patients need explanation, informa-tion, and the opportunity for discussion. However, many GPs and nurses find it difficult to allocate suf-ficient time for this in routine consultations. A recent randomised controlled trial found that proactive com-munity pharmacist follow-up by telephone with patient-centred advice increased adherence and reduced medi-cine-related problems. The simple questions used by the pharmacist began with ‘How are you getting on with your medicines?’ before asking more specifically about any problems with the new medicine, how the patient was taking it and whether they had any questions about it.
Changes in NHS policy and their effects
In 2000 The NHS Plan made a series of commitments relating to repeat medicines (see Table 1).
Progress is more advanced in some areas than others, and some interdependencies have emerged. The Electronic Prescriptions Service (EPS), for example, has the potential to enable fuller implementation of other services such as repeat dispensing. Currently most practices and pharmacies have to use a cumber-some system of hard-copy prescriptions and records for repeat dispensing. It is therefore perhaps not surprising that in 2006 only 0.7% of prescription items in England were dispensed through repeat dispensing.
The Department of Health is introducing infor-mation prescriptions, and a set of pilots will be evaluated before a future service is specified. One pilot specifically deals with information about medicines for children across hospital and primary care. The government’s recently announced NHS Choices website will offer, among other things, ‘Access to a vast library of approved medical literature, previously only avail-able to clinicians, to enable a deeper understanding of conditions & treatment options’.
Primary care contractual changes
Both the revised ‘new General Medical Services’ (nGMS) contract and its Quality and Outcomes Framework (QOF) in 2004 and the new Community Pharmacy Contractual Framework (CPCF) in 2005 included several requirements and incentives relating to medi-cines management (see Box 3).
Table 1: Commitments made in The NHS Plan and progress by 2007
‘Transfer of prescription data between GPs, pharmacies and the Prescription Pricing Authority will be carried out electronically, using the NHSNet, in the large majority of cases by 2008, or even earlier.’
National roll-out began in 2005. By March 2007 the Electronic Prescriptions Service (EPS)a using Release 1 systems was responsible for ‘over 8% of daily prescription messages’ and ‘1669 practices were actively operating EPS’. Later in 2007 ‘initial implementer’ primary care trusts (PCTs) will use Release 2 systems prior to full roll-out in 2008. Thus by the end of 2008 patients should be able to nominate a pharmacy where their prescriptions will be sent electronically. Repeat dispensing will then become more feasible to implement on a wider scale.
The introduction this year (2000) of ‘‘Patient Group Directions’’, which enable nurses and other professionals to supply medicines to patients according to protocols authorised by a doctor and a pharmacist.
Patient Group Directions (PGDs) are now widely used in primary care, e.g. practices; walk-in centres; community pharmacies.
‘By 2004 a majority of nurses should be able to prescribe'.
Independent prescribing by nurses and pharmacists is now established with flexibility to prescribe any medicine from the British National Formulary according to individual competence.
‘... a wider range of over-the-counter medicines available.’
Several key medicines have been switched from prescription-only medicines (POM) to P (pharmacy), mainly for self-limiting acute problems (e.g. chloramphenicol eye drops).
‘By 2004 every primary care group or trust will have schemes in place so that people get more help from pharmacists in using their medicines.’
New pharmacy contract was introduced in 2005 with repeat dispensing as an ‘essential’ and medicines use review (MUR) as an ‘advanced’ service.
‘By 2004 there will be repeat dispensing schemes nationwide to make obtaining repeat prescriptions easier for patients with chronic conditions.’
‘NHS Direct nurses will be in regular contact to help patients manage their medicines and check that older people living alone are all right.’
At the end of 2006 repeat dispensing schemes were operating in many PCTs but only involved 0.7% of prescription items.
NHS Direct ‘is keen to develop ... these [interactive digital TV] and online services further’ to support people with long-term conditions.
a EPS, formerly Electronic Transfer of Prescriptions, ETP.
The GMS QOF introduced the first standards for prescription ordering and collection, and for medi-cation review:
The number of hours from requesting a prescrip-tion to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays)
a medication review is recorded in the notes in the preceding 15 months for all patients being pre-scribed four or more repeat medicines (excluding over-the-counter (OTC) and topical medications): standard 80%.
More patients do now have their medicines reviewed and the Medicines Management Services Collaborative made this a key area of work from its inception, which pre-dated the QOF by several years. There are different types of review, not all of which involve the patient or carer. Ideally the patient or carer will be involved in the review. This is not a requirement of the QOF, and practices are likely to prioritise cases where face-to-face discussion is likely to be of particular benefit (for example multiple medical conditions and medicines, patients frequently admitted to hospital, and those in residential or nursing home settings). Medicines use review (MUR) by community pharmacists is intended to focus on practical aspects of medicines use, provide education to increase patients’ understanding of their medicines, and to act as a filter for identifying patients who might need a clinical medication review from the GP or practice pharmacist. However, evidence so far suggests that MUR is not yet sufficiently integrated into primary care in a number of ways. GPs and primary care nurses can refer patients to a local com-munity pharmacist for a MUR where, for example, a new medicine has been started and the clinician perceives a need for further education and informa-tion, or a patient is taking several medicines and they seem to be having problems in managing them.
Other changes have been introduced by local prac-titioners to meet patients’ needs. When compared with the situation in 2000:
prescription ordering using email and fax has been introduced by some practices
prescription collection arrangements between phar-macies and surgeries are much more widespread
prescription delivery is offered by many phar-macies
information leaflets are now offered by many sur-geries using the practice computer system.
There are no figures on the extent of changes in prescription-ordering methods in practices. Some practices are wary of introducing email or faxed requests, for safety reasons. Anecdotally, a high proportion of repeat prescriptions are now dealt with within existing informal collection and delivery arrangements. This should make the process of nominating a preferred pharmacy for the EPS straightforward for many patients. Although there are professional standards for pre-scription-collection services, these do not include a minimum time in which the collected prescription will be dispensed. Prescription delivery is offered by many community pharmacy services in response to patient need, and its costs are met by pharmacies, with no contribution from the NHS. Unsurprisingly not all pharmacies offer the service and since it is not an NHS service there are no nationally agreed criteria to define who should be eligible to have their medicines delivered. Pharmacies tend to operate informal criteria and offer the service to patients who are housebound or who have mobility problems. There are no data on the extent of usage of information leaflets by practices. A small study found variability between practices and between individual clinicians within practices.
In Box 4 we set out a list of possible standards for discussion and local adaptation.16 Achieving quality in medicines management is only possible through local collaboration between general practice, community
pharmacy and other settings where medicines are prescribed (e.g. walk-in centres) in primary care. Input from patients is needed to identify local issues and discuss possible solutions. Those practices that do not have a patient participation group can find alternative ways of achieving this.
A set of possible survey questions to assess areas where standards are met or not met is listed in Box 5.
Medicines management in primary care has improved in many respects since the publication of The NHS Plan in 2000. Primary care teams could adapt and use our proposed patient-centred standards, audit current performance and work with patients towards im-provement in the areas identified.
We would like to thank Julia Bundock, specialist primary care nurse, for her comments on the draft article