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Pharmacy practice

Recognising excellence through changing times

How relevant is the concept of pharmaceutical care some 22 years since the first Pharmaceutical Care Awards?

Source: Nadia Attura

Research pharmacist Ruth Miller discusses her winning project at this years care awards held in London in June

In July 1992 the winners of the inaugural Pharmaceutical Care Awards were announced at the Savoy Hotel in London. The awards were established to acknowledge developments in pharmacy services and to advance the relatively new concept of pharmaceutical care, which had stemmed from the work of US pharmacists, Douglas Hepler and Linda Strand.

This year’s event, supported by GlaxoSmithKline, was held on 19 June at the Royal Institution in London. Although the format has changed over the years — the ceremony is now an interactive evening of poster displays, on-stage interviews and a live vote, the purpose of the awards remains the same: recognition of excellence in pharmaceutical care.

In the 22 years since the awards were introduced, healthcare in the UK and the roles of pharmacy teams have changed substantially. The NHS is organised differently, pharmacy chains continue to grow and pharmacists can now practise as prescribers. Serious failings in care provided to NHS patients have also come to light. So, how has pharmaceutical care held up amidst these developments? And in what direction is it heading?

Change in context, not concept

“The concept of pharmaceutical care has not changed, but the context in which it is now delivered is always changing,” remarks Carmel Darcy, who is a consultant pharmacist for older people in Derry, Northern Ireland and a member of this year’s winning team. She explains that twenty years ago a patient would have stayed in an acute hospital bed for around three weeks, but now the turnover is much faster. The challenges with this, she adds, are finding the time to deliver the same patient outcomes and improving quality of life, but doing so as the patient moves at high speed across interfaces.

The contributions to pharmaceutical care that Darcy has made in her role as a consultant pharmacist – the first one in Northern Ireland – formed the basis of the project that she and her colleagues from Western Health and Social Care Trust entered in this year’s awards. The judging panel chose their work as the best entry out of six finalist teams.

It takes a certain degree of courage to review medicines and actually discontinue them.

The team has developed a consultant pharmacist-led case management service for older people in intermediate care, under which the pharmacist takes responsibility for patients admitted into intermediate care after an acute admission to hospital. The patients are case managed until discharge and for at least one month after. Darcy and her colleagues believe the provision of high quality pharmaceutical care across two interfaces in healthcare was the innovative element of their project that helped secure the win.

David Campbell, chief pharmacist at Northumbria Healthcare NHS Foundation Trust (NHNFT), also believes that the context of pharmaceutical care has changed. “I think pharmaceutical care has developed as the pharmacy profession in the UK has developed,” he explains. “Twenty years ago we did not have pharmacist prescribers. Doctors made the decisions and pharmacists were often peripheral to that. Now, pharmacists are much more autonomous and involved; they are talking to patients and making decisions with them. The pharmacist’s clinical role has matured within the modern clinical setting.” 

Campbell and his NHNFT colleagues were also finalists at this year’s Pharmaceutical Care Awards. Their project, the development of a framework for multidisciplinary review of medicines for care home residents, was voted by the audience as the project which best lent itself to replication elsewhere.

Patient focused

Central to the NHNFT team’s project was the involvement of patients and their families in decisions about their medicines – something that Campbell does not believe is done universally across the UK. “Despite [shared decision making] being something that should just happen, we all know that it doesn’t always happen. “Our healthcare system now encourages patient choice and patient involvement,” he says. “This resonates with our project and I think this is an element that is manifested in what pharmaceutical care means today.”

Matthew Shaw, deputy director of the Centre for Pharmacy Postgraduate Education, agrees that the pharmaceutical care model has changed over the past 20 years to promote greater patient engagement. “We have more respect of patients’ involvement in their healthcare,” Shaw says. “Pharmaceutical care is not just something that a pharmacist provides to a patient. It is a shared relationship in which a pharmacist shares his or her expertise on medicines, patients share their expertise of themselves and together they come up with a plan that will work.”

According to Shaw, who was on the judging panel, it was this approach to patient care that made the Northern Ireland winning project stand out. “The project took the pharmaceutical care model forward from an individual level to one in which a consultant pharmacist takes overall responsibility for a group of patients.”

Confident and competent

Shaw helped shortlist the 31 entries the Royal Pharmaceutical Society received for this year’s awards. “This year we saw pharmacists starting to think proactively,” he reflects. “We also saw an ongoing recognition that, for pharmaceutical care to excel, we need to step outside our normal boundaries. The team from NHNFT did this: they saw a job that needed to be done and used what they knew worked in hospital and applied it to a care home setting.”

NHNFT’s David Campbell adds: “We wanted to demonstrate the importance of the intervention and how a significant proportion of residents in care homes have got the capacity to be making decisions about their medicines.” 

“We identified an issue, came up with a solution and provided the leadership to improve the care of this group of patients … I think this is a key message for all pharmacists. 

Campbell and his colleagues designed multiple models for conducting multidisciplinary meetings about residents’ medicines in care homes. In one such model, pharmacist prescribers made prescribing decisions in place of a GP. The primary outcome of the service was to optimise medicines use, which often involves stopping medicines.

“It takes a certain degree of courage to review medicines and actually discontinue them, and I think this is a great example of what modern pharmaceutical care is all about,” he says. “It is not about trying to address issues that have been determined by someone else, but instead providing a full package of care tailored to each patient’s needs. It’s what I now understand to define the extent of the pharmacist’s role in delivering medicines optimisation” 

“I had very confident and competent clinical staff in my team delivering this project, who were able to do this sort of work. I recognise that not everybody will necessarily have their skills, but the model of patient involvement in decision-making we developed and tested can, and should, be used more widely, indeed it should become standard practice.”

Darcy, too, believes that for pharmacists to have the confidence to work at a higher level they need to be trained as clinical practitioners. “Strategically, we also need to look at the skill mix of our workforce. We need to continue to up-skill technical staff to perform medicines management and free pharmacists to deliver a more focused clinical role.”

Spreading innovation

Often a barrier to innovation is funding. Half of the audience members at the care awards who responded to a request for feedback, agreed that money was the biggest challenge when undertaking service improvements.

Both of this year’s winning teams had received funding to support their work. Darcy and her team at WHSCT were funded for two years through the Northern Ireland Department of Health, Social Services and Public Safety’s “regional innovations in medicines management” programme, and Campbell’s team at NHNFT were funded by the Health Foundation SHINE programme.

However, it seems that having the funding to support innovation is only part of the solution. “The report ‘Innovation health and wealth’ in 2012 was quite critical of the health service for being slow to adopt good practice,” says Campbell. He suggests that improved collaboration, better sharing of evidence and learning between the professions and across sectors within pharmacy will help to overcome some of the barriers that exist to delivering optimal patient care.

Darcy says that having access to pharmacists with research expertise and using clinical interventions that have been proven to work are crucial in getting new services off the ground: “Build in a robust and focused evaluation of your service and plan for the time this will take,” she advises. “The application of validated research methods was guided by our research pharmacist and allowed us to undertake a robust evaluation of our service.”

Her comments echoed those of John Cromarty, chairman of the RPS Scottish Pharmacy Board, in his closing remarks at the event. “It is really good to see previously validated methodologies being used in studies to give them that robust edge,” Cromarty declared. “We have also seen a range both of quantitative and qualitative research assisting in the evaluation of these projects.” 

Here to stay?

When the Pharmaceutical Care Awards were launched, it would have been difficult to predict how the concept would grow in the following two decades. But, recalling the winning entry from 1992 – a community pharmacy that sought to enhance the clinical service available to its users by supporting further education for its staff – the pinnacle of pharmaceutical care at the time is now fairly embedded in practice.

It is to be hoped that the successful elements of this year’s winning projects will be considered routine 20 years from now.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20065586

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