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Positive study data from new medicine service provide hope for extension

Adding mental health drugs and assessing the cost-effectiveness of the new medicine service were hot topics at a recent stakeholder meeting. Elizabeth Sukkar reports

“Patients who have experienced the new medicine service have been really quite positive about it,” according to Rachel Elliott, professor of medicine and health at the school of pharmacy at the University of Nottingham. She has been tasked with an important study, assessing the effectiveness of England’s NMS, which was launched in October 2011.

Based on the outcomes of the Department of Health-funded study, NHS England may decide either to drop the service or to extend it beyond the four existing conditions of asthma and chronic obstructive pulmonary disease, type 2 diabetes, antiplatelet/anticoagulant therapy and hypertension.

“Black triangle” drugs and treatments for mental health conditions seemed to be the favourites for inclusion in an expanded service at last week’s stakeholder meeting, hosted by the study team in London, and which involved regulators, NHS officials, pharmacy leaders and patients.

Funding has been secured for the NMS until September 2013, but the findings from the DoH evaluation will not be out until February 2014, a delay from the original summer 2013 deadline. The study team will finish recruiting patients at the end of September and will follow them for two months. Based on discussions at the meeting, there is an expectation that the DoH will extend funding until the study’s results are out.

The study is broadly in two parts: a technology appraisal involving a randomised clinical trial and cost-effectiveness analysis, and a qualitative workstream.

So far, the study team has qualitative results based on interviews with four pharmacists and 20 patients going through the service. It aims to interview 58 pharmacists in total and another five patients. Professor Elliott says: “What we are tending to see is that pharmacists are very keen to provide the service.

“The thing you find with community pharmacy services is that patients don’t tend to be very aware of them so they don’t necessarily demand them.”

She believes that what will happen with the NMS is that once patients have experienced it and realised they can have a different sort of relationship with their pharmacist, they will feel able to talk about their medicines in an open and honest way.

“I think that the whole crux of this intervention is trying to get people just to be honest about the problems they are having with their medicines,” she says.

NICE’s £30,000 question

One of the aims of the NMS is to reduce hospital admissions, something that the study team is measuring along with adherence at two months and resource use. However, Professor Elliott recognises that it can take a long time for non-adherence to turn into poor health. “For example, if you don’t use your asthma inhaler, you might have an asthma attack that week, so the link is quite noticeable. But in diabetes and hypertension, it can take up to five years for poor adherence to turn into a poor outcome.

“Therefore you would need to do a very long study. So what we’re doing is building economic models of each of the diseases to say, right, ‘this is the adherence rate we’re getting from the study, how does this translate into outcomes and costs?’,” she says.

When one thinks of cost-effectiveness in the NHS, one thinks about the National Institute for Health and Care Excellence’s £30,000 threshold for quality-adjusted life years (QALYs) gained and the study team is no different. “Obviously, if the service is going to be cost-effective, then the cost per extra QALY generated would have to be below £30,000. That’s the standard threshold for NICE… . But it might be that if we look at the individual diseases some will be more cost-effective than others.”

Professor Elliott agrees her research “is turning into an important study” because of the commissioning question, but are the qualitative data showing promise so far? The data are showing that when people have the service and can see the point and value of it, they want it again in the future. “What the data can’t show is whether the service improves patients’ medicines-taking behaviour.”

She adds: “If pharmacists deliver [the NMS] appropriately, then it does work. What we need to be able to do, though, is not just to have a service that is theoretically effective and cost-effective. It has got be something that pharmacists want and are able to deliver, and that other members of the health team want to happen as well… . Pharmacy does need to show more effectively that it is a clinical profession.”

The study team has bought the PharmOutcomes dataset, which was collected by the Pharmaceutical Services Negotiating Committee and contains data on NMS interventions for some 350,000 patients. It has done this because its randomised controlled trial contains only a small sample of patients, and having the dataset will help the study team work out how representative its work is. Professor Elliott estimates that probably half a million NMS interventions have been done so far.  

Future outlook

Sue Sharpe, PSNC chief executive, told The Journal that it is “working very hard” to try to secure the continuation of the NMS beyond September until the results of the DoH evaluation come out.

“Our own evaluation gives very strong indicators that it is going to be positive and its going to show its value for the NHS. Based on that then I would certainly hope we will be looking at quite a short time frame at its extension to other [therapeutic] areas. The key is going to be the healthcare economic outcome of that evaluation.”

Rob Darracott, chief executive of Pharmacy Voice, believes “the more we think about [the NMS] as a new service the more we create a barrier to changing the way we do things”.

Why do some pharmacies do it better than others? Mr Darracott answered: “Ultimately change is difficult. No profession stands still. All professions move on and you start to think about the fact that in five years’ time you will be doing something very different to what you do now. Some people get that straight away. Some people have a great early experience of knowing they’ve made a difference to somebody; other people find it harder.”

Crucially, for any NHS-funded service to take off, pharmacists need the resources and training support to aid them. Is there enough out there now?

Mr Darracott believes there is but “on occasion, a group of organisations who are helping to support this probably haven’t framed it for pharmacists in the way they need to hear it”.

Mike Holden, chief executive of the National Pharmacy Association, would like to see the NMS extended to a wider group of drugs. “Any drug that is initiated to treat a long-term condition should be considered.” He would also like to see the under 16s covered.

He is adamant that there “is nothing to say the NMS is stopping in September. We have got some interim data that are looking very positive from this study. And the data being captured from PharmOutcomes are showing benefit to the system.”

Mr Holden added that pharmaceutical care needs to be delivered well and rewarded appropriately. “The whole approach to how we support patients on the back of our supply system needs to be rethought so that we have a recurring support system that not only gives benefits to all patients with chronic conditions but also gives pharmacy owners and pharmacists who are delivering the service the appropriate reward for doing so.”

Christoper Cutts, director of the Centre for Pharmacy Postgraduate Education, agrees that if the NMS were to cover all medicines, then there would be a need to look at a skill mix approach. He suggested that depending on the risk associated with a medicine, then it does not necessarily have to be a pharmacist that does the follow up call, but a pharmacy technician could, for example.

“I think a staged [approach] would be better, because if we went to all medicines we would have to think about different payment mechanisms and things like that.”

Mr Cutts would also like to see pharmacists tailor the questions they use as part of the NMS. “There are still stories around of people using the questionnaire too rigidly.” He hopes pharmacists will revisit what they have learnt. People get into bad habits, he said. Every year or couple of years pharmacists should remind themselves what the aims of this service are and how they should do it.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11122564

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  • The NMS study website invites patients to get involved in the research

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