Report finds new medicine service improves treatment adherence and saves NHS money
The new medicine service is cost effective and increases the number of patients who are adherent to their medicines by around 10%.
Source: Photofusion / Rex Features
A service delivered by community pharmacists that helps patients take new medicines effectively has been found to increase the number of patients who are adherent to their treatment by about 10%.
The authors of a long-awaited report, ‘Understanding and appraising the new medicines service in the NHS in England’, recommend that the new medicine service (NMS) should continue to be funded by the NHS.
The NMS is performed by community pharmacists when a patient is prescribed a new medicine for one of four therapy areas – hypertension, type II diabetes, anticoagulation/antiplatelet therapy and asthma/chronic obstructive pulmonary disease. Around 7 to 14 days after the patient presents at the pharmacy with the prescription, the pharmacist offers a consultation to find out if the patient is having any problems taking their medicine and provides support to remove any barriers to adherence.
The Department of Health (DH) initiated the NMS in 2011 to address the problem of poor adherence to medicines, which is considered a major public health concern. The report’s authors highlight that 25% of medicines for long-term conditions are not taken as directed. For conditions like diabetes, poor adherence can be up to 78%, they say.
The DH commissioned an evaluation of the service in 2012 to help determine if it should continue to be funded by the NHS. A research team led by the University of Nottingham, in collaboration with University College London, were awarded a grant to carry out the evaluation, which included conducting a randomised controlled trial of the service.
The results show that since the implementation of the service there has been wide adoption by community pharmacy, with 91.2% of community pharmacies conducting at least one NMS.
Pharmacists are paid £24.60 each time they conduct the NMS. In the financial year 2013–2014 there were 763,401 NMS interventions performed according to the NHS Business Services Authority, costing NHS England £19m.
“The NHS is constantly challenged to provide evidence of the effectiveness of interventions,” says David Branford, chairman of the Royal Pharmaceutical Society’s (RPS) English Pharmacy Board. “Here we have a rigorous and thorough piece of work that leaves me in no doubt that this service is benefitting patients through improved use of medicines as well as saving money through fewer hospital admissions.”
Branford wants to see the service expand. “People with depression and dementia would be a wise place to start a wider roll out of the NMS to patients.”
This sentiment is mirrored by Gary Warner, chairman of the service development subcommittee of the Pharmaceutical Services Negotiating Committee (PSNC), which negotiates with NHS England on behalf of pharmacy contractors.
“It has been a massive success, now let’s see it expanded out to other disease areas and patient groups; this is what I’ll be saying to NHS England,” he says.
“We will be using the outcomes to inform our ongoing negotiations with NHS Employers (who are acting on behalf of NHS England),” explains Sue Sharpe, chief executive of the PSNC. “Given the results, we are of course optimistic about the future development of the service. We expect an announcement to be made when the whole package has been agreed.”
Since the decision to commission the evaluation, responsibility for funding the service has shifted from the DH to NHS England. But because funding negotiations over the pharmacy contract are still ongoing, NHS England says it cannot comment on the report.
But Keith Ridge, chief pharmaceutical officer at NHS England, was positive.
“We now need to explore with clinical commissioning groups how this service can be linked into pathways of care, including whether there are other options to enhance the service further,” he says. “For example, how clinical pharmacists in GP practices can contribute to improved patient care, linking with their community pharmacy and hospital colleagues.”
New medicines service intervention
Randomised control trial shows NMS improves adherence
Patients in the randomised control trial received either “current practice” care from the pharmacy or the NMS. Adherence to medication was assessed after ten weeks. Adherence to treatment was 64.9% in the current practice group and 74.7% in the NMS group (95% confidence interval 1.09–2.58; P=0.018), including patients who switched or stopped medicines after advice from their healthcare professional. When the analysis was restricted just to patients who continued with the same medication, 60.5% were adhering to their medicine in the current practice group, compared with 70.7% in the NMS group (95% CI 1.06–2.62; P=0.027).
The researchers used data on the effects of adherence to treatment to model the long-term effects of the difference between the patient groups.
“For example, not taking your antihypertensives can lead to higher blood pressure, which can lead to stroke and lower quality of life,” says Rachel Elliot, Lord Trent professor of medicines and health at University of Nottingham, who led the study. “We modelled the long-term effects based on probabilities of outcomes that were based on levels of adherence in both arms.”
Among the patients classified as adherent, the researchers are assuming an 80% adherence level and in the non-adherent group, a 50-60% adherence level. “So actually the differences in adherence levels are quite small, but on a population level, this can make a big difference,” says Elliot.
Using this information, the researchers calculated that for each patient taking part in the NMS, the NHS saves £190 and the person gains 0.06 Quality Adjusted Life Years (QALYs) — QALYs are used as a measure of the state of health of a person by the National Institute for Health and Care Excellence (NICE) to assess health gains from a new technology. For comparison, a 65-year-old man with moderate hypertension and mild to moderate chronic kidney disease who is prescribed a statin will gain 0.10 QALYs. One QALY is equal to one year in perfect health. Looking at the NMS service, it was found that for each QALY gained on a population level, the NHS saves £3,005; the threshold for implementation of a technology is usually a cost per QALY of £20,000.
“In the long term, our economic evaluation suggests that it is likely that NMS will deliver better outcomes at overall reduced cost per QALY well below most accepted thresholds for technology implementation,” the researchers’ report says.
Health economist, Sam Keeping, researcher at London School of Economics Health and Social Care, says that the study seems robust and that the NMS appears to be a good example of how delivering care in novel ways and settings has the potential to deliver savings for the NHS.
Elliot explains that the cost to the NHS is less for NMS patients because their economic model predicts that these patients will have fewer adverse events and so will make fewer contacts with the health service than patients who did not receive the service. Even during the ten weeks of the study, it was found that patients visited their GP fewer times and so delivering the NMS was cheaper. However, the study was not designed to show differences in use of NHS services during the ten weeks that it was conducted, but rather to model outcomes in the future based on adherence — adverse effects from not taking medication sometimes do not happen for years, says Elliot.
The pharmacist needs to provide a package of care over a period of time. It’s about ongoing patient management
None the less, the finding that the service improved adherence and reduced burden on the NHS was welcomed by the Royal College of General Practitioners (RCGP).
“Patients have a lot to gain from the NMS,” says RCGP chairman Maureen Baker. “The RCGP has recently warned that half of all adults in England find the health advice given to them by doctors and health professionals too complicated – including instructions on how to take medication appropriately. And so we are optimistic that this study shows the NMS to significantly increase patients’ adherence to their new medicine.”
She adds that the study makes it clear how important it is for GPs to work closely with pharmacists, one of the key recommendations from the study.
“A lot of pharmacists and patients liked the service, but it needs to be much better integrated into primary care in general — virtually none of the patients were referred by their GP and GPs weren’t very aware of the service,” says Elliot.
Warner argues that the service needs to be both integrated into primary care and more longitudinal. “This means that the pharmacist is providing a continuing package of care over a period of time, rather than discreet services such as the NMS, medicines use reviews or dispensing,” he says. “It’s about ongoing patient management that doesn’t cease after the service is completed.”
Elliot believes the service could be extended to other diseases. “It is interesting that the effectiveness of the intervention was the same across the different diseases, which is an encouraging finding,” she says. “It shows that the NMS is applicable to other areas. Plus, we had much higher withdrawal from the study in the current practice arm; it shows patients seem to like the NMS.”
Mental health is one of the areas that the report recommends could benefit from the NMS. Warner agrees. “Antidepressants are a good example; they take three weeks to work and often by week two the patient may be experiencing side effects without any benefit and become disengaged from their treatment,” he says. “This is when the pharmacist can step in.”
But Warner goes further, arguing that there should now be a move towards all patients with long-term conditions being offered the NMS.
One of the unexpected outcomes from the evaluation was that patients who received the NMS through a small multiple were twice as likely to be adherent to their medication as patients who were given the NMS through an independent pharmacy.
“We weren’t expecting to find that small multiples were better,” says Elliot. She explains that one of the small multiple pharmacies involved in the study recruited 99 patients out of a total of just over 500, which may have skewed the findings. In addition, the study was not powered to identify differences between types of pharmacies.
As part of the evaluation, the researchers observed how the NMS was conducted in 23 pharmacies, as well as interviewing patients and pharmacists.
“The most successful pharmacies were very good at team working which allowed them to accommodate services — they were flexible with good communications skills,” says Elliott. “This is not necessarily specific to a type of pharmacy.”
In addition, she adds that patients seemed to volunteer more information to the pharmacist when the consultation had a less rigid format. “Listening to patients is something healthcare professionals can struggle with, but it is really important,” she says.
The report also recommends allowing access to patients’ records, which could help facilitate the advice given to patients.
Panel 1 How the trial was conducted
Community pharmacies in the East Midlands, South Yorkshire and London were recruited to take part in the study. A total of 61 pharmacies participated, although four withdrew after study initiation.
Pharmacists recruited patients when they presented at the pharmacy with a prescription for a new medicine. After accepting the invitation to take part, the patients were randomised to receive either current practice (n=253) or the new medicines service (n=251).
Current practice was the normal supply and advice associated with presentation of a prescription for a new medicine for a long-term condition and did not exclude patients from contacting the pharmacist or another healthcare professional if they wished.
The primary outcome of the study was patients’ adherence to their medicine. Adherence was measured at week 6 and week 10 by telephone interview and by using the Morisky’s medication adherence scale 8-item version and the Visual Analogues Scale, assessed by self-completed postal questionnaire.
During the telephone interview patients were asked: “People often miss taking doses of their medicines, for a wide range of reasons. Have you missed any doses of your medicine, or changed when you take it?”
Secondary outcomes were patients’ understanding of their medicines, health status and healthcare costs.
Qualitative research was conducted to assess if the service was well received by patients and healthcare professionals. Interviews were carried out with 47 pharmacists, 19 patients and 11 GPs, and 23 pharmacies were profiled.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20066177
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