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Care homes

Care homes are better off with local pharmacies

When it comes to pharmacy services, care homes should consider the benefits of keeping it local.

Care homes should use local pharmacies

Source: Callie Jones

The sudden exit of pharmaceutical provider Pharmacy Plus from the care home market in the UK is still a matter of concern to pharmacists (The Pharmaceutical Journal  2014;292:522). Many local pharmacies should be applauded for stepping in to pick up the pieces with as little as two weeks’ notice. As the dust begins to settle, it will be interesting to see what the affected care homes will do next with respect to sourcing permanent pharmaceutical supply and clinical advice.

Residential and nursing homes should make use of local pharmacy services, which can provide the kind of personalised clinical input that national guidelines advise. Care homes provide long-term care for those unable to look after themselves, but many have now taken on additional roles in rehabilitation after acute illness and in palliative care. 

There are more than 20,000 care homes in the UK. It is a highly fragmented market dominated by four key players: Four Seasons, BUPA, HC-One and Barchester. Consolidation of the market is likely to happen rapidly in the next few years as increasing numbers of small care homes close their doors because of insurmountable debt.

Currently, the care home market is serviced mainly by national pharmacy chains, such as Boots and Lloyds. Some independent pharmacies will have care homes within their patient base, but some will choose not to for reasons such as workload and small profit margins.

Care homes in the UK, in numbers

Care homes, like many other businesses, are looking for ways to minimise costs and maximise profit while maintaining high standards of safe and effective care for their residents. For large national care home providers there is a desire to have central control over the local care homes that they own. T here is a tendency for the large national care home providers such as BUPA or Barchester to use a national multiple pharmacy provider.

As a distance-selling pharmacy that operated a hub-and-spoke type model to thousands of care homes, Pharmacy Plus could deliver a dispensing operation that was efficient, with substantial savings that could be passed on to the care home. As well as the obvious economies of scale associated with specialising, savings potentially include better margins as a result of bulk drug procurement and reduced staffing costs through automation and IT. Furthermore, it had the ability to provide care homes with multi-compartment compliance aids, because of its volume-based procurement capability, despite the controversy surrounding such devices. Throw in a free refrigerator, a fax machine, a drug trolley and the home was for the taking!

However, what is missing in this type of national arrangement is the personal relationship that can be nurtured between a care home and a local pharmacy, particularly in supporting the care home in a clinical capacity.

Medicines management in care homes has long been on the agenda but will be of increasing importance for everyone involved in care home medicine use, given the recent publication of National Institute for Health and Care Excellence (NICE) guidelines . The guidelines were introduced following two Department of Health reports: one in 2009 which revealed that around 7 in 10 residents in care homes could expect to experience an error in their medication at some point during their care, and a second report in 2012 which highlighted problems caused by poor use of monitored dosage systems and the lack of a multidisciplinary approach.

What is missing in this type of national arrangement is the personal relationship that can be nurtured between a care home and a local pharmacy, particularly in supporting the care home in a clinical capacity

The public quite rightly expects a higher standard of care and greater compassion in care homes. Yet implementation of these guidelines, which includes the care home having a medicines policy that is reviewed regularly, accurate and up to date records and medication reviews for each resident, will be more than challenging. As a consequence, many care homes will need more input from pharmacists to provide the level of support around medicines that NICE recommends. For community pharmacies, this presents a great opportunity for pharmacists to reach out to care homes in their local areas and build a compelling case to improve medicines management.

The business pitch to the care home needs to be about what the pharmacy can do for the local home. An honest and open dialogue with agreed objectives will help manage expectations and deliver desired outcomes.

Local pharmacy providers have several advantages over their national counterparts. The pharmacy can provide advice, training and support to care home staff on safer medicines management, as well as addressing any problems with medication in a timely and flexible manner. Local pharmacies tend to have the same people working there, allowing the pharmacy team and care home personnel to develop a relationship. Another advantage is the shorter distance required to deliver urgent medicines compared with a national pharmacy. Care home providers should consider the quality of service provided and not be persuaded by fancy brochures and slick presentations from national pharmacies.

Any misunderstandings between the pharmacy and the care home can be resolved quickly and openly at a local level. Provision of services can be closely monitored and reviewed. Quality is subsequently raised with fewer mistakes and reduced risk of having sanctions imposed by the Care Quality Commission (CQC), which checks whether hospitals, care homes, GPs, dentists and services in households are meeting national standards. This improved performance will increase the profitability of the care home. Indeed, the ‘Review of NHS Pharmaceutical Care of Patients in the Community in Scotland’ by Hamish Wilson and Nick Barber, published in August 2013, endorses the position that care homes should use a local pharmacy for all their pharmaceutical care.

If local pharmacies build trust with the care home, and hold regular meetings and audits, it will minimise the risk of the care home being enticed away by national pharmacies.

NICE advises that medicines reconciliation, a method where pharmacists check and amend patients’ drug prescriptions written by doctors in care homes, has the potential to reduce medication errors and reduce hospital admissions. Local pharmacy can make a real difference to medicines management. It can improve care for residents and enhance the reputation of the care home. So it makes good business sense for a care home to keep it local.

Mimi Lau is director of pharmacy services at Numark, a membership organisation for independent pharmacies.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20065903

Readers' comments (4)

  • Community pharmacies simply don't have the resources to dedicate pharmacist time to the levels suggested in this article when there is no corresponding funding for it.

    Perhaps care homes should employ their own pharmacist who can dedicate the time needed to undertake medicines reconciliation, pharmaceutical care and medicines optimisation on site in the care home?

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  • I am an ex. Hospital pharmacist now working as a clinical care home pharmacist in a CCG. I do med reviews for the frail and complex elderly patients found in care and nursing homes today. I would love care homes to use more local pharmacies. Every day I see why corporate tie ups between care home groups and multiples are not working. Corporate care home & pharmacy medicines policies often do not reflect current clinical, pharmaceutical or risk management evidence or practice and are very light on practical procedures to enable staff to consistently deliver safe care with medicines. Staff training and time resource to safely manage medicines is often insufficient resulting in medicines waste, errors and sometimes patient harm. I have often witnessed this lack of knowledge in homes extending up to regional level and beyond meaning homes are constantly fed incorrect information and poor practice.
    Speed of response for urgent medicines such as antibiotics is often poor when pharmacies are over an hour away with rigid delivery schedules which has resulted in unnecessary hospital admissions.

    I hope all concerned go back to the drawing board and use the latest NICE guidance to make their policies and proceedures fit for purpose, inline with the medicine needs of the residents they now care for and they reconsider how to best use the pharmaceutical expertise out in their local communites.
    E.g my residents - average age 90, meds 10, some with swallowing difficulites, dementia, lack of capacity, need for covert medicines and all who need prompt antibiotic delivery & administration to avoid hospital admission.

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  • Graham Phillips

    We are a small independent pharmacy group. As such we endorse both Tariq and Helen's comments.

    We aim to provide the sort of service that Helen rightly outlines; but we also face the hurdles that Tariq mentions and more. On top of that we find ourselves having to provide free trolleys, cupboards etc to compete with the large multiples. So there's an upfront investment of some £2000-£3000 before we have dispensed the first script, never-mind being paid for it!

    So what's the answer? There should be a national service spec based on the size and nature of the home - which would take account of Helen's points. ....But there should also be a matching remuneration structure funded either by the NHS or the home. Or we could simply continue as we are of course...
    Graham Phillips
    Supt Pharmacist
    Manor Pharmacy Group, Herts

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  • The generic drug shortages in the UK, Canada and elsewhere around the world were "Made in the USA" by the anticompetitive contracting and pricing practices of giant US hospital group purchasing organizations (GPOs). Check out our new website, www.physiciansagainstdrugshortages.com, which explains everything. It's the old story: when the US catches a cold, the rest of the world gets pneumonia. British officials need to pressure the Obama Administration to address this root cause of US shortages. Only then will the global marketplace return to normalcy.
    Phil Zweig MBA
    Executive Director
    Physicians Against Drug Shortages
    New York, NY

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