{"id":42461,"date":"2018-06-26T12:22:09","date_gmt":"2018-06-26T11:22:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=42461"},"modified":"2018-07-06T16:44:54","modified_gmt":"2018-07-06T15:44:54","slug":"time-pharmacist-support-general-practice-improve-medicines-optimisation","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2018\/06\/26\/time-pharmacist-support-general-practice-improve-medicines-optimisation\/","title":{"rendered":"Time and pharmacist support in general practice are needed to improve medicines optimisation"},"content":{"rendered":"<p class=\"standfirst\">More time and pharmacist support in general practice would reduce medication errors<\/p>\n<p><!--more-->Many doctors are aware that medication errors pose a serious threat to their patients and that this needs to be addressed. Many are aware that it is a growing, complex, overwhelming, and stressful problem. Some striking statistics <a href=\"http:\/\/www.eepru.org.uk\/prevalence-and-economic-burden-of-medication-errors-in-the-nhs-in-england-2\/\">published earlier this year<\/a>,<span class=\"c0\">\u00a0and widely shared by the mainstream media, shed light on the scale of the problem:<\/span><\/p>\n<ul class=\"c10 lst-kix_3gy9vnhoq2am-0 start\">\n<li class=\"c3 c5\"><span class=\"c0\">An estimated 237 million medication errors occur in England every year.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0\">An estimated 712 deaths in England occur every year from medication errors.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0\">One in 20 prescriptions has an error.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0\">One in 550 is a serious error.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0\">Errors are more likely to occur in medications for older people and patients with multiple conditions who are using many drugs (polypharmacy). <\/span><\/li>\n<\/ul>\n<p class=\"c3\"><span class=\"c0\">Given this, the management of polypharmacy could be seen as a new type of specialism that has to be embraced in an already overloaded work schedule.<\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">Exacerbating the problem is that while life expectancy has grown steadily since the 1980s (the projected life expectancy in 2039 is 96 for women and 93 for men), healthy life expectancy is not increasing as steadily. This means more people living longer, but with a growing proportion of that time in poor health. This increase in the number of patients with long term conditions increases the amount of polypharmacy. <\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">Also relevant is that the ageing body becomes less able to metabolise medicines safely. Prescribers need much greater awareness of the importance of a patient\u2019s weight and liver function, and to take more detailed assessments of renal function than is standard practice in consultations.<\/span><\/p>\n<p id=\"h.gjdgxs\" class=\"c3\">The Royal College of General Practitioners (RCGP) has called for older patients to have support to manage their medication. <a href=\"http:\/\/www.rcgp.org.uk\/-\/media\/Files\/Policy\/A-Z-policy\/RCGP-Responding-to-needs-of-Multimorbitiy-2016.ashx?la=en\">One recommendation<\/a> is to prioritise the care of patients living with multiple long term conditions by adopting face-to-face dedicated medicines reviews, which incorporate the skills of GPs and practice based pharmacists. There&#8217;s already a growing inclusion and acceptance of practice based pharmacists. And <a href=\"http:\/\/bjgp.org\/content\/68\/667\/85\">from our experience<\/a>, a practice based pharmacist has improved our confidence to raise the quality of our prescribing and manage day to day problems that arise in the practice. In addition, the new <a href=\"https:\/\/www.nhsbsa.nhs.uk\/epact2\/epact2-dashboardsspecifications\/medicines-optimisation-polypharmacy\">ePACT2 polypharmacy prescribing comparator datasets<\/a><span class=\"c0\">\u00a0allow much easier ways for practices to benchmark and identify patients most at risk.<\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">It now seems sensible to propose that the routine management of polypharmacy should be \u201cowned\u201d in primary care. This is where the holistic overview of patients in their own environment (which is key) can best take place. It cannot be managed in hospital silos.<\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">Ongoing professional development for all clinicians in primary care needs to place greater emphasis on developing capability for this task. Generating new knowledge, coping with change, and improving efficiency are all essential requirements for the effective management of polypharmacy and reducing medication errors.<\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">While many practices are already striving to achieve this, we think that giving practices support so they become medicines optimisation \u201caware\u201d would help develop understanding of key prescribing issues and the implementation of improved medicines optimisation processes. This model is already proven for dementia friendly practices; for example, in Wessex. <\/span><\/p>\n<p class=\"c3\"><span class=\"c0 c2\">A medicines optimisation &#8220;aware&#8221; practice would, for example:<\/span><\/p>\n<ul class=\"c10 lst-kix_9mbsc16horq9-0 start\">\n<li class=\"c3 c5\"><span class=\"c0 c2\">Show awareness of\u2014and implement a prescribing guidance policy for the practice that takes account of\u2014polypharmacy and &#8220;red flag&#8221; high risk medications. In particular, those that contribute to preventable hospital admissions (NSAIDS, anticoagulants, antiplatelets, diuretics); those that should be prescribed with extreme caution in older people; and those that risk prescribed drug dependency. The guidance should also have clear processes for managing national medication alerts, eg from the\u00a0Medicines and Healthcare Products Regulatory Agency.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0 c2\">Show awareness of\u2014and pragmatically deploy\u2014stratification tools, such as PINCER, PRIMIS, and ePACT2, to identify patients at the greatest risk of harm from medicines.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0 c2\">Record body weight and renal function as a minimum requirement in all reviews of patients with a long term condition. \u00a0<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0 c2\">Provide an annual learning update for all clinicians about the risks of inappropriate polypharmacy and practical de-prescribing tips and techniques.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0 c2\">Have a clear process for reconciling medication changes for hospital discharges.<\/span><\/li>\n<li class=\"c3 c5\"><span class=\"c0 c2\">Demonstrate a working relationship with their local community pharmacies using electronic repeat dispensing. They would report and learn from medication errors together.<\/span><\/li>\n<\/ul>\n<p class=\"c3\"><span class=\"c0\">Medicines optimisation is a time consuming process that does not appear to have been given adequate assessment by health economists. By investing in better systems at the primary care level, potential cost savings could be made to the greater healthcare economy. It is not currently financially possible, practical, or sustainable to expect individual practices to resource this work.<\/span><\/p>\n<p class=\"c3\">Northern Ireland has secured unconditional pharmacist support in general practice. Now is the time to insist that NHS England provide ongoing support for pharmacists in general practice, as well as educational support and protected time for the whole practice team to be able to work towards improving medicines optimisation.<\/p>\n<p style=\"font-weight: 400\"><em><strong><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-42462\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/06\/Lawrence_brad.png\" alt=\"Lawrence Brad\" width=\"115\" height=\"91\" \/><\/strong><\/em><\/p>\n<p>&nbsp;<\/p>\n<p style=\"font-weight: 400\"><em><strong>Lawrence Brad<\/strong> is a GP partner at Westbourne Medical Centre, Bournemouth and RCGP representative for clinical pharmacists.<\/em><\/p>\n<p style=\"font-weight: 400\"><em><strong>Clare Howard<\/strong> is a pharmacist with a background working at a very senior level in the NHS. She currently leads the Medicines Programme at Wessex AHSN.\u00a0<\/em><\/p>\n<p style=\"font-weight: 400\"><em><strong>Steve Williams<\/strong> currently works as a senior clinical pharmacist at Westbourne Medical Centre after spending 25 years working in the hospital sector. Twitter\u00a0<a href=\"https:\/\/twitter.com\/STEVECHEMIST\">@STEVECHEMIST<\/a><\/em><\/p>\n<p><strong><span class=\"c1 c7\">Competing interests<\/span><\/strong><span class=\"c1\"><strong>:<\/strong>\u00a0Nothing further to declare<\/span><span class=\"c1 c12\">.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Elliott R, Camacho E, Campbell F et al. Prevalence and Economic Burden of Medication Errors in The NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. \u00a0Policy Research Unit in Economic Evaluation of Health and Care Interventions. Universities of Sheffield and York. 2018. Available from\u00a0<\/span><a href=\"http:\/\/www.eepru.org.uk\/prevalence-and-economic-burden-of-medication-errors-in-the-nhs-in-england-2\/\"><span style=\"font-weight: 400\">http:\/\/www.eepru.org.uk\/prevalence-and-economic-burden-of-medication-errors-in-the-nhs-in-england-2\/<\/span><\/a><\/p>\n<p class=\"c3\"><span class=\"c0\">Baker M, Jeffers H. Responding to the needs of patients with multimorbidity. A vision for general practice. Royal College of General Practitioners. 2016. Available from\u00a0<a href=\"http:\/\/www.rcgp.org.uk\/-\/media\/Files\/Policy\/A-Z-policy\/RCGP-Responding-to-needs-of-Multimorbitiy-2016.ashx?la=en\">http:\/\/www.rcgp.org.uk\/-\/media\/Files\/Policy\/A-Z-policy\/RCGP-Responding-to-needs-of-Multimorbitiy-2016.ashx?la=en<\/a><\/span><\/p>\n<p class=\"c3\"><span class=\"c0\">Williams SD, Hayes JM , Brad LD. Clinical pharmacists in general practice: A necessity not a luxury? <em>BJGP<\/em> 2018;667:85. Available from\u00a0<a href=\"http:\/\/bjgp.org\/content\/68\/667\/85\">http:\/\/bjgp.org\/content\/68\/667\/85<\/a><\/span><\/p>\n<p class=\"c3\">The Medicines Optimisation Polypharmacy Prescribing Comparators. NHS Business Services Authority. 2017. Available from\u00a0<span class=\"c9\"><a class=\"c4\" href=\"https:\/\/www.nhsbsa.nhs.uk\/epact2\/epact2-dashboardsspecifications\/medicines-optimisation-polypharmacy\">https:\/\/www.nhsbsa.nhs.uk\/prescription-data\/medicines-optimisation-polypharmacy<\/a><\/span><span class=\"c0\">\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>More time and pharmacist support in general practice would reduce medication errors [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2018\/06\/26\/time-pharmacist-support-general-practice-improve-medicines-optimisation\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":42464,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[236],"tags":[],"class_list":["post-42461","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-nhs"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - 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