(Click to read the full version of this article in the online magazine)
With NHS cost pressures reaching crisis point, eyes inevitably turn to one of its biggest expenditures – medicines. While the cost of new medicines is important, ensuring that existing medicines are used optimally is just as vital to NHS finances.
At its core, medicines optimisation is about getting the right medicine to the right patient at the right time, a more difficult task than it might seem. Medication errors occur in up to 11 percent of prescriptions, while seven percent of hospital admissions are associated with adverse drug reactions, up to two-thirds of which are preventable. Given the size of the problem, getting it right would not only save money but prevent considerable patient harm.
For the Royal Pharmaceutical Society (RPS), the best approach is to focus on patients – empowering them to improve their own outcomes, take their medicines correctly and avoid taking unnecessary drugs.
“Between 30-50 percent of patients don’t take their medicines as intended,” says Heidi Wright, policy and practice lead for England at the RPS. “If patients are brought into the decisions about their medicines, they are much more likely to take them, and because they’re actually getting a health benefit there’s a cost benefit from the resulting reduced hospital admissions.”
Wright believes the key to success is supporting people to make decisions about, and to get the most from, their medicines. “Usually healthcare professionals (HCPs) tell the patient what to do but don’t actually involve them in the decision. It’s about having a two-way conversation with the patient about their treatment, making sure they’ve got the most up-to-date, evidence-based information. With that kind of conversation, they decide to take a medicine and take ownership of that decision, and so feel empowered, plus they know they can come back if they have an issue.”
Recognising that the situation changes throughout the patient’s lifetime journey on a particular medicine is also important, she says. “When patients have a long-term condition and they’re going to be on that medicine for life, if they’ve taken it for five years it’s tempting to think they’re fine and they know what they’re doing. But things may have changed in their life that affect their treatment; they may have acquired another long-term condition or have had a trauma in their life or developed dementia and so forget to take their medicines.”
The answer is an ongoing conversation not just a one-off clinical medicines review and occasional check. “It’s about keeping the dialogue open, looking at the individual and making sure medicines are right for them at their time of life. We need to increase the demand for that type of conversation through patient education – making sure patients expect to be asked those kind of questions or demand them if they’re not being asked.”
The RPS has already taken steps towards this, says Wright. “We’ve looked at several different conditions and developed guidance sheets. For example, if you’re talking to a patient with asthma, we include information on what HCPs should be thinking about in regards to their medications. We’ve also developed factsheets for patients about getting the most out of their medicines, as well as the kind of questions you might want to ask your healthcare professional.”
Cultural change within the NHS is essential – for both patients and HCPs. “It’s also about making sure the new workforce is trained for these kinds of conversations with patients, and asking how we up-skill the current workforce if they are a little scared of having such conversations because it’s handing over some of their power.”
Team players
An essential component of medicine optimisation is easy access to robust, accurate information about a patient’s condition and treatment, says Wright, who stresses the need for greater integration of different parts of the health service.
“We need more information sharing, which is a huge IT problem at the moment. As a patient you don’t want to be asked the same question by your doctor, your pharmacist and your nurse. If everyone could see the same information it would make life a lot easier for everybody, including patients.”
Technology holds the answer, says Ethan Richardson, product manager for medicines management software company JAC. “Today, a patient arrives at hospital and there’s a big Cluedo game as to what kind of drugs they are actually on, what dose they are taking and whether they are actually taking it. Many techniques and tools are used to try and figure out what’s going on but it’s highly error-prone and things get missed, which is a huge source of risk for the NHS.”
He adds: “Then, when patients move to a different care setting, their information needs to move too, and it needs to be timely and accurate. Where people are not using electronic prescribing this is typically paper-based, and may even be down to things like carbon copies.”
The key to improvement is greater use of paperless, connected systems. “The vision of the future is that the patient arrives at hospital and is uniquely identified, which enables HCPs to access their record and know what medication they’re on. Then they can take that information and turn it into prescriptions in the hospital – no transcriptions, nothing manual, no getting it wrong – so that information automatically feeds into prescriptions within secondary care.
“Once the patient is ready for discharge, that information is sent back not just to their GP but to the community pharmacist, mental health nurse, social worker, so that everybody can see what’s going on. This would give you an extremely rich picture of the patient, unambiguous, with the quality and accessibility of information very high.”
The benefits to patients are obvious. “Care is more efficient and better-targeted, and better care decisions are made because they’re supported by high-quality information,” says Richardson. “There are also less likely to be interruptions in care.”
However, like Wright, he notes that new technology will not be enough and healthcare systems must make sure they are working in an integrated, efficient way. “The missing piece at the moment is the idea of ‘shared care’ or the integrated aspect,” he says. “Probably the best example in the NHS is in north-west London, where they brought together the providers in the hospitals, community pharmacies, GPs and a myriad of other healthcare providers and brought them into a single environment to share this information. They’ve proved that the model can work so it’s now only a matter of replicating it elsewhere.
“It’s really getting people to change the way they think about healthcare and to understand that they’re all part of a single ecosystem not lots of different ones, where information needs to be shared across boundaries.”
Integration is also about improving the trust between HCPs, adds Wright. “If a pharmacist does a blood pressure measurement in the pharmacy, the doctor might then do it again because he doesn’t trust the measurement. It’s about building trust between healthcare professionals.”
It seems blindingly obvious that medicines usage would improve when both HCPs and their patients are well informed about treatment, but it is taking the health service a while to catch up. Things are looking up, but there’s still a long way to go before the true impact of medicine optimisation will be felt.
(Click to read the full version of this article in the online magazine)
