Community Pharmacy and Practice Based Commissioning

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Community Pharmacy and Practice Based
Commissioning
Osteoporosis and Falls

• Mike Holden

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Objectives

• To understand the need
• To consider a potential solution

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• We need to be better commissioners than the
  commissioners
• Gary Warner, 2007

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Influencing and Negotiation
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Definition of Influence

• Causing something without any direct or
  apparent effort
• To affect or change how someone or something
  develops, behaves or thinks
• Power to affect persons or events
• Shape or give direction to

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Principles of influencing

• Scarcity
• Authority
• Social proof
• Liking
• Reciprocity
• Consistency/Commitment

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Definition of Negotiation

• The activity or business of coming to terms
• A discussion intended to come to an agreement

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Essentials of Negotiation

• Prepare
• Probe
• Propose
• Package

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If you., then I
Essentials of Negotiation
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Our place in Commissioning

• PBC is about engaging practices and other
  primary care professionals in the commissioning
  of services. Through PBC, front line clinicians
  are being provided with the resources and support
  to become more involved in commissioning
  decisions.
• DH 2006

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Review current service provision
Decide priorities
Assess needs
Design service
Assess need
Service redesign
Patient and public feedback
Managing demand
Shape structure of supply
Performance management
Managing performance (quality, performance,
outcomes)
Manage demand and ensure appropriate access to
care
Clinical decision making
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Assess Need

• Osteoporosis affects an estimated 3 million
  people in the UK
• 1 in 2 women and 1 in 5 men over the age of 50
  develop osteoporosis
• One in three women over 50 will suffer vertebral
  fracture and 1 in 6 a hip fracture
• Around one third of patients who suffer a hip
  fracture will die within a year

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Assess Need

• Cost to the NHS of fractures in osteoporotic
  patients is in excess of 1.5 billion
• In SE Hampshire 544 hip fractures in 1 year
• Average length of stay 16 days
• Hospital costs of 650,000
• Calcium D3 supplement cost 250,000
• Potential saving of 400,000?

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Assess Need

• 1 million spent on prescribed treatment in
  Hampshire alone
• 40 of patients are not fully compliant with
  their treatment (RECORD)
• Up to 20 of prescribed medication wasted

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Service Design

• Discussion with PCTs, Consultants, Falls Leads,
  GPs and CPs to assess existing provision and
  service gaps
• Integrate all existing services
• Consider new services to fill gaps
• Redesign pathways

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Integrating Existing Services

• Group Discussion
• What do we do already which could be integrated?
• 10 minutes

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Essential Services

• Dispensing supply of medicines and appliances
• Repeat Dispensing Service
• Disposal of unwanted medicines
• Promotion of healthy lifestyles
• Signposting
• Support for self-care
• Clinical governance

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Medicines Use Review
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Concordance
Necessity
Concerns
COMPLIANCE
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Integration Where we can make a difference
Community Pharmacy
Reduced admissions Care in the community Reduced
waste
Domiciliary support Medicines Management Concordan
ce/compliance
Screening/monitoring Healthy lifestyle
promotion Signposting Support for
self-care Medicine supply
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Service Aims

• Improved concordance and adherence of patients on
  osteoporosis treatment
• Assessed appropriate intake of Calcium and
  Vitamin D3 by patients already taking
  osteoporotic medication with initiation of supply
  and referral if appropriate
• Assessed osteoporosis risk of patients on
  long-term oral steroid therapy or chronic
  mal-absorption condition such as Crohns, Coeliac
  disease or colitis and refer as appropriate

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Service Aims

• Assessed falls risk and referral as appropriate
• Improved access to support, particularly for
  those traditionally hard-to-reach patients
• Integration of community pharmacy services into
  patient care pathways

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Service Overview

• Identify at risk patients
• Conduct MUR to assess and address compliance/
  concordance issues
• Assess and address CalciumD3 intake
• Falls risk assessment

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Fall Risk Assessment

• 5 Questions to score
• Is there a history of falls in past year?
• Is patient on polypharmacy or multiple drugs?
• Does patient have diagnosis of stroke or
  Parkinsons Disease?
• Does the patient report problems with balance?
• Is patient unable to rise from chair unaided?
• Refer to GP and/or Falls team is appropriate

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Group work - costing the service

• Should we use the MUR service fee as a base?
• What would be an appropriate add-on fee for the
  elements outside of the existing specifications?
• What would be an acceptable fee if a home visit
  required?
• 15 minutes

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Group work what else?

• What else could be done within this service?
• What other therapy areas could the MUR option be
  applied to?
• 5 minutes

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Summary

• Improving Access

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Improving access to deliver

• Osteoporosis risk assessment
• Appropriate and cost-effective prescribing
• Improved concordance/ adherence
• Falls risk assessment
• Reduced unplanned admissions and waste
• Professional integration