Clare A Mackie Medway School of Pharmacy

1
Clare A MackieMedway School of Pharmacy

• Training and Developing a Pharmacy Workforce that
  is
• Fit for the purpose
• to Deliver Advanced Services
• Medicines Use Review

2
Overview

• Background to MUR
• Development of a competency framework
• Accreditation to provide MUR services
• Identifying and managing risks

3
Major Shift in UK Policy

• Conservative policies focussed on the GP as the
  gatekeeper to the NHS- relationships,
  responsibilities and continuity of care
• New labour relieved GPs ( others) of monopoly
  and improved access through
• NHS Direct, Walk in Centres
• Direct supply of medicine schemes
• PGDs to meet immediate need
• Major extension of non-medical prescribing
• Supplementary prescribing

4
New Labour Blueprint for Health

• Decentralisation- shifting responsibility for
  delivery to local level
• Matched by strong control from the centre and
  wish to systematise, structure and set standards
  (NICE, NSFs) - algorithmic models of care
• Move from paternalistic model ( NHS will provide)
  to patient engagement and responsibility

5
New Primary Care Contracts

• New GMS contract presents opportunities
• Chronic disease management
• Management of long term conditions
• New community pharmacy contract (England)
• Pharmacist supported health care
• Demand management
• Levels 1-2 national contract not PCT led
• Level 3 locally commissioned from National
  Service Specification

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Level 2 Advanced Services

• Medicines Use Review- periodic as part of
  National contract, not PCT led but PCT can target
  specific patient groups in line with local
  priorities
• Prescribing interventions- infrequent triggered
  by events , not scheduled as in MUR above
• Not for all contractors this service requires
• Private areas and appropriate facilities
• Pharmacists must demonstrate competence for
  advanced services

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Aims of Service

• To improve knowledge, compliance and use of
  medicines by
• Establishing actual use understanding
• Discussing resolving ineffective use of
  medicines
• Identifying side effects and drug interactions
• Improving clinical and cost-effective use and
  reducing medicines wastage

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Service Specification Planned

• Generally face to face in the pharmacy
• Every 12 months for patients with multiple
  medicines and long term conditions
• Periodic MUR- must be regular pharmacy user (3m)
• Consultation area essential- sit down area,
  confidential from public and other staff
• Specific groups may be targeted by PCOs
• Recommendations to GP on National Template

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Service Specification Unplanned

• Prescription intervention significant problem
  identified during dispensing of regular
  prescriptions
• Does not have to be regular patient
• Does not have to be 12 months since last review
• The initiating issue will be discussed with the
  patient and communicated to the GP
• Consultation area essential- sit down area,
  confidential from public and other staff
• A copy of MUR summary and recommendations given
  to patient and GP and retained as part of PMR

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Examples of Interventions

• Practical problems in ordering rx , quantities
• Effective use of PRN medicines-rx and otc
• Advice on use of formulations- inhalers
• Advice on tolerability and side effects
• Generic substitutions-with exclusions
• Branded substitution where appropriate
• Dose optimisation- 20mg instead of 2x10mg
• Suggestions to improve clinical effectiveness

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Overview

• Background to MUR
• Development of a competency framework
• Accreditation to provide MUR services
• Identifying and managing risks

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What are competencies?

• Task-based competencies- descriptions of tasks or
  job outputs used in NVQs/ SVQs.
• Behavioural competencies these are thought of as
  underlying characteristics of individuals which
  result in effective performance. They are
  described as a combination of knowledge, skills,
  motives and personal traits. Competency in this
  sense is generally best seen in the way that
  someone behaves.
• Reference www.npc.co.uk

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Development of a competency framework for MUR

• A collection of competencies central to effective
  performance to ensure fit for the purpose
• A tool to support CPD and/or accreditation
• Pragmatic approach- limited to those able to be
  demonstrated/ assessed by HEIs including 5
  competencies grouped into three clusters
• Clinical and pharmaceutical knowledge
• Accessing and applying information
• Referral
• Broken down into 18 behavioural statements

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Example

• Mrs S requests an analgesic for migraine
• PMR Mrs S age 73 no conditions listed
• Prothiaden 75mg nocte
• co-proxamol 2 prn
• digoxin 0.125mg 4 daily for three days
  then one daily
• Note no previous episode of migraine, symptoms
  included headache, disturbed vision, nausea and
  vomiting

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Competencies for MUR

• Demonstrate relevant clinical and pharmaceutical
  knowledge taking into account individual needs
• Demonstrate the ability to identify and make
  recommendations relating to patient safety
• Demonstrate the ability to identify, access,
  critically analyse and use written sources of
  info
• Demonstrate ability to obtain directly from the
  patient an accurate history of use including otc
• Ensure recommendations agreed with the patient
  are referred appropriately in a timely manner

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Overview

• Background to MUR
• Development of a competency framework
• Accreditation to provide MUR services
• Identifying and managing risks

17
Accreditation

• Key principles
• Only HEIs can accredit (independent QA)
• No restriction on providers of training and
  support
• Competencies can be assessed by a range of
  methods- formal interviews, direct observation,
  written examination or portfolios
• Controversy re level
• Masters level- make decisions with incomplete data

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Skills for the Future

• Launched June 04 collaborative PSNC, CD and
  Medway School of Pharmacy supported by education
  grant GSK
• 20 modules over 40 weeks bring pharmacists up to
  speed on latest guidelines in a number of areas
  followed by CD Rom requiring Masters level
  competency assessment of 3 care plans
• Recruitment gt500 per month since launch
• Other providers will enter the market- monopoly
  not in interests of profession or government

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Overview

• Background to MUR
• Development of a competency framework
• Accreditation to provide MUR services
• Identifying and managing risks

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Risk of not engaging in the service

• Question Do we need MUR?

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ADR as cause of admission to hospital ( BMJ July
2004)

• 1225/18,820 admissions (6.5) related to ADRs in
  patients gt 16 years (in Merseyside over 6 months)
• 80 of ADR directly leading to admission
• 16.6 drug interactions
• 8 days bed stay 4 of hospital bed capacity
• 0.15 deaths, equivalent to 5,700 annual deaths
  in UK
• 466m projected annual cost to NHS
• Drugs implicated aspirin, diuretics, warfarin
  and NSAIDs

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Challenges

• Initial accreditation to provide MUR services
• Communication and information exchange (national
  template)- partnership approach
• Skill mix within pharmacies-free up time
• Maintenance of competence (CPD) - peer review
• Local ownership difficult with National service
• No clear role for local commissioners
• How can you influence/ target local need and
  prevent duplication of services

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The Way Forward

• Resist the urge to take control, instead
  identify and manage risks and support local
  implementation by provision of
• Encouragement to pharmacists to demonstrate
  competencies for MUR
• Local leadership to develop effective
  communication networks to facilitate delivery
• Positive advice re targeting to meet local need
  and avoid duplication
• Facilitation of multi-disciplinary peer review
  within local clinical governance scheme

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Acknowledgement

• My colleagues Denise Farmer and Linda Dodds who
  worked with me to develop the competency
  framework for MUR and to our fellow members of
  the steering group at the DoH who added much
  polish to the final version!
• Contact details
• c.a.mackie_at_gre.ac.uk