Locally Enhanced Service for Medicines Usage Reviews on patients with complex needs

This Local Enhanced Service (LES) Specification details the agreement between NHS Devon (the commissioner) and Community Pharmacy (the service provider) for the provision of Medicines Usage Reviews on patients with complex needs.

LES Timelines

Time Plan Date Start 1st May 2010 End 31st March 2011 Review 31st March 2011 Renewal Domiciliary MUR Programme based on cases identified by the Complex Care Team.

Pilot Service in East Devon Cluster (Axminster, Seaton, Sidmouth), Newton Abbot, and Barnstaple

1. Background

Medicines are the single most expensive intervention paid for by the NHS but the cost of drug treatments does not stop there. The use of medicines also has a number of risks associated and which in some extreme cases can outweigh the benefits. On average medicines are thought to account for 6.5% of emergency admissions, this causes a significant cost to the NHS through the additional unscheduled visits to hospital. It is widely recognised that most patients on long term therapy are not compliant with it after 2 years.

Pharmacists have been recognised as a resource to reduce unscheduled hospital admissions caused by medicines. The recent white paper ‘Building on strengths’ reported about ‘tailored support service’ which is currently being offered in Bournemouth and Poole PCT. This service involves community pharmacists developing care plans for people with long term conditions so that they are able to administer their own sometimes highly complex treatments safely.

In the Bournemouth scheme, patients are referred by any healthcare or social services professional that identify patients who may be having problems with their medicines. The patient is then assessed in their home by a pharmacist by using a medicines use review, if compliance is seen as an issue affecting the patient then necessary steps can be taken to deal with or reduce the identified issues.

The benefits of the service are:  Reduction in waste medicines  Improvement in healthcare outcomes by improving compliance and understanding  Rationalisation of treatments in order to reduce the risk of medicine related hospital admissions.

In the case of the Devon pilot, referrals to the scheme will be made by the Complex Care Team.

2. Service Description

A suitably accredited pharmacist will carry out a Medicines Use Review and make specific recommendations in regard to any issues that are identified as barriers to the patient achieving concordance. It is forecast that between four and six MURs could be completed in a day, depending on geography and logistics.

The review will be thorough and within national MUR guidelines, and is expected to take about one hour in the patient’s home. It will cover all medicines in the home (including non-prescribed items); will look for possible interactions between medicines and the appropriateness of medicines. Compliance with dosage instructions will be assessed, and recommendations will be made in terms of improvements to compliance from a range of established solutions.

The PCT will include the LMC in the service set-up phase so that the needs and rationale are fully appreciated and accepted as an important component in patient care.

3. Eligibility

For this pilot, it is planned to have two accredited pharmacists in each of the three localities. The Complex Care Team Core Group will refer patients to these pharmacists. The Complex Care Team will set up and agree eligibility criteria, based either on a scoring system using multiple criteria, or on the basis of a critical incident. [Process to be specified] 4. Contestability

This service will initially be provided by nominated and accredited pharmacists, two in each locality. It will be necessary for other pharmacists working in these localities to understand and endorse the pilot scheme and to agree in principle to accept recommendations that are made.

5. Clinical Governance

The participating pharmacists will observe Data Protection guidelines, Information Governance, Caldicott and Freedom of Information directives as appropriate for this service. These will be in line with NHS Devon policies.

6. Risk Management

The full process from receipt of referral to reporting and provision of recommendations will be covered by a generic Standard Operating Procedure.

7. Indemnity

It is the professional responsibility of the pharmacist provider to ensure that they have adequate professional indemnity cover before undertaking this service.

8 Aims and intended outcomes

 Reduced admission to hospital/care home  Improved compliance with intended medication regimens  Reduced waste of medicines through synchronisation and avoidance of unnecessary medication and stockpiling  Simplified ordering of repeat medicines  Integration of community pharmacy and community health teams

9. Service delivery

1. The Co-ordinator will identify suitable patients using the agreed criteria (see point 3 above). 2. The Co-ordinator will complete a Consent to Share and Protect Your Personal Information form (to include the patients NHS number). 3. The Complex Care Team will discuss the referral with the patients registered GP (or Deputy) and obtain an extract of medical/drug history of patient. 4. The Co-ordinator will book the pharmacists appointments. 5. Prior to each MUR, the Complex Care Team or the GP will provide the Pharmacist with a list of current prescribed medication, and information on what underlying conditions are being treated. 6. The provision of a MUR by an accredited pharmacist (normally in the home of the patient). 7. The MUR will a. Establish the patient’s actual use, understanding and experience of taking the drugs. b. Identify, discuss and assist in the resolution of poor or ineffective use of drugs by the patient. c. Identify side effects and drug interactions that may effect the patient’s compliance with instructions given to him by a health care professional for the taking of the drugs. d. Assess prescribed medication in relation to Devon formulary and evidence reasons for any departure e. Improve the clinical and cost effectiveness of drugs prescribed thereby reducing the wastage of the drugs. f. Enable advice to GP of quantities of medicines to prescribe in order to synchronise patients medication supply g. Establish the re-ordering process for repeat medications and simplify where possible. h. Recommendation of any compliance aids (such as MAR charts, or MDS). This may include an assessment under the DDA using the Devon Concordance Tool.

8. The Pharmacist provider is expected to give specific actionable recommendations rather than comments and suggestions. This is important so that proper monitoring can be undertaken. 9. Should issues be identified that are outside the scope of the MUR process, the Pharmacist provider will prepare a consultation note for the GP 10. If, on meeting the Patient, the pharmacist considers the situation too complex for an MUR, the pharmacist will refer the case back to the Community Matron or the registered GP as appropriate.

Complexity may arise from one of three areas, to be dealt with as follows:

Source of complexity Description Disposal Patient Pharmacist believes that the Abandon MUR and refer back to patient is not cooperative or does Complex Care Team not have sufficient understanding for the MUR to be effective Disease Pharmacist believes that there Abandon MUR. Detail concerns in aspects of an underlying clinical note for GP. Advise condition that need to be Critical Care Team addressed before the MUR can be undertaken Therapy Pharmacist considers that a Adjourn MUR. Either obtain second opinion is needed on one second opinion and then or more aspects of the therapy complete MUR or refer back to Critical Care Team with suggestion of what special expertise or knowledge may be necessary to complete process.

11. The required paperwork will be submitted to the CCT core group meeting for discussion and coordination of action. (copies to be supplied to the patient, the pharmacy normally supplying that patient, the patient’s GP and NHS Devon). The Co-ordinator will assume responsibility for ensuring delivery of actions. 12. The GP, on receipt of MUR form from provider to consider the comments/suggestions and indicate on the same form any changes to be made (including responses indicating that in the clinician’s judgement no action was necessary). 13. The patient’s life long record should be annotated with any changes and an indication made on the Review form that this has happened. 14. The Core Group meeting will be responsible for identifying patients who require a follow up MUR. The Group will review the patient after 3 months to see if the recommended changes have been made [with consequent correspondence with PCT]. This review will form the basis for a statistical assessment of the service benefits by evidencing the percentage of recommendations implemented and the associated outcomes. 15. The PCT will follow up with the prescriber if after 3 months they have not received the signed form from the GP or there has been no notification of changes in PMR by provider. 16. Only pharmacists with relevant training can provide the service 17. All forms must be completed in full and submitted to PCT by deadlines indicated to ensure payment. As the LPC is holding the funds the PCT will then have to copy invoice to the LPC 18. The scheme will be audited 10 Training

Pharmacists carrying out the service will need to have undertaken the following training

 MUR accreditation  CRB Clearance initiated by Devon PCT (as for EHC provision)  Have attended a relevant workshop held by the PCT covering the procedural aspects of the service, and to meet and develop a practical working relationship with members of the Complex Care Team  Be familiar with and have available a copy of the current local joint formulary and prescribing advice for Devon  Have completed the CPPE Pack Older People: Managing Medicine 37030P prior to starting the service  The PCT will provide identification for each pharmacist and will brief on lone-working policies  Participating Pharmacists will be given the opportunity of shadowing an established home-visit worker to become familiar with situations that can arise during this type of encounter.

11. Assessment

Assessment criteria are to be established. Measures of service provision will include:

 The number of MURs completed per four-week period  Proportion of services including a DDA assessment  Number of recommendations made per service  Proportion of recommendations accepted  Proportion of accepted recommendations implemented

Recommendations from completed MURs will be categorised as follows so that the analysis described above can be completed. (Note that this categorisation is based on a presented paper from Medway School of Pharmacy):

The MUR highlighted the following issues:

Potential issue Agreed by GP (Y/N) Implemented (date) Adverse drug reaction Drug interaction Inappropriate choice of therapy Duplication of therapy Inappropriate dose or dose schedule Additional therapy required Ineffective therapy Unsuitable drug form or delivery system Non compliance Monitoring required Synchronisation required

Measures of outcomes will include

 Hospital/nursing home admission rates  Cost savings by correction of adherence to formulary, or elimination of medicines, or cost of unwanted medicines returned for destruction  Recommendations acted upon by the prescribers and Complex Care Teams  Review of use of hospital services by patients following an MUR by Community Pharmacist. 12. Payment for services

 The service will be provided on a full-day basis, and it is anticipated that work will be available on a total of six days each month (one day per pharmacist).  Four to six reviews will be undertaken each day, including any preparation and reporting.  Providers will be paid a total of £250 per day plus £28 per MUR, with no additional payment for travel expenses as these will be local.  The £28 MUR payment (nominal 1 hour) will be met through the national contract funding mechanism, (i.e. claim through the normal PPA process), with the remainder paid by the LPC on behalf of NHS Devon.  The 3-month post-MUR assessment will be included as an additional service provision to be met through the national contract funding mechanism as an annual MUR**.  As with other commissioned services, this is not subject to VAT. **These sums subject to adjustment in line with any general change in MUR fee.

13. Monitoring Arrangements

Records should be kept for 2 years for monitoring purposes.

14. Protecting Patient Confidentiality*

Caldicott Guardianship is based on being thoughtful about the way in which patient information is handled, protecting data, using it appropriately and minimising the risk of inappropriate disclosure.

A Caldicott Guardian is a senior person responsible for protecting the confidentiality of patient and service- user information and enabling appropriate information-sharing. The Guardian plays a key role in ensuring that the NHS, Councils with Social Services responsibilities and partner organisations satisfy the highest practicable standards for handling patient identifiable information. Local Enhanced Service – Domiciliary MUR DMUR1 Agreement Sheet

This document constitutes the agreement between the service provider and Devon PCT in regards to the local enhanced service for Domiciliary MUR.

Service Provider Name and Address

Payment Schedule Daily Rate £250 Plus payment per MUR completed* £28 per MUR

*Providers will receive £28 per MUR (nominal 1 hour) to be met through the national contract funding mechanism, (i.e. claim through the normal PPA process) in addition to £250 made by the LPC on behalf of NHS Devon. The 3-month post-MUR assessment will be included as an additional service provision to be met through the national contract funding mechanism as an annual MUR.

Signature on behalf of the service provider:

Signature Name Date Job Title

Signature on behalf of the PCT:

Signature Name Date Job Title

The agreement is to cover an 11 month period commencing 1st May 2010.

Payments will only be made once the PCT is in receipt of a signed copy of this sheet.

For NHS Devon CRB check completed? Yes/No Date: Use Only:

Please complete this form and fax it to Solveig Sansom on 01392 267886 Local Enhanced Service – Domiciliary MUR DMUR2

CLAIM FORM

Pharmacist Name

Pharmacy F Code

Pharmacy Address

Month of Claim

Date MUR Patient NHS Initial MUR Follow Claim for completed Number up MUR £28 made to PPD Example 2/9/09 7473037423783 Yes

Total claimed from NHS Devon £ (£250 per day, one day per month)

I confirm that the information given on this form is true and complete. I understand that if I provide false or misleading information I may be liable to prosecution or civil proceedings. I understand that the information on this form may be provided to the Counter-Fraud and Security Management Service, a division of the NHS Business Services Authority, for the purpose of verification of this claim and the prevention, detection and investigation of fraud.

Pharmacist signature:______

Please return this form to: Solveig Sansom, NHS Devon, 2nd Floor, The Annexe, County Hall, Topsham Road, Exeter, EX2 4QL