I want to tell you about Mrs S. She’s a patient who has a significant drug burden and as time has progressed has found it harder to manage her regime. We’ve reviewed and rationalised, and what’s left is as simple a therapy as is possible without jeopardising her care. She’s cool with it all and wants to adhere but can’t as she finds it tricky to consistently remember exactly which medicine is taken when. Reminder charts have been useful but as another bit of paper, they’ve succumbed to the inherent risk of becoming inaccurate, lost or incomprehensible without anyone noticing until too late.
Unsurprisingly at this point the idea of a NOMAD was raised by a colleague. For those of you not in the pharmacy-know, NOMAD is one version of what are collectively termed “Multi-compartment Compliance Aids” or MCAs – these are those trays that people have their medicines popped into by a pharmacist, friend or relative such that each day of the week has morning, afternoon, tea-time and night-time medicines neatly separated.
For Mrs S, it seemed like a good idea: none of her medicines were excluded from being in a MCA and she clearly needed something more to support her. A call was put into her usual pharmacy to discuss, but was met by an almost instant refusal. There was no capacity to do any more I was told. It was unsafe to accept another patient onto the system was the explanation. There was nothing more that could be done for Mrs S was the closing statement.
It’s not that often that I get so pissed off with my pharmacist colleagues that I bad-mouth them to my GPs, but I’ll admit to losing it over this phone call. It’s not that I don’t understand the risks of these devices – as a locum, nothing in the world worries me more than arriving to find a note telling me there’s eight MCA to complete that day – but I’m angry that a patient who would likely benefit from one is being denied it because the system is already at capacity. Is this position unfair of me? I think not for the following reasons:
- Making ‘reasonable adjustments’ to dispensed medicines is a requirement of the Equality Act (EA) (previously Disability Discrimination Act) and is an essential part of the retail pharmacy contract. To this end, all pharmacies get a monthly payment from the NHS to help them provide such adjustments (up to 6.6p for each item they dispense regardless whether the item requires ‘reasonable adjustment’). Of course an argument exists whether a MCA is ‘reasonable’ in this case, but this wasn’t part of the pharmacy’s reasoning or conversation. At the least the pharmacist was under obligation to assess the patient themselves or discuss alternate solutions with me.
- Now more than ever pharmacy should be demonstrating its worth as the best support option for patients unable to take their prescribed medicines. You can term it the shiny new ‘medicines optimisation’ or call it good old-fashioned good pharmaceutical care, but if it’s not being done for those most at need why will I turn to the sector for help in the future? Why wouldn’t I just commission a more responsive nurse-led service?
- The large multiples – mostly Boots – have pushed these devices as a free service for years, as a way of getting what they term ‘lock in’; that is, once a patient is hooked on a MCA they won’t take their medicines in any other way and therefore will be locked in to taking their prescriptions to Boots until the day they pass on.
- I know that this store in particular, because of point 3) above, provides MCA to a chap on just two medicines (one once daily, one twice daily) who whilst seeming useless at taking these two drugs is quite able to run his own, successful, painting & decorating company: hardly a suitable candidate under EA?
I’ll admit early that I’m not the biggest fan of these devices, and after years providing a domiciliary medication review service you can count the number of MCA’s I’ve initiated on the fingers of one head. But my experience suggests that the people that benefit are those like Mrs S – unintentionally non-adherent to their medicines, orientated in time and space, able to manipulate the packaging and capable of remembering that they need to take their medicines and whether they’ve already done so. Yet I’m now in a position whereby a suitable candidate is geared up for it but is being denied because the system is full of patients who either aren’t benefiting from them, who get them simply out of their own laziness, or because the pharmacy had a target to reach and have ‘sold’ them to unnecessarily straightforward patients.
I know there’s no formal funding for this service, I’ve previously spoken to the LPC at length about 7-day prescriptions and remuneration (the argument doesn’t wash for me– see point 3) and so I appreciate pharmacies are caught between a rock and a hard place. But ultimately Mrs S needs help and can’t get it from her usual pharmacy because they’ve put targets before service and maxed themselves out.
So my next steps? Easy – Mrs S has switched pharmacies to one that has capacity and will be locked in to another pharmacy for the foreseeable future. She’s doing well, reports no problems and despite a few teething problems getting prescriptions ready and redirected, it looks like it was the right solution for her. It still leaves the issue with the near-by maxed-out pharmacy, and with an ever increasing population of complex elderly patients in the community, I can see them losing out time and again.
So why the blog? Because I want pharmacists to think about their MCA service. If you recognise your store in this scenario perhaps it’s time to re-assess your MCA patients: do they really need it or are they’re a case in point of targets before care?
Thanks for the comment, which raises some interesting points. I agree that levels of care currently available don’t match patient need, but given the austere times I can’t see this changing. This, and the impending Franics report, should give pharmacy a real impetus to challenge poor care – including inappropriate MDS use – that may result in avoidable harm such as the overdosing you mention. Have you evidence of both the increased waste and over-dosing of this patient? This would be powerful stuff to formally take to the GP and/or their CCG, demonstrating your good patient care and appreciation of wider health economy.On a personal level we do do 7-day prescriptions, but where it’s clinically indicated only: however I’d see this situation as easily fitting here and would have no problems supplying batches, which is often tied into the medication review – and rationalisation – process.
what you need is a n eMAR system that links directly to the pharmacy dispensing system. This then evidences adherence, prompts patient via their smart phone (75 yr olds are using tech nowadays). CareMeds does this and eliminates need for NOMADS where they are used just to help sort the regimes and adherence. This saves money on plastic and provides valuable quantifiable drug wastage figures, and also identifies the patients failing to adhere. A good DDA assessment should ID the candidates for such technology, often its also an NMS opportunity too so extra income all round and better outcomes. Thats just a non pharmacists view! PS Like your blog and thoughts, particularly on meds optimisation, I understand this is the buzz phrase at the mo. my view is its about stopping the switching done by GP’s using script switch to cheaper generics then then lead to two more meds to counter cheaper meds side effects. It looks at the whole process including knock o primary/secondary and social care costs. i.e. 1 to be taken 4 times a day. Nurse has to visit 4 times to admin meds in community. Change to 2 taken twice a day and saved half the visits! There are companies appearing offering this expertise to PCT’s and CCG’s reviewing care home prescribing etc, saving big money!
Keep up the good work
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