abandoned

abandoned

Please don’t judge me, but I’ve abandoned my wife & child and headed off to Cornwall to see friends, catch some sun, drink beer and watch Eddie Izzard perform at the Eden Project.

I’ll be back on Wednesday 5 June but probably won’t get to e-mails until Friday.If you need a response before then please contact my PA Linda who will redirect your query accordingly.

Cheers,

J

 

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enforced

Image

I’m currently on ‘use it or lose it’ annual leave until Tuesday 2nd April, despite a pile of work to do and no real desire to be off when the weather forecast is so rubbish.

If you need a response before April please contact my PA Linda who will redirect your query accordingly.

Otherwise I’m probably going to do anything I can to avoid the DIY jobs the Mrs has lined up for me, so don’t be surprised if I get back in touch before my official return.

Cheers,

J

prime

prime

Over the last two days I’ve had Rick Astley going round and round in my head (you’re welcome), but also going round and round on my timeline has been a discussion on whether ‘medicines optimisation’ is ‘medicines management’ after a haircut, shave and with a nicer tie on.  140 characters hasn’t been enough to effectively explain why I don’t think that’s the case, so this blog is my attempt to say why I think medicines optimisation is not just a rebranding exercise.

I was struggling where to start this blog until this Thursday, when I had a practice visit by the currently PCT, but soon-to-be-CSU, pharmacist. I’ve got plenty of time for this pharmacist, certainly compared to their colleagues, and it’s always nice to have a chat and catch up.  Towards the end of our meeting they came to the last item on what turned out to be their ‘must discuss’ list from the boss, which was a copy of a recalled prescription from NHSBSA. The item was a ‘specials’ cream prescribed to Mr R: a mash-up of Betnovate, coal tar and salicylic acid, used in this case for psoriasis, a 200g pot of which was costing me a grand total of £447.

Now whether you live and breathe healthcare or not, you can’t have failed to notice that the NHS is a little stretched for resource, and let’s face it, a cream coming in at nearly 3.5 times the price of silver seems somewhat extravagant. But to me, it’s right here that the difference between medicines management and optimisation is clear, and through the power of alternate history I will try to explain all…

It is the time of Medicines Management: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  Betnovate on its own, with separate Cocois is suggested and the new GMC guideline on prescribing unlicensed medicines is wheeled out to drive the point home.  This is relayed to the prescriber who feels he has no option but to ‘trial’ the new regime with the patient. The PCT pharmacist returns to base safe in the knowledge that the special has been managed out of the system and the cost contained…

But consider also…

It is the time of Medicines Optimisation: the pressure to cut costs from the drugs budget under the banner of QIPP is unrelenting even though as a CCG we’re already £400,000 under-spent despite two rounds of ‘efficiency savings’ being removed from the budget.  The PCT pharmacist asks what can be done about the cream: it’s clear that it’s not deemed acceptable and that suitable cheaper alternatives must be sought.  We pull up Mr R’s medical record and look to see what’s going on.  The cream was initiated in 2011 by the dermatologist at the local acute after a series of attempts using other preparations, guided by NICE, failed to control the plaques on this 71 year old’s trunk and lower limbs. His next step will be oral methotrexate but in numerous clinic letters the consultant says the patient is adamant he’s not started this medication, and goes on to note that since initiation of the special cream his plaques have subsided to two small patches the size of a 50 pence piece so we can probably avoid the cytotoxics. Whilst Mr R uses an emollient each day, he has reduced his application of the specials cream so that 200g lasts about three months.  His personal circumstances are also reviewed, including his reducing mobility and dexterity.  Realising that for Mr R, what matters is keeping his plaques under control as easily as possible so that he isn’t forced onto methotrexate, the decision is taken that despite the high cost and unlicensed status, the specials cream is the right medicine for him and so far is proven to deliver the outcome we all want.  A note is added to his record that it will be prudent to discuss the risks associated with long term steroid application and consider a switch in the choice of emollient, and the PCT pharmacist agrees to relay back to the CSU that this patient’s therapy has been optimised to achieve an appropriate outcome.

What I didn’t speculate on in my alternate history is what would’ve happened to Mr R had the change in his therapy been forced under medicines management. Would he have adhered to the new medicine regime, would his plaques return and would he feel pressured into starting methotrexate?  I don’t know and that’s why I didn’t speculate, but it’s not hard to imagine that some of that would apply.

So is medicines optimisation the shiny new version of medicines management? No, I really don’t think so, though I admit that’s not always been the case.  It is different in my mind, but perhaps that’s the problem – every other bugger’s going to have a different opinion because although the term has been formally around since 2010 no-one official has come up with a decent, acceptable definition. How can anyone get behind something that’s taken two years to define? How can a profession coherently apply themselves to something that’s seemingly insubstantial?

For me that’s the prime issue in all of this – let’s stop going round and round on whether it’s different or not, but let’s, all of us, make sure it is different.

And for the record, one of those alternate histories is a true reflection of last Thursday. I’ll leave you to decide which you think it is…

nomads

Nomads

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:

  1. 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.
  2. 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?
  3. 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.
  4. 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?

 

isolated

Isolated

This is an impromptu blog: I’ve been meaning to do a few recently but haven’t managed it, but I wanted to share these thoughts before they drift away.  They’re not directly pharmacy related but have some lessons for us nonetheless.

We moved house a year ago to Yateley which although has a population leaning towards the older side, has some awesome schools for Little’un.  After moving we went round the seven other properties in our close and introduced ourselves, but aimed to get everyone round to us for a BBQ once we’d settled. The weather never let us, so we said that New Year drinks would be good, but then chicken pox got in the way. So today we finally had the neighbours round for drinks and nibbles; eight people (youngest >60) from five of the seven households showed up and a couple of things really struck me that I want to share.

  • They didn’t eat much, despite the huge spread, but after 45 minutes I had to pop to the shop to buy much more wine
  • The oldest frail guy, who lives alone, was the wittiest
  • The dour Scottish chap who talks little outside had the best stories
  • Three households had at least one person who was effectively houseboud through illness or age, and their lives run on the help from unpaid carers (mostly family)
  • When one chap starts drawing his pension next year he automatically loses the carers allowance he currently recieves: he reckons they’ll be financially worse off from this despite nothing in their life actually changing apart from the date on the calendar

But the most stricking thing? Social isolation is a killer for these people.  Few of them go out much, and when they do it’s not far and locally there’s no longer much for them to access despite the population demographic.  What really hammered this home was that two of the households had not even spoken to each other properly in the seven years they’d lived on the same 200 metre strip of road.

So what’s this got to do with pharmacy? Well it wasn’t easy hiding my profession and so I’m now versed on all their ailments and therapies, and this is key: they all get their medicines delivered from the local pharmacy and none of them have spoken to a pharmacist since this service was started. 

It’s known that these patients may have higher needs and there’s already ideas around how pharmacists can support their care; what I’d ask is that if you’re a pharmacist who provides a medicines delivery service to housebound patients, please reflect on how long it’s been since you last saw these people or even simply spoke to them (and remember from above that they are people, not just ‘patients’); maybe it’s time to pick up the phone?

 

 

exposition

Ptms

Pharmacy in the UK, along with much else, is in a period of serious change, to some extent serious jeopardy and of course serious seriousness, and so it was with immense relief that I read Mr Dispenser’s first – and with luck, not last – entertaining book “Pills, Thrills and Methadone Spills”.   An eclectic compilation of blogs, stories and witticisms, it jogged me to remember that no matter how serious things are in the world of pharmacy, it’s a world that will always be able to put a smile on your face.

Personally I wouldn’t know where to start in writing a book, but if a serious drinking session disrupted my thought processes such that I made an attempt, I can’t imagine how I’d make pharmacy  the theme.   As such I had little idea of what to expect; in the back of my mind I did have memories of the excellent read by Drug Monkey ready to compare it to, but I need not have worried. 

I’ve followed Mr Dispenser on twitter pretty much since I joined it eighteen months ago and thought I’d have seen most of the book’s content through this, but thankfully I was wrong.  A wonderfully informal and original piece of work, if somewhat a little unstructured in parts,  I read it in one go, not out of a need to tick another job off the list, but because even at 1am when the Mrs was seriously pissed off I still had the bedside light on, it was compellingly difficult to stop.   Immensely reflective of my past experiences and gloriously enlightening on the experiences of others, funny in most places and sincere in parts, it’s a genuinely worthwhile read.  

The New Year will invariably make people reflect on their previous twelve months, and as usual, hearing “If I only knew then, what I know now” won’t be uncommon.  Similarly if I’d only read this book before I qualified I’d have been so much better prepared for the wonderful world of pharmacy.  I would have never ruined my favourite cream and pink striped tie had I been pre-warned that checking the lid is secure before shaking was the most critical part of antibiotic reconstitution.  If I’d only read the patient attempts to pronounce medicine names I wouldn’t have had my own infamous “ferocious sulphate” incident.   And although I read @weeneldo’s account of his pre-reg and wept with laughter, I do wonder that had I read it before qualification whether I’d have switched to another course… 

But that’s not to say this book is only suitable for students – far from it.  I almost wept with relief after reading the ‘Locums Deserve Respect’ section: here was someone who understood my woes, my fears, my wishes.  And the wise words within Candy Sartan’s genius “Badges” should now be the theme-tune for all pharmacists, though I do worry which of her ‘male pharmacist’ breeds I fit in.  On the serious(-ish) side there’s also the excellent contribution from @OptForOptimism – even after a decade of being a pharmacist it was good to be reminded how we, and our services, may look to patients .

So in these austere times do I recommend that you spend your hard-earned pounds on this book? Yes I do, regardless of whether you’re in pharmacy, planning to join it, come in to contact with it regularly, or have no idea what it actually entails.  You’ll love the ‘Pharmacy Films’, laugh at our Gangster similarities, be amazed at the lengths we go to when supporting and helping our patients, and come away with the feeling that whilst we sometimes get  unfair flack when trying to keep people well with their medicines, we’re also always able to see the funny side of it all.

 

The e-book is available for download from Amazon and I’m happy to report that 5% of sales will be donated to Pharmacists Support a charity that offers a helping hand to pharmacy colleagues who find themselves in difficult circumstances.  There really is no excuse not to buy a copy.

 

predictions

The end is nigh (of 2012) so I thought I’d get in early with some pharmacy predictions for 2013, and given how much uncertainty the NHS will be in from April I’m expecting to be as good as the Mayans in getting this right. 

 

Starting from April the biggest changes will obviously affect our colleagues currently in primary care: the lucky ones will end up being part of a Commissioning Support Unit (CSU), the really lucky ones will be in a Clinical Commissioning Group (CCG). Many won’t be lucky and there’s a real risk that some great talent that may be lost from pharmacy altogether: at a certain level in PCT-land you’re not clinical enough to keep your banding in a hospital, and you’re earning too much to go straight into retail.  Pharma is one option, but they’re not a safe bet if your mortgage depends on it.

For the lucky ones their work will be dependent on how focussed and forward thinking their CCGs are: there are some real opportunities to make a difference to patients and their medicines, but I fear that most of their work in 2013 will be nickel & diming.

 

Sticking with the NHS, let’s consider our hospital colleagues. Again money dominates: acute trust funding, FT or not, is going to get a kicking especially when CCGs try to squeeze tariffs or pull activity via referral reduction or re-commissioning work into the community. In this instance, retention will be about specialisation – focus on a speciality disease area, be super clinical on it and prove you make a difference; my money’ll be on cardiovascular and endocrine.  Other opportunities will exist though for those in trusts who hold vertically integrated community services….

 

Community services pharmacy is, I think, where the exciting stuff will start to happen: whether CFT, FT or independently based these services are being seen as the answer (wrongly) to the NHS’s ‘troubles’ and will need to really innovate to deliver outcomes on restricted budgets.  Where better to show the value of pharmacists? If Medicines Optimisation has a natural home then this will be it.  Hand in hand with this are our colleagues in mental health services: the new Health Secretary’s focus on dementia will play well here as funding will follow – again another good place for medicines optimisation to thrive.

 

Retail pharmacy: my roots and love in all of pharmacy.  I think 2013 will be a holding year for retail with little changing, but I suspect that it’ll be the calm before the storm of self-selection and remote supervision in 2014.  The difficulty will come from a lack of proven outcomes for what is done already, a squeezed budget from central NHS coffers and a lack of a cohesive plan for more commissioned clinical services.  An influx of pharmacists from PCT-land may also add pressure to the workforce, and staff may find (as locums are now) that remuneration and T&Cs are adversely affected.  And if that’s not bad enough you’ll all still be selling homeopathy.

 

Academia: I have no idea! You’ll have to speak to Messer’s Bush and Cox (no seriously, they’re called that, and they aren’t a late-night Channel 5 comedy duo: go follow @josephbush and @drarcox  to find out)

 

Industry – err. Dunno?!

 

Overall? 

There will be opportunities to do some innovative things in 2012 but it’ll be small-scale, patchy and uncoordinated; if experienced pharmacists have the balls then they’ll start up their own provider company (no CQC registration needed remember) and approach CCGs with ideas on what they can do to makes medicines count for patients.

In retail, the opportunities will be outside the NHS and with Local Authorities, using their key geographical positions, extended opening hours and enviable reach and footfall to place themselves at the forefront of what’s left of public health. But if anything, pharmacists are the most business-minded of healthcare professionals and in this current climate that is a huge strength.

 

But then again the best laid plans of mice and men and all that…

Roll on the New Year

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