08 Making better use of pharmacy Chair Donal
08 Making better use of pharmacy Chair: Donal Markey, Head of Primary Care Commissioning, NHS England (London Region) Transforming London’s health and care together
Making the most of community pharmacy Donal Markey Pharmacy Advisor HLP Children & Young People
Aim and purpose of this session How can Healthy London Partnership: • Support the role of community pharmacy in supporting CYP? • Promote understanding for future workforce planning and development? • Consider the barriers to the better utilisation of pharmacy and how to overcome them? 1 Overview of community pharmacy 2 Examples of services commissioned in pharmacies which support CYP 3 Opportunities to consider community pharmacy in Out of Hospital care pathways
Overview of community pharmacy Pharmacy services in England: Key facts 2015/16 7. 8 m items of Fluticasone Propionate (inhaled) dispensed 1. 08 billion prescription items dispensed in the community £ 9. 27 billion was the cost of prescriptions dispensed in the community 11, 688 community pharmacies in England 1862 in London 3. 3 million Medicine Use Reviews , average of 280 per annum for a London Pharmacy 34. 4 m Simvastatin was the most prescribed chemical Fluticasone Propionate (inhaled) remains the highest costing medicine at £ 376 m 35. 4% of items dispensed by EPS 821, 893 New Medicines Services interventions, average 78 per annum for a London Pharmacy
Overview: Community Pharmacy Services Categories & Funding sources Service Essential Advanced Commissioner NHS England Central Global Sum Dispensing Public Health Campaigns Audit NHS England Funding Source Examples Central Global Sum Medicine Use Reviews New medicine Service National Flu Service (+ 18 years of age) Urgent medicine supply services Quality Payment NHS England Enhanced Central – Global Sum Inhaler D surveillance NHS Choices Local - NHS England Regions Minor Ailments Service Extended opening hours Immunisation Higher level medication review services NHS England Locally Commissioned CCG or Local Authority Local Stop smoking Sexual health services Screening Minor ailments
Pharmacy Integration Fund Support transformation in FYFV, £ 42 m 2016 -18 Integrate and develop clinical pharmacy practice in a wider range of primary care settings. Free up community pharmacists and their teams to: • spend more time delivering clinical services and health improvement for their patients; • work in a variety of NHS settings • Utilize technology. The initial priorities for the fund in 2016 -18 are: Deployment of clinical pharmacists and pharmacy services in community and primary care including groups of general practices, care homes and urgent care settings such as NHS 111. Development of ‘infrastructure’ through the pharmacy professional workforce, accelerating digital integration and establishing the principles of medicines optimisation for patientcentred care. https: //www. england. nhs. uk/commissioning/primary-care/pharmacy/integration-fund/
Out of Hospital care for children & young people provided by pharmacies Public health campaigns & audits
Asthma Management Children & Young People
Highlights Final results 1, 865 Community pharmacies across the whole of London were invited to a take part 1, 225 Pharmacies responded 65. 7% 32 of the total number of pharmacies 9, 690 9. 4 responses Average of participant boroughs (all) took part Participation per borough 100. 0% 90. 0% 80. 0% 70. 0% 60. 0% 50. 0% 40. 0% 30. 0% 2 October till Results 20. 0% 10. 0% 9 1 in 4 Average entry per pharmacy Entries were using a smart device 0. 0% Hackney Westminster Barking and Dagenham Lewisham Newham Lambeth Islington Greenwich Bromley Merton Tower Hamlets Camden Bexley Redbridge Richmond upon Thames Croydon Wandsworth Waltham Forest Sutton Southwark Harrow Hillingdon Kingston upon Thames Havering Barnet Kensington and Chelsea Haringey Enfield Hammersmith and Fulham Ealing Brent Hounslow Campaign extended to 10 weeks 36% 25% 48% 70% 64% 23% 96% Did have a flu jab last year Had to make an emergency request for an inhaler in the last 12 months Do have an asthma action plan or wheeze plan Had a inhaler technique assessment in the last 12 months Have a spacer device Live with someone who smokes Do not smoke
On-line Asthma Toolkit Support across the system to improve asthma care https: //www. healthylondon. org/children-and-young-people/london-asthmatoolkit
Oral Pain Management Children and Young People
Summary Headlines 65% 9% 66% purchasing or seeking advice about children’s pain medications reported that their child had pain in their mouth and/or a tooth reported that their child had signs and symptoms suggesting a dental emergency that required immediate attention who reported that their child had definite pain in their mouth and/or a tooth had not seen a dentist before visiting the pharmacy 54% 15% 41% who had a definite pain in their mouth and/or a tooth and a regular dentist had not actually seen their dentist who had a definite pain in their mouth and/or a tooth had seen a GP before visiting the pharmacy who had a definite pain in their mouth and/or a tooth reported signs and symptoms indicative of a toothache of parents of children
Examples of services which support CYP Minor Ailments Service Mixes of NHSE and CCG services in London Present 22 boroughs in London Support Common Ailments in CYP • Head lice • Nappy rash • Cough & cold Cited in 5 YFV as a key enabler in support GP practices in capacity management NHS England reviewing the commissioning model in 2017/18 Potential for integration with OOH pathways, NHS 111 Asthma Assessment Service, Bexley CCG Pilot scheme makes use of pharmacists’ expertise Encourages closer working between GPs and pharmacists
Incorporating community pharmacy It’s not working. What could we do better? Home Source R Chavasse , St Georges School Nurse Primary Care School 2 nd / 3 ry Hospital Care
Plenary session: Next Steps for discussion 1 Would any of these ideas work or transfer into your CCG or STP footprint? 2 Consider how HLP could support 3 Talk to the NHS England DOP team; they can provide additional information on Pharmacy 4 Identify locally which pharmacy leads could take any ideas and opportunities forward within the system.
What is stopping Pharmacy being fully utilised? “Community Pharmacy is not seen as ‘the NHS’ by the public and there is a lack of patient understanding of the services we can offer” “Some GPs do not understand what pharmacists can do” “We need support to understand what commissioners want” “We need support to understand how we can deliver to outcomes” “Pharmacists often aren’t involved in redesigning services” “There is a lack of good news stories about pharmacy. “Services are fragmented and there are multiple agencies – how do we work with them all? ” “Pharmacists are thought of as a shop keeper or private business rather than a clinician” “We need support understanding the future system” “Community Pharmacy has been seen as ‘less clinical’ than other pharmacists” “Pharmacists are often left out of the conversations”
NHS 111 / Integrated Urgent Care: making better use of pharmacy Gill Chambers, Healthy London Partnership
NHS 111 / Integrated Urgent Care Patient Flow NHS 111 has been in place across England since 2013 to provide a 24/7 single point of access for assessment of urgent health needs, with the aim of signposting or referring to ‘right place, first time’. When you have an urgent health need … Referral to A&E, via 999 or walk-in Further telephone assessment by the Integrated Urgent Care clinical assessment service, a multi-disciplinary team including a prescribing pharmacist Referral to a range of services including community pharmacy, using direct booking where available NHS Pathways assessment Call closed with advice only Age profile of callers to NHS 111 in London* 0 -17 age group * Data for London NHS 111 – 1 st February to 30 th April 2017 (3 -month period) CYP age split
NHS 111 Urgent Medication Supply Advanced Service NUMSAS provides a convenient and cost-effective way of providing emergency supply of repeat medication, accessed via NHS 111. When you have an urgent repeat medication request … Further telephone assessment by the Integrated Urgent Care clinical assessment service, a multi-disciplinary team including a prescribing pharmacist NHS Pathways assessment Referral to a community pharmacist near the caller’s current location Analysis of CYP use of NUMSAS in London* * Data for London NHS 111 – 1 st February to 30 th April 2017 (3 -month period)
NHS 111 / Integrated Urgent Care CYP Flow 0 - to 17 -year-olds make up approximately 27% of calls assessed in NHS 111. A typical patient flow is shown below. 18 Referral to A&E, via calls 999 or walk-in When you Further telephone assessment by the Integrated Urgent Care clinical assessment 60 have an service, a multi-disciplinary team including calls urgent a prescribing pharmacist health Referral to a range of services including community 18 NHS Pathways need … pharmacy, using direct booking where available calls assessment Call closed with 4 100 calls advice only calls CYP case mix in London* Community pharmacy 635 cases – 0. 8% of all CYP calls to NHS 111. Table shows breakdown by type: Potential cases for pharmacist in Integrated Urgent Care and/or community pharmacy – 10% of all CYP calls to NHS 111. Table shows breakdown by type: * Data for London NHS 111 – 1 st February to 30 th April 2017 (3 -month period)
Innovations in community pharmacy Amit Patel, CEO Pharmacy London
Vision Ø The ability to promote self care and prevent escalation of LTCs through easily accessible services Ø Understanding local patient populations and their intricacies Ø The ability to work with a diverse set of partners
Opportunity Ø 1. 8 million patients walk through community pharmacy a day Ø Being able to truly employ family based care Ø Early intervention and prevention, using childhood obesity as an early indicator Ø Working with voluntary sector to look at social issues Ø Vitamin D promotion Ø Young patient education
Business Case GP visit (11. 7 min) - £ 45 GP telephone consultation(7. 1 min)- £ 27 GP home visit (23. 4 min) - £ 114 Nurse Consultation( 15 min) - £ 13 A&E visit - £ 138 Outpatient attendance - £ 117 Pharmacy Cost- £ 1. 50 to £ 2 per minute Large savings to be made Increased ability to see more patients Less pressure on A and E and the rest of the system Increases ability for GPs to see the patients that really need to see them. The ability to seamlessly join services and manage patients holistically ie. Whole care needs planning, Family care planning and education, accessible to all, ability to manage discharge and reduce chances of readmission • But this only happens if CFS is funded!!! § § § § • • •
Positivity with meaning
Questions?
CAMHS & Community Pharmacy Innovative Partnership Project Dr Subha Muthalagu, Project Lead, Consultant Child & Adolescent Psychiatrist, Sussex Partnership NHS Foundation Trust Ray Lyon Chief Pharmacist, Strategy, Sussex Partnership NHS Foundation Trust
Funded by A Health Foundation Innovating for Improvement Award – Round 3
CAMHS Context • Increasing referrals, complex presentations, inadequate resources • Expectation to maintain service safety and quality • CYP on ADHD medications require regular physical monitoring • Compliance with NICE guidelines • 3 monthly BP and HR measurement, plotting on centile charts* • 6 monthly weight and height measurement, plotting on growth chart • Regular monitoring of side effects and review of ADHD progress *Local agreement that once the medication was stable this could be undertaken 6 monthly
Framework used • Needs of the patient and their family at the centre of the innovation • Co-designing the project with key stakeholder involvement throughout: • Stakeholder engagement events - design the patient journey • Lymington Mini-Pilot – testing patient journey • Learning and making continuous improvements with feedback
Care Pathway • Family consent to participate • CAMHS register patient on to Pharm. Outcomes and refer them to their chosen pharmacy • Pharmacy staff book appointment - enter measurements on Pharm. Outcomes • CAMHS team review results and communicate to GP and family and amend the care plan is necessary
Key Achievements • Trained 60+ community pharmacy staff to carry out W, H, BP, HR checks in CYP • 15 community pharmacies currently involved in the project – independents, Boots, Day Lewis and Lloyds pharmacies • Developed ADHD clinic database; 83% of patients were deemed eligible; 94% (142) have consented to participate • 116 have had at least one check; 33 two checks; 3 > three checks
Key Achievements • 100% of families said it saved them time with no additional costs to them; 97% want the project to continue in the future • More than 20 patients will now have annual reviews instead of 6 monthly reviews at the clinic • Established weekly multi-disciplinary ADHD team meetings, reflect on clinical and operational process and make continuous improvements • Developed an ADHD therapy group for CYP and currently in the process of setting up a 2 nd group • Clinic is more compliant with ADHD care pathway and NICE guidelines
Feedback from a parent “Happy with the new service of visiting the chemist for the physical checks. I know the staff there and it was bit more personal when I went for the check for my son - Lot easier and less stressful, unlike at the doctors where they could be running late and everyone looking at me and my son and wondering why he is getting stressed. “
Feedback from children & young people “Closer to home. I don’t have to get in a car” “Long trip Ashurst. Short trip pharmacy”
Feedback from a community pharmacist “Engagement in the CAMHS-Pharmacy project has been a positive experience for me and the pharmacy team. The children appear to be relaxed about coming into the community pharmacy to have their measurements taken and their parents/carers appreciate the convenience of both the location and flexibility of appointment times”.
Feedback from a general practitioner (GP) “More accessible for patients and family … No delay in scripts as we have the measurements all sent through to us before the scripts are requested … much easier for family than having to make appointment at surgery”.
Feedback from CAMHS staff “I have been able to make adjustments to medication more confidently over the phone …[and] Young people and families don’t have to wait for a face to face clinic appointment [or] take time off from work/school for having physical checks or have to attend clinic every 6 months to have these done (many now have annual clinic appointments)”.
Economics • The clinic is estimated to make a saving of at least 40% of its resources with the new service model • Resource saved will be used to reduce waiting lists, respond in a timely way to those who need specialist help, liaise with partner agencies and develop better therapeutic support for CYP and their families • CYP and their family also save money, time and inconvenience • Reduced carbon foot print
Key Benefits For service users For CAMHS clinic For Community Pharmacy Timely physical monitoring and improved access to care Formally included in the patient care pathway Receive regular repeat prescriptions Reduction in missed, delayed or non-attended appointments Greater job satisfaction Minimal disruption to school, work and family life Compliance with NICE standards Saving in travel costs, time and inconvenience Freed up clinical time reduce waiting lists Expert advice on medication Greater use of technology – Pharm. Outcomes, emails Reduced stigma Enhanced quality of care New business opportunities
Particular Thanks To … Paul Bennett Chief Officer, Hampshire & Io. W Local Pharmaceutical Committee Richard Edgeworth, Consultant, Springfield Consultancy Working with The Health Foundation
The Health Foundation ‘Innovating for Improvement Award’ Partners involved 1. Sussex Partnership NHS Foundation Trust (SPFT, Lead organisation) 2. Hampshire & Isle of Wight Local Pharmaceutical Committee (LPC) 3. Children and Maternity Collaborative Hampshire Five CCGs (hosted by North East Hampshire & Farnham CCG) 4. Strategic Clinical Network for NHS England (Wessex) for Maternity, Children and Young People 5. Wessex Academic Health Science Network (AHSN)
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