For many years, the government has been highlighting the potential benefits of closer working between GPs and pharmacists. The introduction of medicines use reviews (MURs) in 2005 was greeted with mixed enthusiasm by GPs, who did not always feel MURs added value to patient care.
In October, the pharmacy contract will see two important changes introduced. These changes could help GP commissioners achieve Quality, Innovation, Productivity and Prevention (QIPP) targets and deliver cost savings.
From October, 70 per cent of all MURs undertaken by pharmacists will need to involve patients taking one or more medicines who have agreed target conditions. These include patients taking high-risk medicines such as warfarin, those recently discharged from hospital and those with respiratory disease. Other targets will follow.
Alongside targeted MURs, a 'new medicine service' will be launched for patients starting a new medicine for a long-term condition. The pharmacist will provide advice, support, reassurance, information and follow-up to address patients' concerns over the first month of treatment. This has been shown to increase adherence.
In England, about 15 million people live with a long-term condition. Community pharmacies dispense more than 800 million NHS prescriptions a year and about 70 per cent of those are for repeat medication.
Between 30 and 50 per cent of prescribed medicines are not taken as recommended, with significant cost implications for the patient, in terms of lost health improvement, and the NHS, in terms of waste and suboptimal return on investment in prescribed medicines.
Research shows that when patients start a new medicine, they often miss some doses or stop taking it, so that just 10 days after starting, 30 per cent are already non-adherent. GPs and pharmacists are often unaware of this, which means that in effect, every time doctors prescribe a new medicine, a third of the time, that investment is wasted. Addressing this problem could be a good way to achieve QIPP targets.
Experts in the field differentiate between two types of non-adherence. Non-intentional non-adherence is when patients do not take their medicines because they forget; perhaps they have a complicated regimen and they make mistakes, or they have physical problems such as difficulty swallowing or poor dexterity. About 55 per cent of non-adherence is due to these and similar reasons.
Intentional non-adherence is when patients weigh up their knowledge of the benefits of their new medicine against their concerns about it, and conclude that it is going to do them more harm than good. In other words, they consciously decide not to take the medicine. This happens in about 45 per cent of cases.
We also know from research that patients' beliefs are often formed in the absence of the whole story – and that just 10 days after starting a new medicine, 61 per cent of patients feel they are lacking information. At four weeks, this is 51 per cent.
Many patients report concerns and problems with their medication, including side-effects. Half report a problem with their medication at 10 days and at four weeks, in 22 per cent of cases, the problem is still there. At four weeks, 26 per cent of patients say that a new problem has emerged.
Just 16 per cent of patients who are prescribed a new medicine are taking it as prescribed, experiencing no problems and receiving as much information as they believe they need. It is no surprise that pharmacies are full of unused returned medicines. There is substantial room for improvement.
THE NEW MEDICINE SERVICE
New medicine service
The new medicine service aims to do something about this. A brief description of the service is given in the table below. The service targets patients starting a new medicine for a long-term condition, taking a three-stage approach - engagement, intervention and follow-up.
From a GP commissioning perspective, these services could be an early win to support QIPP. Funded from the national pharmacy contract, they cost GP commissioners nothing, yet potentially, they can help deliver significant cost savings.
They target patients in need of additional help and support, who are in many cases already targets for QIPP initiatives and an early focus for GP commissioners. If we can integrate them with general practice at the front line, everyone stands to benefit.
GP commissioners who facilitate dialogue between local pharmacists and GPs over the coming months, so that both parties agree on the best way to achieve integration, will see better results and greater cost savings.
Engaging with other groups of professionals is a desirable trait to exhibit and this exercise would also provide an excellent case study for the consortia authorisation process.
With so much money invested in medicines, this new approach has to be worth trying.
- Georgina Craig heads the NHS Alliance's Pharmacy Commissioning Network