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Department of General Practice and Primary Care and NHS Grampian

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Presentation on theme: "Department of General Practice and Primary Care and NHS Grampian"— Presentation transcript:

1 Department of General Practice and Primary Care and NHS Grampian
Modernising community pharmacy in Scotland- how do we know what the stakeholders want? Christine Bond Department of General Practice and Primary Care and NHS Grampian

2 Acknowledgements Research colleagues Funders
Terry Porteous, Mandy Ryan, Tony Scott, Michela Tinelli Phil Hannaford, Sally Wyke Funders Chief Scientist Office, MRC/ESRC, NHS R and D

3 Traditional NHS contracts

4 Traditional contracts
Dispensing of prescriptions volume driven payment Displaying leaflets Providing opportunistic advice on dispensed medicines professional fee Locally negotiated services eg drug misusers, nursing homes, compliance needs assessment, smoking cessation Recognition of other ‘private’ health care roles Sales of OTC medicines

5 New UK community pharmacy contracts (Smoking, Health and Social Care (Scotland) Act 2005)
Scotland (from July 2006) Four core services provided by all pharmacies Minor Ailments (MAS) Public Health (PHS) Chronic Medicines Service (CMS) Acute Medicines Service (AMS) Pharmaceutical Care Services Plan Locally negotiated services based on national specifications Performers List Supplementary (and Independent) prescribing OTC sales function still not NHS

6                                                                                                                          New contracts                                                                                                                                                                                                                                   

7 Policy, culture/society change
Drivers for change Policy, culture/society change Research data Practice norms

8 Policy, culture/society change
Drivers for change Expectations GP workload Skills mix Policy, culture/society change Relationships Convenience Drug budgets Research data Practice norms

9 Policy, culture/society change
Drivers for change Expectations GP workload Skills mix Policy, culture/society change Relationships Convenience Drug budgets Research data Practice norms DCE

10 New responsibilities for pharmacy
NHS role in self care and provision of advice and supply of medicines Community pharmacy led treatment of minor illness Chronic medicines review and supply Medication review Repeat dispensing Prescribing pharmacists What do pharmacists think? What do patients think? DCEs could have informed both of these

11 Will stakeholders accept new policies? Patients
DCEs have been used to assess What patients value in repeat dispensing Bond, C.M. , Matheson C., Jones, J., Williams, S. Repeat prescribing study: an evaluation of the role of community pharmacists in controlling and monitoring repeat prescribing, following protocols agreed with the general practitioner.Report to the Grampian Health Board February 1997 Acceptability of prescribing pharmacist Tinelli M., Ryan M., Bond C.,Patient preferences for increasing the role of the pharmacist in the management of drug therapy IJPP (R93) Pharmacist role in medication review Tinelli M., Ryan M., Bond C., Economic evaluation advancement in pharmacy: discrete choice experiments IJPP A12 The public’s preferences in self care Porteous, T., Ryan, M., Bond, C., Hannaford, P. Preferences for self-care or consulting a health professional in minor illness; a discrete choice experiment BJGP

12 Will stakeholders accept new policies? Pharmacists
Pharmacists’ preferences for contractual changes Scott. A, Bond, C.M., Inch. J, Grant. A, Preferences of Community Pharmacists for Extended Roles in Primary Care – A Survey and Discrete Choice Experiment. Pharmacoeconomics 2007;25 (9) Pharmacists’ preferences for different attributes of an electronic data interchange system Ubach, C., Bate, A.,Ryan, M., Porteous, T., Bond, C., Robertson, R. Using discrete choice experiments to evaluate alternative electronic prescribing systems.. Int.J.Pharm. Pract 2002; 10: Pharmacists’ decision making in OTC advice Roins S, Benrimoj SI, Carroll PR et al Pharmacists’recommendation of the active ingredient(s) of non-prescription analgesics for a simple tension and migraine headache JSAP 1998; 15:

13 Terry Porteous, Christine Bond, Phil Hannaford, Mandy Ryan,
Managing minor illness Factors influencing the choice between self-care and health professional advice: a discrete choice experiment. Terry Porteous, Christine Bond, Phil Hannaford, Mandy Ryan, Sally Wyke This study was part of a research training fellowship funded by the Chief Scientist Office of the Scottish Executive. As we know, self-care encompasses various activities but in this case, I looked specifically at self-care of minor illness rather than self-management of chronic conditions.

14 Study design Qualitative interviews Aim - To describe what factors influence patients when deciding how to manage minor ailments associated with analgesic use Discrete choice experiment Aim - To describe what trade-offs people make when deciding how to manage minor ailments associated with analgesic use It was a two stage process. Qualitative interviews collected in-depth information about how people manage their symptoms And the DCE aimed to find the relative importance of the some of the factors that influence people when they decide how to manage symptoms

15 Qualitative interviews
24 interviews across Scotland asking about: recent experience and management of symptoms associated with analgesic use. reasons for practising self-care and/or consulting health professionals opinions on self-care and use of analgesics Interviewees were a purposive sample of people who had responded to previous survey and had agreed to further participation

16 Influencing factors Reasons for practising self-care
Faster treatment/easier access Use of complementary treatments Avoidance of unwanted treatments Feelings of control/independence Previous experience of same symptoms Advice from friends, relatives or media Perception that condition is self-inflicted Belief that GP will be of limited help Does not want to waste Dr’s time Reasons for not practising self-care Having to pay for treatments yourself No advice from Dr/pharmacist Chance of missing important condition Chance of drug interactions Chance of making things worse Belief that nothing can help or stoicism Lack of knowledge Belief that only medical help will work One of the outputs of this stage was a list of why people do or don’t practise self-care. Some of these are more obvious than others.

17 The attributes The “influencing factors”
Type of management (self-care, GP, pharmacy, practice nurse, complementary, NHS24, do nothing) Time to treatment (the time you have to wait for an appointment, travel time and time taken to get any treatment) (0,1,5 hours, 1,2,5 days) Cost (travel costs and the cost of any treatment e.g. any consultation fee, over-the-counter medicines, complementary remedies etc.)(£2, £5, £7, £15) The attributes for how people manage symptoms of minor illness were derived from the interview data and these three were chosen because they could potentially be influenced by policy or by varying the model of service delivery.

18 The scenario Please imagine this situation:
You have a headache and a fever, your bones are aching and your nose feels slightly blocked up. You are still able to do all the things you usually do but are more tired than usual. The symptoms started to appear four days ago, and were slightly worse when you woke up this morning. This scenario was chosen with advice from a GP. It describes a minor condition that in most cases he’d rather not see in his surgery but often does

19 A sample question Example Which option would you choose? Option 1
Option 1 Option 2 Type of management Self-care GP Availability 1 hour 2 days Cost £2 £7 We used the attributes to develop a series of choice questions like this one – each of the attributes is included in two service options and respondents had to pick which one they preferred. Each person had to answer 13 of these questions differing in the levels of the attributes. We also collected descriptive data, including demographics, lifestyle data, aspects of health and attitudes to medicines but I won’t be discussing these today.. (Tick ONE box only) Option Option Do nothing

20 DCE analysis and results
DCE administered during November 2005 Response rate of 57% (326/573) Analysed using multinomial logistic regression Regression coefficients used to estimate - utility (“preferences” or “satisfaction”) - willingness-to-pay Participants were selected from the people who responded to our original survey.

21 Decreasing preference
Overall preferences For the symptoms presented: Respondents had a general preference for doing something (rather than “do nothing”) Relative preferences for type of management: Self-care Community pharmacy GP consultation Practice nurse NHS Complementary Decreasing preference From the regression coefficients, we found that respondents had a general preference for doing something rather than doing nothing – so rather than wait and see, they preferred to take action Self-care was the most preferred type of management. Advice from a community pharmacy or a GP consultation had similar levels of utility but advice from NHS24 and the complementary option had much less utility.

22 Conditional logit regression analysis

23 Willingness to pay Respondents valued self-care
at £ i.e they were prepared to pay up to £22.62 to treat these symptoms by self-care but beyond this price, they would rather “do nothing”.

24 Willingness to pay They valued other treatment options less
highly e.g. they would pay £17.01 LESS than this to treat symptoms using the NHS24 option

25 Willingness to pay They were prepared to pay £3.69 to reduce the
wait to treat symptoms by 1 day

26 Moving from one “service” to another
Type of management Telephone advice from NHS24 Ask for advice in a pharmacy Wait before treating symptoms 5 hours 1 day We can use willingness to pay to compare different configurations of services that might be available

27 Moving from one “service” to another
Type of management Telephone advice from NHS24 β = -1.48 Ask for advice in a pharmacy β = Wait before treating symptoms 5 hours β = 5/24*-0.321 1 day β = Utility of a service = Constant (1.968) +β (service) Moving from NHS24 to pharmacy management gives an increase in “utility” ie β (NHS24) – β (pharmacy) = – (-0.304) = We can use willingness to pay to compare different configurations of services that might be available

28 Moving from one “service” to another
Type of management Telephone advice from NHS24 Ask for advice in a pharmacy Wait before treating symptoms 5 hours β = 5/24*-0.321 1 day β = Utility of a service = Constant (1.968) +β (service) Moving from a wait of 5 hours to 1 day gives a decrease in “utility” ie β (5 hours) – β (1 day) = – (-0.321) = We can use willingness to pay to compare different configurations of services that might be available

29 Moving from one “service” to another
Type of management Telephone advice from NHS24 Ask for advice in a pharmacy Wait before treating symptoms 5 hours 1 day Overall difference in “utility” is positive and we can quantify it by WTP U (service 1) – U (service 2)/ β (cost) = /-0.087 = £10.60 Rather than get telephone advice from NHS24 with a 5 hour wait, a respondent would be willing to pay an extra £10.60 to get advice from a pharmacy with a wait of 1 day We can use willingness to pay to compare different configurations of services that might be available

30 Conclusions Self-care was the preferred way of dealing with these symptoms It was highly valued by respondents Community pharmacy was the preferred source of professional advice DCE allowed quantification of preferences and expressed them by WTP

31 Assessing what patients liked about pharmacist led medicine management
Tinelli M, Ryan M, Bond C

32 The Community Pharmacy Medicines Management Project*
Aim: to evaluate the introduction of the Medicines Management Service by community pharmacists for patients with CHD Randomised Controlled Trial Setting: Nine Health Authorities in England, 50 Community pharmacies, 39 General Practices Primary subjects: Patients with CHD Intervention: Community Pharmacy face-to-face patient review to include medication and lifestyle advice Control: Usual care The Community Pharmacy medicines Management Project Evaluation team (C. Bond Principal Investigator) The MEDMAN study: a randomized controlled trial of community pharmacy-led medicines management for patients with coronary heart disease. Family Practice 2007; 24(2):

33 The Community Pharmacy Medicines Management Project
Primary outcome measures: appropriate treatment (derived from the NSF), health status (EQ5D and SF36) Secondary outcome measures: satisfaction, experiences and attitudes of patients and health care professionals Time period: All measures were assessed at baseline and 12 months Results: no changes in clinical or QALY outcomes; patients satisfaction higher in the intervention group To use a DCE to Explain the increased satisfaction Inform a CBA for the community pharmacy-led medicines management service

34 Use of DCE Identification of attributes from replies to patient survey
DCE survey questionnaires sent to all patients participating to the trial 2 years after study start (879 intervention; 470 control) DCE compared three options: a novel community pharmacist and general practitioner review of medicines (CPGP) a GP only medicines review (GP) the current scenario WTP in moving from the current situation to ‘CPGP’ or ‘GP’ were estimated Groups compared: intervention all vs control (TAU) (ITTA) intervention still receiving the Medman service vs control (TAU) (PPA) A priori assumed people who had experienced the service more likely to value it

35 Attributes Advice Time (travelling to and in the pharmacy)
None, only on medicines, only on health/lifestyle, both Time (travelling to and in the pharmacy) 10,20,30,40 min Privacy (in the pharmacy) Satisfactory replies to questions Yes, No Chance of receiving most appropriate treatment Very poor, poor, good, very good How much you pay ( medicine + advice+ review+ travel) £0, £10, £20, £30

36 Example of DCE choice Medicines review by GP and Pharmacist
Medicines review by GP only Current situation ADVICE On medicine & health/lifestyle No PRIVATE DISCUSSION Yes SATISFACTORY REPLIES CHANCE OF APPROPRIATE TREATMENT Very good TIME (Travelling to + waiting in the pharmacy) 10 minutes HOW MUCH YOU HAVE TO PAY (Consultation + medicines + travelling) £ 10 WHICH SERVICE WOULD YOU CHOOSE? (Tick one box only)

37 Results Response rates: Intervention (73%) and Control (67%)
44% of intervention still receiving the service, 52% stopped , 4% never The preferred option for all groups was the current option Controls: ‘Chance of receiving the best medicine’ and ‘cost’ were most important If moving from the current service would choose the GP only option

38 Intervention groups Intervention all
‘Advice on medicines’, ‘satisfactory replies’ as well as ‘chance of receiving the best medicine’ and ‘cost’ were most important If moving from the current service would choose the GP only option Intervention still receiving the service ‘Advice on medicines’, ‘satisfactory replies’, ‘chance of receiving the best medicine’ and ‘cost’ remained most important plus ‘advice on medicines and lifestyle’ If moving from the current service would choose the combined GP-pharmacist option

39 Willingness to pay Intervention all
Valued their current service at £19.28 Intervention still receiving the service Valued their current service at £21.99 Would pay £50 to move to a GP-pharmacist service Control groups Would pay £17.09 to stay with their current service rather than move to GP-pharmacist service

40 Cost benefit analysis for trial
Control Intervention all Intervention still receiving the service Mean extra benefits per patient (from DCE) -£17.09 £19.28 £21.99 Mean extra cost per patient £32.67 £18.16 Mean net benefits per patient £-49.76 £1.12 £3.83

41 Decision making process Efficient allocation of resources
Outcome measures Results Economic evaluation Clinical outcome (Appropriateness of treatment) NO difference across groups Cost minimisation Results: increased total NHS costs with the introduction of the service QALY (EQ5D and SF6D) DCEs Differences across groups: Subjects who experienced the new service valued the input from their pharmacists, and preferred it to any other option Cost benefit analysis Results: The increase in intervention costs was partially compensated by increased patients’ valuation for that service

42 Conclusion Patients value the opportunity to have input from both pharmacist and GP Extra costs of delivering the pharmacy led medicines management service were partially offset by increased value to patients The DCE methodology: helped understand what patients valued quantified value of the service within a CBA is useful for use in pharmacy policy decision making

43 Summary DCEs can inform emerging policy and evaluate implemented policy Add a dimension not otherwise available In pharmacy research has explained what stakeholders want and how it is valued

44 Thank you for listening


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