1. Community pharmacy Call to Action
Clare Howard – Deputy Chief Pharmaceutical Officer
Alison Hemsworth - Senior Programme Manager CPCF
Jan 2014
NHS | Presentation to [XXXX Company] | [Type Date]

2. The Call to Action Why are we here? Why are we really here?
The case for change – medicines optimisation
How does this relate to the Call to Action, Winter pressures work, the Urgent & Emergency Care Review and the ‘Earlier the Better’ campaign?
Key questions
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

3. So why are we here?
Call to action: a vehicle to inform the development of a five to ten year Community Pharmacy Strategic Framework
Planning guidance: Area teams will:
set out a five year strategic plan for how that service will improve within available resources, including dealing with any structural deficit;
include more granular detail for the first two years;
Local plans and national enablers
Why are we here today?
Recognises that significant change needs to happen to meet the needs of patients, problems with access to a GP and A&E and to meet current financial difficulties
It’s important that ATs include reference to the 5 year strategic plan to the pharmacy CTA so that results from local consultation can be fed into the local strategic framework.
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

4. So why are we really here?
We all can recognise that the use of medicines is sub optimal. Medicines optimisation.
Community Pharmacy can play a significant role in supporting patients to get more from their medicines.
Community Pharmacy can play a significant role in supporting patients and the public with public health issues
Urgent and Emergency Care Review. Recognised the role community pharmacy plays in terms of patients contact and support for out of hospital care.
Why do we need to engage with this for the future?
There is a massive challenge ahead of us in the way we influence how medicines are used.
£13.8b spent of prescribing and £2.5bn+ on CP contract
CP can play a huge role in all of this if the relevant systems are reorganised effectively and this will have a significant impact on patients
NHS | Presentation to Local Call to Action Events Jan-Mar 14

5. Medicines Utilisation in Practice
Medicines still most common therapeutic intervention and biggest cost after staff, but, for example:
-30 to 50% not taken as intended
- Patients have insufficient supporting information
UK Literature suggests 5 to 8% of hospital admissions due to preventable adverse effects of medicines
Medication errors across all sectors and age groups at unacceptable levels
Medicines wastage in primary care: £300M pa with £150M pa avoidable
NHS Atlas of Variation
Relatively little effort towards understanding clinical effectiveness of medicines in real practice
The threat of antimicrobial resistance
Appropriate vs inappropriate polypharmacy
Medicines are the most common therapeutic intervention.
For most patients their only interaction with healthcare professionals in relation to their medicines is the receipt and handing over of a green piece of paper. This has to change.
30-50% of medicines are not taken as intended by the prescriber and so the impact on the ROI is very significant if the issues relating to adherance are not addressed.
Medication errors are a particular problem in vulnerable groups but despite a body evidence showing that, when we place pharmacists in the right place in the patient pathway the risks to patient are significantly reduced, we are not making sufficient use of these skills
Upto £300m spent on waste medicines at least 50% of which could have been avoided
Variations in prescribing rates remain significant

6. We need to make this vision a reality, translating it into how patient care looks and feels
NHS England vision is high quality care for all. How do we make that actually happen for every patient. NHS Has committed to deliver improvements across 5 domains
Preventing premature mortality, enhancing quality of life for LTC,
Helping people recover from episodes of Ill health
Ensuring people have a positive experience of care
Treating people in a safe environment.
Issues like those that occurred at Mid Staffordshire can happen anywhere and we need to consider how to mitigate those circumstances

7. NHS Outcomes Framework; 5.4 Reducing harm from error
On an annual basis the SofS sets out a mandate for the NHS.
The NHS responds by producing the Outcomes Framework.
Medicines are only mentioned once but If you look at all the domains most of them require some medicines support
For example: How can we possible expect to reduce the mortality from respiratory disease without looking at the use of inhales and more specifically inhaler technique?
So by helping patients to use their medicines better will help to achieve all the outcomes on the framework

8. Key outcomes where MO contributes
Outcome indicator
Description
5.4 (Main contribution)
Incidence of medication errors causing serious harm
1.1
Under-75 mortality rate from cardiovascular disease
1.2
Under-75 mortality rate from respiratory disease
1.5
Excess under-75 mortality rate in adults with serious mental illness
2.1
Proportion of people feeling supported to manage their condition
2.2
Employment of people with long-term conditions
2.6ii
A measure of the effectiveness of post-diagnosis care in sustaining independence and improving quality of life 3a
Emergency admissions for acute conditions that should not usually require hospital admissions 3b
Emergency readmissions within 30 days of discharge from hospital
3.6ii
Proportion offered rehabilitation following discharge from acute or community hospital
4.1
Patient experience of primary care
4.2
Patient experience of outpatient care   
NHS Outcome Framework
Medicines Optimisation indicators
Comments
Domain 1 – Preventing people from Dying prematurely
Examples of measures that we might include
Prescribing spend by QOF achievement
1.1 Under 75 mortality rate from cardiovascular disease
Number of high risk medicines (cardiovascular) targeted MURs by 1000 population
Proportion of CVS patients who take their medicines as intended.
1.2 Under 75 mortality rate from respiratory disease
Number of targeted respiratory Medicines use reviews per 1000 population by CCG
Proportion of respiratory patients who take their medicines as intended
Number of unplanned emergency admissions for respiratory disease.
Domain 2 Long term conditions
2.1 Proportion of people feeling supported to manage their condition
Measure of patient experience from community pharmacy patient questionnaire
Proportion of patients compliant with their medicines by day 10
Number of targeted MURs per 1000 patients
Percentage of patients receiving Repeat Dispensing (QIPP Indicator)
Admissions to hospital for medication related events.
2.3.1 Unplanned hospitalisation for chronic ambulatory care sensitive conditions
Proportion of patients over 75 with a diagnosis of dementia receiving low dose antipsychotics.(proposed QIPP Indicator)
Proportion of patients receiving and post discharge MUR per 1000 patient population.
2.6.1 A measure of effectiveness of post diagnosis in sustaining independence and improving quality of life
Domain 3 helping people to recover from an episode of ill health
3a Emergency admission for acute conditions that should not usually require hospital admission
3.6.ii Proportion offered rehabilitation following discharge form acute or community hospital
Number of targeted (discharge) MUR per 1000 population by CCG
Domain 4 Ensuring that patients have a positive experience of care
Proportion of patients receiving Medicines reconciliation carried out within 24 hours of admission
Proportion of patients experiencing omitted and delayed doses by Trust
4.2 Responsiveness to inpatients personal needs
Domain 5 Treating and caring for people in a safe environment.
5.4 Incidence of medication errors causing severe harm
Incident reporting levels for Community pharmacy.
Incidents reporting level for General practice
Never Events
PINCER indicators score by GP Practice
Omitted and delayed doses rates by Trust
Medicine reconciliation rates by Trust
Yellow card reporting level

9. Medicines Optimisation Principles
In May 2013 the RPS produced their principles of MO.
NHS England has publicly committed to the principles and Keith Ridge, Bruce Keogh and Jane Cummings and Keith signed up to the principles.

10. Medicines Optimisation Progress Update 1
Held 2nd national conference in November. Well attended ( over 800 delegates NHS and Industry) and the concept is now widely accepted.
The MO measurement work in progress. Wider reference group and Technical group developing a prototype dashboard.
York and Sheffield Centre for Health Economics reviewing the economics of Medicines Optimisation
NICE have started their short clinical guideline process. (publication in 18 months). Engaged with chair of Guideline Development Group
Kings Fund recently published Polypharmacy and Medicines Optimisation Making it safe and sound
Medicines management had a focus around cost. Meds optimisation is adds in the need to get value from medicines use.
NHS England are currently developing a set of indicators around medicines optimisation so that we can start to benchmark
Kings fund
Key findings
For many people, appropriate polypharmacy will extend life expectancy and improve quality of life. Their medicines use will be optimised and prescribed according to best evidence.
In problematic polypharmacy there can be an increased risk of drug interactions and adverse drug reactions, together with impaired adherence to medication and quality of life for patients.
Many clinical trials and practice guidelines do not consider polypharmacy in the context of multi-morbidity. It is important that pragmatic clinical trials are conducted that include patients with multi-morbidity and polypharmacy. 
Multi-morbidity and polypharmacy increase clinical workload, so doctors, nurses and pharmacists need to work coherently as a team with a balanced clinical skill-mix. 
People often do not take medicines as they are intended. Evidence shows many dispensed medicines remain unused or are wasted.
During medication reviews, prescribers should consider if treatment should be stopped and ‘end-of-life’ care be offered for certain chronic conditions or cancer-related illness. 
Patients with multi-morbidity could have all their long-term conditions reviewed in one visit by a clinical team responsible for co-ordinating their care.
Patients may struggle with complex drug regimens; their perspective on medicine-taking must be taken into account when prescribing.
Policy implications
More training is needed in managing complex multi-morbidity, polypharmacy and other aspects of medicines management, involving GPs, older care clinicians, orthogeriatricians, clinical pharmacologists, nurse specialists and clinical pharmacists.
Systems are needed that optimise medicines use where there is polypharmacy so that people gain maximum benefit from their medication with the least harm and waste.
There are numerous evidence-based guidelines for the treatment of single conditions, but there is a need for guidelines on the treatment of multi-morbidity.

11. Medicines Optimisation Progress Update 2
RPS and ABPI are engaged and supporting the strategy development. ABPI secondee started Jan 2014.
Specialised Commissioning MO CRG now operational. First output released January. optimisation/
NHS England Community Pharmacy “Call to Action” published in December. Local events being organised by Area Teams to consider questions asked. Most Local Professional Network chairs appointed. All will impact on MO implementation.
The first NHS England MO patient engagement event was held in Leeds on 21st November. Report due Feb 2014.
Gain share
‘Principles for sharing the benefits associated with more efficient use of medicines not reimbursed through national prices’ published
NHS England’s Specialised Commissioning Medicines Optimisation Clinical Reference Group has published a document that sets out how collaborative arrangements between NHS England (as the direct commissioner of ‘specialised’ NHS services) and Trust providers of NHS services can work together to create incentives that achieve both better outcomes for patients and greater efficiencies in the use of drugs not reimbursed through national prices.
It is requested that NHS colleagues inform their medical directors and directors of finance of this publication.

12. MO measurement areas will move away from a cost focus towards other areas such as how patients are supported to get their repeats and how well they are supported to use medicines. E.g. repeat dispensing. In the CPCF since 2005 but utilisation is hugely variable.
We need to get to a point where community pharmacy can provide services that patients like and want to use

13. Community pharmacy
A number of important developments……

14. So… its starting to come together
Community Pharmacy so important to medicines Optimisation.
Much more to do in terms of engagement.
Call to action responses need to reflect this. Its not a “wish list” for community pharmacy. The call to action is the chance to outline the opportunities that community pharmacy presents to help improve patient outcomes and reduce some of the issues highlighted at the start.
We are starting to get there but there is still a huge amount of work to do in terms of engagement
The Call to Action is about what how CP could be better organised to support patient better its not about producing a wish list of all the services you would like to provide
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

15. Public Health Role (1)
Community pharmacies are located in the heart of communities
They are trusted health professionals on the high street, in supermarkets and shopping centres
They are especially accessible to deprived communities who may not access other conventional NHS services
Community pharmacies are already making a contribution to health improvement and protection and reducing health inequalities.
This contribution needs to be enhanced further
HLPS supported by their trained health champions are making a real difference to population health locally, using every interaction as an opportunity for a health promoting intervention, making every contact count.
There are growing numbers of HLPs across the country and that has been achieved without the concept being part of the CPCF. How could we capture what has been learnt in the contractual framework?
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

16. Public Health Role (2)
It is clear that community pharmacy can play an important role in improving the health of the population in England.
PHE has recently expressed keenness to explore:
The role of the HLP
Health marketing
NHS Health Checks
Blood pressure checks
Vaccination
Smoking Cessation
and have highlighted community pharmacy’s excellent track record in delivering these services
These are some of the issues that PHE wish to explore further with community pharmacies.
Smoking cessation results tend to be better for community pharmacy than for other providers of smoking cessation services but how can we make that universal?

17. Timeline NHS | Presentation to Local Call to Action Events Jan-Mar 14
Transforming Urgent & Emergency Care End of Phase One Report
13th November 2013
Long term strategy
Community Pharmacy - Helping with Winter Pressures
2nd December 2013
Short term solution
Improving Health and Patient Care Through Community Pharmacy
10th December 2013
The Earlier, The Better
20th January 2014
Short term campaign
Timeline
UECR is a national review with transformational change at it’s heart.
There has already been a phase one report and now they are moving towards the mobilisation stage
The vision is that this review will be fully implemented by Given the scale of change necessary this is a relatively short timescale.
The End of Phase One Report want to ensure that the skills and expertise of the community pharmacy workforce are much better integrated in patient care then is currently the case.
ATs and CCGs will need to consider which services they can and should commission from community pharmacy in order to progress the general trend of the review. For example that has been much talk about how better use of minor ailment services can keep patients out of A&E and GP practice services particularly during the evening and at weekends.
The UECR has a vision that all community pharmacies will be able to offer a minor ailment service. How we commission that service, be it locally or nationally, has still to be debated. Your views and those of your patients and the general public locally are key to those discussions.
The Earlier the Better campaign that was launched on 20th Janaury 2014 is the beginning of the public awareness campaign in relation to the services that community pharmacy can offer. However there is still a need for local awareness as you may be commissioning services that are discrete to your population.
Still in the vision stage is the concept of how 3rd sector partners and expert patients can get involved in educating patients and the public about their medicines, how they might safely be involved in medication reviews and adherance issues and helping the more vulnerable to collect their medicines in a timely manner.
Consistency of service provision, whoever the provider is, is a key theme throughout the end of phase one report. Currently access to services provided by community pharmacy, other than dispensing, are piecemeal.
There is a willingness to explore patient registration with pharmacies. However, as direct access to pharmacy without the need for an appointment at any of the 11,500 plus pharmacies in England is currently community pharmacy’s uniques selling point. Do we want to loose that?
As an interim measure whilst the UECR is still underway and the Call to Action (CTA) is still out for consultation it was decided that an interim position was needed for this winter.
With this in mind the document Community Pharmacy: Helping with winter pressures was published on 2nd December. This contains details of four services that ATs can commission either on their own behalf or on behalf of CCGs in the event of a looming winter pressure locally. The services are designed to be switched on when necessary and switched off again when the local pressure has fallen back to normal expectations.
This model could be the precursor to national templates for service specifications in the future. (NB: this is not the same as national commissioning)
The ultimate product of the Call to Action will be the development of a 5-10 year strategic framework for community pharmacy. Therefore it’s really important that response to the Call to Action are not just a wish list of what pharmacy professionals and their patients would like in the pharmacies. NHS England will need to set priorities and so it’s important that feedback tells us about real need for pharmaceutical services.
key points that the Earlier the Better campaign is aiming to get across:
Increase public understanding of where to access self-care information and advice.
Increase public understanding of and confidence in community pharmacy services.
Increase the number of people accessing self-care information and advice on NHS Choices when they have a minor ailment.
Increase the number of people accessing community pharmacy services when they have a minor ailment.
Target audience over 45s, over 60s via their friends, family and carers and carers years
NHS | Presentation to Local Call to Action Events Jan-Mar 14

18. Visit your local pharmacy first
Prime intention of all
Visit your local pharmacy first
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

19. What is digital media telling us?
The heavier and bigger the font and the brighter the colour the more dominant the word is in the word cloud
Colour importance:
Purple
Orange
Lilac
Blue
Black
NHS | Presentation to Local Call to Action Events Jan-Mar 14

20. Share of voice from twitter conversations
This is just a snap shot of the twitter feeds between 21st January and 11th Feb and demonstrates that the majority of the conversations that are being had (in relation to the set search) are around the call to action.
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

21. What are the Key Questions
??????
We will be discussing the key questions later on this evening so be prepared to give your views and have your chance to make an impact
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

22. What about engagement with Patients?
Nationally we will be:
Holding focus groups with patients and the public from ‘seldom heard voices’ groups
Disseminating a patient questionnaire via community pharmacies including online access
Developing a briefing sheet/slide pack for third sector organisations who may wish to run their own events
Tap into events already planned by Healthwatch England
Host webinars
This is not just about pharmacy professionals and commissioners having their say. Patients and the public should be a major part of the consultation.
These are some of the things the national support centre is putting in place to engage patients but……
NHS | Presentation to Local Call to Action Events Jan-Mar 2014

23. How will you engage locally with patients?
….. What are you doing locally?
NHS | Presentation to Local Call to Action Events Jan-Mar 2014