As the NHS looks to achieve dramatic savings over the next few years and become ever more patient-centric, an area of increasing priority is the of using medicines to their maximum ability.
This idea of medicines optimisation is not necessarily a new one, but it is one that is currently riding high on the agenda of a healthcare system that is increasingly looking to put patients at the heart of treatment, and make them feel in control of their medicines.
Current research suggests that just 16 per cent of patients in the UK who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need.
On top of this, almost a third of patients become non-adherent to treatment regimens just 10 days after starting a new medicine – for both intentional and unintentional reasons.
There are also issues with how well healthcare professionals (HCPs) are delivering these medicines, with studies suggesting that in UK care homes, over two thirds of residents were exposed to one or more medication errors, while in general practice an estimated 1.7 million serious prescribing errors occurred in 2010.
Such practice is obviously not good for the health of a patient but medicines optimisation is also crucial in economic terms considering medicines remain the most common therapeutic intervention in healthcare and wastage is estimated to cost £300m a year.
That’s not to mention the knowledge that at least six per cent of emergency re-admissions are caused by avoidable adverse reactions to medicines.
This increased urgency in the area from all healthcare stakeholders is exemplified by the launch in May 2013 of the Royal Pharmaceutical Society report Medicine Optimisation: Helping patients to make the most of medicines.
Not only was its content important – offering four guiding principles to healthcare professionals in England to help patients achieve the best outcomes – but its wide variety of supporters was evidence that a joined-up, collaborative approach was of interest for all.
These supporters represented all facets of UK health: NHS England, the Association of the British Pharmaceutical Industry (ABPI), the Royal College of General Practitioners (RCGP), the Academy of Medical Royal Colleges and the Royal College of Nursing.
By adding their names to the document, each organisation agreed with the Royal Pharmaceutical Society’s four principles: aim to understand the patient’s experience; evidence-based choice of medicines; ensure medicines use is as safe as possible; and make medicines optimisation part of routine practice.
These are four simple, even obvious principles, but they aim to tackle some of the key reasons for poor medicines optimisation – a term that encompasses many factors including adherence to drug regimens and awareness and effective management of side effects.
Reasons behind poor optimisation from a patient’s perspective vary, but they can include a patient’s personal beliefs. Why should someone take a medicine if he genuinely doesn’t believe he has asthma?
More practical reasons include the difficulty of acquiring medicines, possibly due to living in a rural area, or socio-economic problems in circumstances where patients have to pay for medicines.
Perhaps the most overriding reason, however, is a patient’s poor understanding of his medicine, which, more often than not, is down to a lack of communication between a patient and his pharmacist, or other healthcare professional.
And if a patient doesn’t understand his medication, the consequences can be serious.
Prof Carol Farrow, clinical director of pharmacy services, Norfolk and Norwich University Hospitals Trust and honorary professor, School of Pharmacy, University of East Anglia, speaks from personal experience when explaining the need for knowledge to achieve medicine optimisation.
“If patients don’t understand how to take medicines and what to do with them, that leads to poor medicines optimisation,” she says.
“My father was on diuretics, and when he dialysed himself, he thought he didn’t have to take his medication anymore. Nobody had helped him understand the reason he was taking his medicine.”
But who is responsible for ensuring patients are informed about their medicines? According to Prof Farrow, it’s a task for all HCPs, with leadership from pharmacists.
“When you look at medicines optimisation, it’s all about getting the best outcomes for patients,” she says. “As pharmacists we have been doing medicines optimisation for years, but what we have never done is engage with the full multi-disciplinary team – explaining and getting nursing and medical staff on board to all breathe medicines optimisations.
“Pharmacists can train HCPs though and educate on adherence. There’s also the potential for specialist pharmacists to work with colleagues at ward level.”
Of course, improving communication with the patients is another vital aspect.
“Pharmacists can influence patients in a number of ways in hospital,” says Prof Farrow. “Part of that is gaining skills to look at what a patient is doing with their medicines and being able to question and counsel them at the same time.”
“And when looking at patients in clinics, there are pharmacists in places like HIV clinics working with the patient to ensure they understand what they are doing and taking their drugs to accommodate lifestyle. This can be as simple as what to do if a drug is meant to be taken with breakfast but a patient doesn’t eat breakfast.”
Pharmacists also need to help equip patients to communicate information between the different components in their treatment, according to Farrow. This may be simpler in hospital, but patients must need to be able to effectively deliver information to community pharmacists, dentist, GPs and other groups who impact their health.
“In those incidences we’ve got an opportunity to look at developing better means of communication, be it through handheld records, medication passports or electronic communication. There’s a lot of work to do to put patients at the heart of medicines optimisation.”
The significance of improved medicines optimisation would have wide-reaching effects across the entire NHS, according to deputy chief pharmaceutical officer Clare Howard.
Speaking at the Pharmacy Management National Forum in 2013, Howard spoke of the impact medicines optimisation would have on the key areas to improve across the five key domains of healthcare outlined by NHS England.
As an example, Howard said it was “it was inconceivable that we will reduce premature mortality for people with respiratory disease without supporting people to use their inhalers correctly”.
For Howard too, the answer is improved collaboration and communication both within the healthcare system and with patients, and following the principles produced by the Royal Pharmaceutical Society.
“I’ve been under significant pressure to deliver a strategy around medicine optimisation. We’ve always said all along with medicines optimisation that we as HCPs would no longer think we have all the answers but we must engage with patients and have a conversations that asks what do services need to look like so that you are more likely to take medicines as intended.”
