General Comments

We are pleased to see that the outcomes framework is focused on the three elements of quality; safety, patient experience and effectiveness. Pharmacy can, and does, play a major role in all three of these areas, particularly the effective usage and safety of medicines. We welcome the fact that the outcomes suggested involve a multidisciplinary approach.

The EPB agrees that joint-working is essential in delivering healthcare. The Framework needs to promote integrated care, which is currently not as evident as it should be. Similar frameworks will be developed for the social care and public health services in due course and these frameworks will all need to interlink and support each other. In fact, the ideal situation would be to have one overarching framework with each of the three elements, NHS, Public Health and Social Care, as subsets.

The consultation focuses on patient safety which suggests that the pharmacy profession may face greater scrutiny and pressure to reduce errors and increase reporting of mistakes where they occur.

The most evident block to an open exchange of information on dispensing error and other related mistakes is the existence of the sections within the Medicines Act that deem a dispensing error a criminal offence. A true exchange of information will not take place until this legislation has been changed.

The consultation looks to establish a set of five outcome domains and the EPB would like to take this opportunity to highlight how pharmacy can help the NHS to deliver in these areas:

1. Preventing people from dying prematurely. Pharmacy plays a major role in preventative health (public health). Some examples include their role in early awareness and diagnosis of cancer, substance misuse and smoking cessation. They are frontline clinicians that are easily accessible by the public and often have contact with people, including vulnerable groups, that don’t access the NHS anywhere else. Pharmacists also provide advice to patients and the public on self care. Pharmacists advise patients on their medicines, their appropriate use, the possibilities of side effects and interactions with other medicines and the most appropriate way in which to take them. There should be a greater focus on reducing the incidence of hospital acquired infections (HIAs) such as MRSA and C.Diff. Pharmacists in hospital settings and those implementing primary care antibiotic formularies play a major role in the reduction of morbidity from HIAs.
2. Enhancing quality of life for people with long-term conditions. The suggested ‘first prescription service’ outlined in the Pharmacy White Paper ‘Building on strengths – delivering the future’, should continue to be developed and commissioned at a national level. This will provide patients with the opportunity to learn more about their condition and the associated treatments as well as the self care and management aspects when they are first diagnosed with a condition. In the longer term this is likely to increase adherence to medicines, thereby reducing part of the estimated £100m per year of wasted medicines [1], in addition to unplanned admissions to secondary care.  Community pharmacists are providing a Medicines Use Review (MUR) service which has been well received by patients and targeted MURs are producing results in terms of reduced hospital admissions and better medicines adherence. A number of pharmacists have prescribing status and they too play a role in the management of long term conditions (LTCs). The EPB would like to see a move towards pharmacists managing the care of patients with long term conditions, after their initial diagnosis.
3. Helping people to recover from episodes of ill-health or following injury. Pharmacy has a major role in the treatment of minor ailments and a number of successful minor ailment services have been developed and implemented at a local level. We suggest that the government considers the development of a nationally commissioned Minor Ailment Service, as is the case in Scotland. Pharmacists can also help with injuries such as advising on pain management and correct management of sprains and strains. The recent Bow Group report suggests a possible 57 million visits to G.P. can be transferred to community pharmacy with a net saving of £812 million per year [2].
4. Ensuring people have a positive experience of care. We believe that many patients have a positive experience of community pharmacy. Community pharmacist contractors, as part of their national contract, need to ensure that they carry out an annual patient satisfaction survey, the results of which could be shared at both local and national levels. Pharmacy can also play an important role in the development and delivery of Patient Reported Outcome Measures (PROMs) as they have access to a wide range of patients and the public and interact regularly with patients who have long-term conditions.
5. Treating and caring for people in a safe environment, protecting them from avoidable harm. One in 10 hospital prescriptions have errors which are picked up by pharmacists, thereby preventing harm to patients[3]. A recent study has demonstrated that pharmacists help to reduce GP prescribing errors and concludes that ‘given the high risk of serious iatrogenic harm associated with these errors, reductions of the magnitude observed in this trial are likely to be clinically important’ [4]. Patients are exposed to avoidable harm when they transfer from one care setting to another.  Pharmacy already pays a role in medicines reconciliation on admission and also on discharge. We believe, that with the right support, pharmacy can take responsibility for the transfer of care agenda in relation to medicines management and we are currently working to deliver this. Pharmacies have established clinical governance systems and procedures as part of their working practice, including complaints procedures, reporting of incidents and errors as well as continuing professional development. The number of complaints around pharmacy remains low.

Overall, we believe that there needs to be more emphasis on joint working to develop patient pathways allowing for inputs from a wide range of professionals with each professional being involved at the most appropriate point on that pathway. The NHS needs the ability to focus on joined-up care so patients get the maximum output from every contact with the NHS and its service providers.

We believe that the following changes would help to deliver quality against the NHS Outcomes Framework:

• Fair access to enabling technology for all providers would ensure more consistent care and improve patient safety, for these reasons we would support the ongoing work on access to the Summary Care Records for relevant healthcare professionals. This technology could also support a contribution to PROMs and other national quality initiatives.
• We encourage the national contracts for healthcare professionals to be more aligned with one another and we would support the development of a quality and outcomes based contract for pharmacy. We believe this could raise the standards and equity for all professionals
• We think that an outcome around medicines management needs to be included as part of the Framework. This could include making sure patients stop taking medicines when they should (by medication review in pharmacies) which would release savings to NHS. There should also be an indicator on ensuring patients are taking prescribed medicines as and when they should. This will focus on medicines adherence where there is currently a large number of medicines being prescribed and either not being taken or being taken inappropriately, between 30 - 50% of medicines are not taken as the prescriber intended [5].

Back to top »

Specific Questions

1.  Do you agree with the key principles which will underpin the development of the NHS Outcomes Framework?

Yes.

2. Are there any other principles which should be considered?

No.

3. How can we ensure that the NHS Outcomes Framework will deliver more equitable outcomes and contribute to a reduction in health inequalities?

In order to achieve this there needs to be wide engagement with professions and patients in developing and delivering the framework. The government should work with appropriate stakeholders, especially patients, to develop quality measures and outcomes for reducing inequalities across both health and local government boundaries. The EPB would like to be involved in the development of any outcome frameworks that include medicines or pharmacy.

4. How can we ensure that where outcomes require integrated care across the NHS, public health and/or social care services, this happens?

All professions involved in providing healthcare services need to be incentivised to work together, just as GPs are currently incentivised to meet certain healthcare objectives.

There is a need to make sure the commissioning model is right and that it identifies where integrated care will be required to deliver high-quality health outcomes.

The EPB believe that outcomes that apply across the NHS, public health and social care services should include the correct and timely transfer of information about medicines as patient transfer between the three domains.

Commissioning for any service should involve the provision of services by professions best placed to provide every aspect of care on that specific pathway. This will be for commissioners to identify, after consultation with service providers. Commissioners should encourage service providers to form multidisciplinary teams to manage every individual element on the specific patient pathway being commissioned.

5. Do you agree with the five domains that are proposed in Figure 1 as making up the NHS Outcomes Framework?

We agree with these domains. However, we would recommend that health inequality is included as an extra domain which would fit in with the area of ‘patient experience’. Pharmacy has many roles in reducing health inequalities, specifically the role of pharmacists who provide services in under doctored areas. They also provide services to those people who are often the most vulnerable in the community.

These domains seem a reasonable starting point but we would like to see more sophisticated domains being developed over time, supported by academic research. For example, the development of proxy indicators for patient outcomes.

Do they appropriately cover the range of healthcare outcomes that the NHS is responsible for delivering to patients?

Yes. However, the indicators should be capable of measuring outcomes in these domains over time as quite often the intervention on health takes many years to have a positive effect.

7. Does the proposed structure of the NHS Outcomes Framework under each domain seem sensible?

We are concerned about how data will be captured and by whom. We need further detail before we can give a complete view.

8. Is ‘mortality amenable to healthcare’ an appropriate overarching outcome indicator to use for this domain? Are there any others that should be considered?

Yes, this should be an ultimate measure.

9. Do you think the method proposed at paras 3.7-3.9 is an appropriate way to select improvement areas in this domain?

We have concerns that this may lead to certain conditions being ignored which could result in inequality for patients.

We have no specific comments on Q10 – Q14

15. As well as developing Quality Standards for specific long-term conditions, are there any cross-cutting topics relevant to long-term conditions that should be considered?

We suggest that the topic of medicines adherence is included. Research has shown that around 30% to50% of patients do not take their medicines as intended [1] . If this was resolved it would ensure better patient outcomes as well as a reduction in waste and overall costs to the NHS through a reduction in unplanned admissions.

16. Are the suggestions at para 3.28 appropriate overarching outcome indicators for this domain? Are there any other indicators that should be considered?

The overarching outcome measures appear appropriate.

We have no specific comments on Q17 – Q26

27. What action needs to be taken to ensure that no-one is disadvantaged by the proposals, and how do you think they can promote equality of opportunity and outcomes for all patients and, where appropriate, NHS staff?

Patients and healthcare professionals would benefit from incentives that encourage multidisciplinary and integrated team working.

We have no specific comments on Q28 and Q29

30. How can the NHS Outcomes Framework best support the NHS to deliver best value for money?

The national contracts for healthcare professionals need to be aligned to encourage and facilitate joint working. The drivers to improve productivity and efficiency through Quality, Innovation, Prevention and Productivity (QIPP) programmes must be integral to the quality and outcomes framework in order to deliver best value for money.

We have no specific comments to make on Q31 – 35.

 

Further information

For further information or any queries you may have on our consultation response please contact Heidi Wright at  or 020 7572 2602.

Back to top »

References

1. National Prescribing Centre; Reducing Waste in Primary Care; accessed July 2010

2. The Bow Group target paper. Delivering Enhanced Pharmacy Services in a modern NHS: Improving Outcomes in Public Health and Long-Term Conditions

3. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education – EQUIP Study. Dorman et al. GMC Dec 2009.

4. Pharmaceutical Journal 9 October 2010 (Vol 285) page 396.

5. National Institute for Health and Clinical Excellence (2009) Clinical Guideline 76; Medicines Adherence.

Back to top »