RPS Recommendations for Integrated Care Systems

Case Study 1

Population Health-Based Approach to Medicines Optimisation – Northumbria

The Pharmacy team in Northumbria has developed a model which describes how medicines optimisation could be delivered across a large place-based system using a new population health-based approach across North Tyneside and Northumberland (2,500 square miles: population of 520,000). 

The model is ideally led by a consultant pharmacist for population health and includes a programme of quality improvement work relating to medicines use across the health and social care system. The whole-system pharmacy leadership post would be owned by all local key stakeholders, with an expectation to work with all relevant health and care organisations, patients and patient groups to:

• Better understand and define the problems with medicines use by engaging with other senior leaders
• Better understand all available data sources and gaps in intelligence and insights
• Agree key metrics and performance measures and timescales for a series of specific, integrated, time bound projects
• Identify resources available to the system and sources of new funding
• Co-develop solutions and pathways to test for improvement
• Agree other deliverables and associated timelines
• Use continuous quality improvement (e.g., PDSA) to implement, iterate and improve.

This approach would ensure that the best value and health outcomes from medicines are achieved by identifying and tackling issues that more traditional medicines optimisation activities may fail to deliver. 

Using a population health management approach, there is an opportunity to deliver key objectives, for example:

• Aligning the medicines optimisation priorities of the local Trust to that of the wider system, and vice versa; joining up the actions and efforts of otherwise disparate teams, working more effectively together, in the pursuit of better patient care
• Investing in relationships and bringing key partners together (e.g., other Trusts, Primary Care Networks, Commissioning Support Organisation, Community Pharmacy, Public Health, Social Care); blurring organisational boundaries, developing shared priorities and delivering system wide working
• Understanding and better linking key data sources for medicines to understand variation across the system
• Using data and analytics to better inform decision making, directing medicines optimisation strategy, policy and actions and driving enhanced clinical care
• Using national and local levers and contracts to drive a unified approach to medicines optimisation (e.g., structured medication reviews in PCNs and new community pharmacy contract)
• Tackling inequalities in the prescribing and deprescribing of medicines; identifying wider causes of inequality and working with new partners on collective strategies for improvement
• Liberating and/or better utilising system wide resources.

The Northumbria population health-based model and a draft business case for a consultant pharmacist in population health are available on request ( [email protected])

Case Study 2

Integrated Clinical Pharmacy Service – Wirral, Cheshire and Merseyside ICS

Wirral University Teaching Hospitals NHS Foundation Trust hosts an integrated clinical pharmacy service in which staff work across Primary Care Networks and within the hospital trust in Wirral Place, one of the integrated care partnerships (ICPs) in the system. The service grew out of an initial pilot, involving just four members of staff, to a team of 25 within just two years. Some staff rotate across the sectors, while some are permanently working in split roles across both sectors.

The service was co-designed and developed with partners, resulting in an environment in which those delivering the service are naturally ‘system thinkers’, agnostic in terms of organisation, focusing instead on the patient. The ability to link with clinicians and other professionals across the local system; the use of IT systems in both sectors; as well as the relationships and trust which have been built, support the speedier resolution of any issues which might impact on patients and the local population.

As well as supporting members of general practice to resolve medicines issues encountered, the pharmacy team are also invaluable assets in the day to day running of practices. They have their own clinical caseload, run medicines optimisation clinics and support implementation of medicines safety strategies. Whilst working in hospital, they undertake clinical ward rounds across a range of specialities, with a particular focus on admissions and frailty to support safe transfer of care. Working as one has many benefits, not least that team members are always cognisant of their actions and the impact they will have in a different part of the system.

Case Study 3

Integrated Pharmacy and Medicines Optimisation System Leadership Programme - South East London ICS

The South East London (SEL) ICS delivered sessions on expanding pharmacy leadership. The leadership training programme aimed to bring together a cohort of pharmacists from across the system to expand their leadership skills together. Pharmacists from a broad range of care-settings participated, meaning the cohort were able to meet and form relationships with pharmacists in different sectors to their own; useful in developing an understanding of the needs of pharmacists in other sectors and mobilising pharmacists around a Primary Care Network (PCN).

The approach was a bespoke training programme delivered by the Kings Fund and development of a cross-sector network of ICS pharmacists.

The programme had impacts on the development of networking abilities, increased understanding of ICS's and the integration of pharmacy, as well as enhanced leadership skills. A network was enabled for course peers to liaise outside the course to improve their local network and to better support patients, across the primary and secondary care divide.

By 2022, the expectation is for each PCN is to have up to six pharmacists to support their local neighbourhood, including one clinical pharmacy lead to work closely with a PCN Clinical Director. The Pharmacy Leadership programme was an opportunity to identify lead pharmacists and develop their skills to start building relationships to create a neighbourhood network of pharmacists and other health and care professionals involved in supporting people with their medicines.

The programme created the building blocks for a pharmacy network to deliver excellence in medicine use and patient outcomes in all care settings in SEL. The outcomes of the programme will help the system model pharmacy’s leadership role in delivering the NHS Long-term plan.

Case Study 4

Integrated Mental Health Hub - Central and North West London NHS Foundation Trust

In Central and North West London NHS Foundation Trust, an 8B independent prescribing pharmacist worked within a consultant psychiatrist team covering one adult community mental health hub (17 GP practices) and a population of approximately 105,000 to help manage referrals and wait list for assessment and treatment as a result of the pandemic.

Referrals received from GPs, home treatment team and occasionally liaison psychiatry were triaged and allocated to members of the consultant psychiatrist team as appropriate. The prescribing pharmacist took on the responsibility of reviewing patients with complex medication needs, which released capacity within the team, allowing the psychiatrists to focus on non-medication related reviews. Within three months, this model reduced the wait time for assessment and treatment from 12-16 weeks to 4-6 weeks from the point of referral.

The pharmacist supported the team one day a week; each session comprised of reviewing 3-4 patients. These included conducting a mental state examination, risk assessment, doing a thorough medication review and prescribing as appropriate followed by any necessary paperwork; writing outcome letters to GPs/referrers; follow-up and reviewing physical health tests such as bloods and ECGs. The clinic is in the early stages of implementation but since starting in July 2021, the pharmacist has released 21 hours of psychiatrist time over a 3-month period by reviewing 40 patients. 

Interventions included initiating, switching or stopping medication; medicines' optimisation; physical health monitoring; side effect management and referral to services such as social prescribing and psychology. On one occasion, the pharmacist was involved in organising an urgent admission following assessment of a patient who had significantly deteriorated in their mental state. Patients, staff and GPs are very satisfied with the service and the CMHT staff have reported feeling better supported as they have greater access to a specialist pharmacist for advice on medicines.

Case Study 5

Community Pharmacist Consultation Service (CPCS) – Bristol, North Somerset and South Gloucestershire ICS

Pier Health Group based in Weston-Super-Mare were one of the initial pilot sites for CPCS implementation. The service has now become part of business as usual. The triage to a community pharmacy is part of a digital system, and receptionists are trained to undertake the triage when on the phone to patients.

The whole system is administrator led and does not involve contact with GPs. Training of staff, both within the practice and at the pharmacy is key to making this work. The practice staff have full confidence in the referral they are making.

Contact details are shared between the practice and the community pharmacies so any difficulties and issues can be discussed and dealt with quickly.

GP practices are struggling with capacity and the CPCS service can help with these workload issues. In this one practice alone around 110 CPCS referral were made in one week, and during the peak of Covid this went as high as 200 referrals in a week.

The practice has demonstrated that the service is safe and incorporates a feedback loop to ensure patients are seen or escalated appropriately.

One of the critical elements of the service is the use of appropriate language when referring patients. For example, receptionists say, We’ve triaged your request and have decided that the most appropriate place for you to go is for a consultation with your pharmacist, which pharmacy would you like to go to?

Case Study 6

One Medication Record – Dorset ICS

Work is underway in Dorset ICS on a range of digital initiatives. One of these is the One Medication Record project as part of the wider Wessex Care Record.

NHS Pharmacy teams, IT teams, analysts, system provider partners and a range of stakeholders are working to develop a proof of concept at Dorset County Hospital and the aim is to use the shared care records to maintain a reconciled list of medications and feed this information back into other systems.

Within the Hampshire and Dorset systems, information relating to a patient’s medication is recorded in multiple locations, including but not limited to the GP systems, community pharmacy patient medication records, and NHS provider organisations, often using electronic prescribing and medicines management systems. There are also specialist medication records, for example that used for the substance misuse service in Dorset, chemotherapy prescribing and Integrated and Urgent Care Services.

With several different IT platforms holding information relating to a patient’s medication, this invariably leads to a fragmented information source, with no one system having a complete record. This can lead to potential patient safety risks as patients move between different care settings within the system, for example, being admitted for an acute episode of care, or being managed by a specialist mental health service.

Working as an ICS to bring all the relevant pharmacists together, the lead pharmacist for the project anticipates that in future this system will reduce the many admission related prescribing errors when medicines are omitted, doses incorrect or medicines being re-prescribed that the patient no longer takes.