Case studies

  • Case studies 1-5 illustrate some of the issues that can arise if pharmaceutical services or aspects of medicines management are not planned early in the process of service development.
  • Case studies 6-11 illustrate good practice in this area; they show how innovative services have been developed to meet local needs

Case study 1: Domiciliary care/Care at home Case study 1: Domiciliary care/Care at home

After his wife's death Thomas struggled to take his tablets, particularly his warfarin, as she had dealt with all that for him. Although he was offered home care by Social Services the care staff were not allowed to administer his medicines, as this was believed to be a 'health responsibility'. His GP argued that it was not the district nurses’ responsibility to visit every day to give Thomas his tablets, as this was a 'social care issue'. 

As a result of this impasse Thomas's health deteriorated and he was admitted to a care home.

What is needed:

  • Joint working between health and local authority:
  • Professional support to develop policy that influences medication practice by care workers 
  • Close monitoring of the current contract to ensure that care workers are trained in safe medication practice 
  • Joint commissioning of care i.e. health and social care together securing a service in line with local need.

Case study 2: Communications Case study 2: Communications

A care home decided to change the pharmacy that supplied its medicines. The new community pharmacist ordered medicines on behalf of the care home. He sent a letter to the GP Practice explaining the change in pharmacy arrangements along with a request for the monthly prescriptions for residents.

The medicines requested for Mr Brown were correctly issued by the practice using his computerised record. However, at this point, a mistake was made and three additional items from Mr Green’s records were accidentally added to Mr Brown’s medication record.  

The prescriptions were sent to the community pharmacist who did not realise that extra items had been added. Both the pharmacy Patient Medication Record (PMR) and the Medicines Administration Record (MAR) were updated and the medication was dispensed into the monitored dose system (MDS).

The care home staff did not check or query the additional items for Mr Brown. The additional medicines were administered to Mr Brown. When the medicines for Mr Brown were reordered, the extra items were prescribed again because they were now listed in the computerised records at the surgery.

After two months Mr Brown became ill in the care home. The GP was called and he noticed that the medicines list contained medicines for a disease that Mr Brown did not have. Mr Brown was transferred to hospital, where he contracted an infection. After three months in hospital he died.

In this case the Health Service was responsible for the costs of his prolonged hospital stay and there were also additional costs in holding his care home bed open. 

What is needed:

  • A robust system that can check that the correct medicines have been ordered and received and respond to changes. This needs to be a three way process between the prescriber, the pharmacist and the care home involving the checking of prescriptions before they are dispensed.
  • Access by the community pharmacist to the relevant patient’s summary care record
  • A robust system for care homes to check the individual’s current medication regimen for new admissions or following hospital transfers and out patient visits

Case study 3: Domiciliary care/Care at home Case study 3: Domiciliary care/Care at home

The domiciliary care agency has decided that the only way that domiciliary care workers can give solid dose medicines safely is when they are provided in a Monitored Dose System (MDS)*. (It appears to have overlooked the fact that not all solid dose medicines can be packed in a MDS.) This means that some of the medicines are dispensed in normal containers and domiciliary care workers are told that they may not give them. The care workers are put into a position where they realise that the person needs the medicines but know that they cannot record administration as they have been told that they are not to give medicines that are not in the MDS. In practice, what happens is that the care workers remind and support the person to take these medicines but do not make any record of what they are doing. This means that there is no way of auditing whether the medicines are being given in accordance with the prescriber’s directions nor is there any way of identifying if an error has been made. Also, the care workers only receive training on using the MDS so people cannot be certain that they are receiving their medicines safely.

Instead of ensuring good adherence and safe medicines’ administration, this poorly thought-out scheme, based on the perception that MDSs are the only solution, has made the situation less safe. The use of MDS introduces different risks into the system.

What is needed:

  • Social workers to commission medicines support based on individual pharmaceutical needs assessment as per Care Quality Commission guidance bearing in mind that self medication is the aim for all patients capable of self administration.
  • Agencies to get independent professional advice on what is safe practice.
  • Agencies requiring the use of MDS should establish formal contracts with Community Pharmacies to provide medicine support. Contracts should include a realistic cost element for medicine support where patients fall outside DDA** requirement.
  • Training to administer all medicines safely.
  • Clear understanding of benefits and risks of using an MDS system.
  • Clear checks of the processes for the individual’s medicine regimen.

* MDS in this example incorporates all types of monitored dosage systems

**DDA is the Disability Discrimination Act 1995

Case study 4: Care home Case study 4: Care home

The care home manager wants to get advice on safe and effective homely remedies. The local Health Service does not fund a pharmacist to provide support to care homes. The community pharmacist who dispenses prescriptions for the care home is unwilling to give additional time to the care home because he receives no payment for this service.  As a result the care home does what it thinks is reasonable and buys products to keep as stock. For example, cold preparations that contain paracetamol. As paracetamol is also routinely used for aches and pains, e.g. headaches, also often in combination products such as co-codamol, this could result in someone being given too much paracetamol and requiring emergency hospitalisation.

What is needed:

Joint working between health and local authority: 

  • Professional support to develop policy that influences medicine practices (including the use of homely remedies) by care workers
  • Commissioned training programmes in safe medicine practice for care workers
  • Joint commissioning of care
  • Contracts should include a realistic cost element for medicine support.

Case study 5: Children's home Case study 5: Children's home

The care staff are looking after a young person who now needs insulin to manage her diabetes but is unable to administer it herself. The care staff would like training so that they can safely administer the insulin and monitor blood glucose. As training has not been provided, the district nurse has to visit the young person twice a day to administer the doses of insulin.

What is needed:

In this case, and in other social care settings, the Health Service needs to balance the cost of training the care workers against the savings that could be made if visits by the district nurse were not required.

Case study 6: Medicines management in care homes Case study 6: Medicines management in care homes

Care home residents have significant health needs and can require a great deal of support from both primary and secondary care services. In November 2004, Chorley and South Ribble (now Central Lancashire) Primary Care Trust (PCT) identified four care homes in a defined area of South Preston that are mainly supported by three GP practices. Louise Winstanley, a pharmacist practitioner (also qualified as a supplementary prescriber) and Wendy Brennan, a nurse practitioner (also qualified as an independent and supplementary prescriber) took a proactive approach in developing a support service for these care homes.

One of the care homes is mixed residential and nursing, two are residential and the fourth is a nursing home. The nurse clinician spends half a day each week in each home and is available for urgent visits within normal office hours. She requests tests, can refer residents to other health professionals, regularly monitors the residents and liaises between the care home and the GP practice. The pharmacist practitioner provides medication review, undertaken jointly with the resident, care home staff and the nurse clinician. In this way, there is proactive three-monthly monitoring and review of medicines for those living in these care homes.

All the main parties have welcomed the service and found it to be helpful, effective and informative, especially the GPs and the care home staff. Audit data have shown:

  • a reduction in GP callout of 96.2% for Practice 1, 93.6% for Practice 2 and 89.7% for Practice 3 (these figures do not include GP visits where the homes have contacted the surgeries directly. The estimated cost of a GP callout is around £50, so the cost of health professionals was more than compensated for by savings in GP time);
  • a 7% reduction in hospital admissions, with potential saving of £18,564;
  • a reduction in the total number of falls by an average of 32%; and
  • a reduction in the number of fractures of 60% for total fractures and 80% for hip fractures – four fewer hip fractures give a saving of £56,160.

Email Louise Winstanley and Wendy Brennan for further information.

(Taken from Pharmacy in England: Building on strengths – delivering the future, p28)

Case study 7: Reducing admissions through tailored medicines managment support Case study 7: Reducing admissions through tailored medicines managment support

The medicines management team at Bournemouth and Poole PCT provides a tailored support service to vulnerable people in their own home. The team develops pharmaceutical care plans, which enable people with long term conditions to administer their own highly complex treatments safely. The team accepts referrals from all health and social care professionals and from any member of the public who encounters an older person who, unaided, is unable to take their medicines correctly. The service is supported through a service level agreement with local community pharmacies, who provide enhanced services to support people taking their medicines with aids such as organisers and reminders. The benefits of the service include the following:

  • People remain in their own home, avoiding admissions to hospital or long term care.
  • contributes to compliance with therapy and hence better outcomes.
  • People receive education about their medicines and long term conditions, which contributes to compliance with therapy and hence better outcomes.
  • Reduction in wasted medicines as people’s own medicines are utilised before new supplies of medicines are issued.
  • Pharmacies take over the ordering of medicines on a 28-day cycle, preventing people and type of service.
  • Pharmacies all work to an agreed quality standard so that people receive the same level
  • Support for people on high-risk medicines such as warfarin.

Data from 2004 and 2006 show a reduction in emergency admissions to hospital of 18% and 25% respectively among the client group. In 2006/07, annual prescribing cost savings for the service were £25,631. The annual cost per patient for the service in 2006/07 was £430. The service only needs to prevent a two-day stay in hospital for each patient in order to cover its running costs. Prevention of overdose using secure supply methods and assistive technology.

Email Pam Grant for more information.

(Taken from Pharmacy in England: Building on strengths – delivering the future, p28)

Case study 8: Supporting healthy outcomes through signposting Case study 8: Supporting healthy outcomes through signposting

National Association of Women Pharmacists has been running a project in Cardiff in conjunction with The Princess Royal Trust for Carers.

The aim of the project is to identify carers, both hidden and known, living in the community and be able to offer them help, advice, information and support, via Pharmacists, General Practitioners, Carers Champions, Carers Centres and The Princess Royal Trust for Carers.

A pilot study has been carried out in 12 pharmacies in the Cardiff, which NAWP members either worked in or owned. This covered 25 surgeries with approximately100 doctors. Stickers are attached to prescription bags that say, “Are you a carer?  Do you need support? Ask us how.” There is also a poster. 

Once carers are identified they are put in touch with the help they so often need. Pharmacists initiated and led the project, in close collaboration with The Princess Royal Trust for Carers. Medicines use reviews (MURs) could be arranged for both carers and patients.

Email Anita White for more information.

Case study 9: Mobile pharmacy information service reduces care home and hospital admissions Case study 9: Mobile pharmacy information service reduces care home and hospital admissions

A mobile pharmacy information and advice service to help older people manage their medicines has been developed. Working as part of the Croydon-based Partnership for Older People (POP) project a pharmacist offered advice on medicines-related issues and other services including blood pressure checks, medication reviews and, where necessary, referral to other healthcare professionals. The aim of the project was to reduce care home and hospital admission and help patients live independently.

In the first six months of the project (from March 2008) 593 people received a leaflet about the service and the pharmacist made 163 interventions. The interventions were judged to have averted 29 (20 per cent) and 68 (42 per cent)  ‘likely’ or ‘possible’ hospital or care home admissions respectively.  Assuming that the estimated cost of a hospital admission was £3,500, the service was projected to produce an annual saving of £200,000 - £250,000.

Contact: Victoria Williams 

(Taken from The Pharmaceutical Journal, 4 Jul 2009)

Case study 10: Safe and effective use of medicines in care homes Case study 10: Safe and effective use of medicines in care homes

A team of nine pharmacists and five nurses in Central Lancashire provides the Care Homes Effective Support Service (CHESS).  The team is contacted when a home needs medicines expertise or support and it provides many of the services that GPs have traditionally provided. 

The team makes an in-depth assessment of each home, discusses it with the care home manager and agrees a plan of action. Chess also provides health monitoring and assessment and has a current caseload of 1200 patients.

From August to December 2008 the team made 445 medicines interventions and 1143 healthcare interventions. During this time 22 medicines incidents were identified, of which three were serious.

During the pilot phase of the project (involving 160 people in four care homes) a one-year evaluation revealed that GP call outs, which cost the NHS around £50 each, had dropped by between 96.2 and 89.7 percent. A seven percent drop in hospital admissions was estimated to have saved £18,564.

The number of residents suffering falls had been reduced by 32 percent with the number of fractures dropping 60 percent, including an 80 percent reduction in hip fractures. Here the resulting saving to the NHS was estimated at £56,160.

Amongst other things the project has shown that, for a small investment, managing dementia appropriately, reducing medication, improving end-of-life care and ensuring appropriate, regularly reviewed medication is possible.

Email Louise Winstanley for further information.

(Taken from The Pharmaceutical Journal, 4 Jul 2009)

Case study 11: Provision of homely remedies in care homes Case study 11: Provision of homely remedies in care homes

Exeter PCT (now part of Devon PCT) identified increasing numbers of care homes making requests of individual GPs to provide individual signed lists of homely remedies for all people living at a care home. Homely remedies are all medicines that are available for purchase over the counter. Different homes wanted different medicines on their lists.

The PCT worked with the pharmacist inspector of the regulatory body to establish what the legal requirements of the home were in respect of these medicines. A discussion was also arranged with the PCT prescribing lead. It was agreed that they would issue a standardised list of medicines that would be approved on behalf of all the GPs working for the PCT.  Within the list there would also be information about how and when the medicines were to be used, how to obtain further advice before administration, and how information should be fed back to the person’s normal GP if the use of a homely remedy became regular or was not effective.

This agreement was signed by both the Medicines Management Lead for the PCT and the Prescribing Lead for the PCT and a copy distributed to each of the care homes in the PCT area. (See Homely remedies standardised list and agreement). As part of the agreement the care homes were responsible for ensuring that all staff that would be using the remedies had received appropriate and adequate training and that clear recording systems were in place.

As a result of this initiative care homes in the surrounding areas asked for similar arrangements and the agreement was shared with the surrounding PCTs. Some of them have now adopted or adapted the agreement for their own use using a similar approval method.

The result of this is that people across the PCT area in a care service have these medicines made available to them. It also means that the GP no longer has to respond to requests for lists for individual people and homes do not have to chase for these.

Contact: Ruth Airdrie, Head of Medicines Management, Exeter PCT