The potential for community pharmacy teams to improve the health and wellbeing of older patients is huge, particularly with those who have been discharged from hospital

Hospitals are discharging elderly patients to their homes without ensuring they are fit or have proper support, says a damning new report from the Parliamentary Health Service Ombudsman. This means that pharmacy teams have the potential to play a huge role in ensuring that elderly patients receive the right care and support when they come out of hospital, as well as helping them to avoid readmission.

Among other things, community pharmacy teams can support patients to ensure that they get the best from their medicines by offering the new medicine service (NMS) and post-discharge medicines use reviews (MURs). Updating patient medication records with changes will also help, and the Royal Pharmaceutical Society (RPS) has already put its weight behind this role.

In December 2014, the RPS Innovators’ Forum published Hospital referral to community pharmacy: An Innovators’ Toolkit to support the NHS in England – the first publication to be delivered by the group set up in response to the report Now or Never: Shaping pharmacy for the future. The Forum was tasked with identifying which new pharmacy service innovation detailed in the Now or Never report would have the biggest impact on health economies across the country if it was replicated and spread. It chose ‘Refer to Pharmacy’ (R2P), the first fully integrated hospital to community pharmacy e-referral system. The toolkit was circulated to every CCG medicines optimisation lead, chief pharmacist, LPN and LPC lead in NHS England, to encourage conversations about effective referrals.

Vision for the future

Explaining the thinking behind the toolkit, the RPS said: “We believe that patients in hospital should be routinely referred to their community pharmacist for post-discharge assistance with medicines. Ideally, such referrals should be made electronically. If discharge letters are electronically produced in hospital, community pharmacists should have access to these as part of the referral process… In five years’ time, we want to see referrals from hospital to community pharmacies as routine; health professionals and patients will expect it.”

Is it working?

East Lancashire Hospitals NHS Trust (ELHT) launched its R2P service in October last year, enabling hospital pharmacists and pharmacy technicians to refer patients directly to their community pharmacist for free NHS services, such as the NMS or a post-discharge MUR. The system sends patients a reminder of their referral by text or email shortly after they leave hospital. They are also contacted by their local community pharmacist to arrange a convenient time to meet and discuss changes to their medication.

Different kinds of support

R2P can also be used to inform community pharmacies of changes to a patient’s medication if they use blister packs, are a care home resident, or if it is important for them to know of changes for any other reason. Alistair Gray, clinical services lead pharmacist at ELHT, explains: “For patients who use blister packs and care home residents, it is not uncommon to have changes made to these when they come into hospital. Often, the community pharmacist would dispense these packs in advance, but the system now enables us to send a hospital admission notice out to community pharmacists to ask them to pause dispensing. Then, when the patient is discharged, the pharmacist automatically gets a copy of the discharge letter with any changes to their medicines. This not only saves time and reduces medicines waste, but it also improves safety and adherence by putting the right medicines in the patient’s vicinity.”

Alistair adds: “We can also can refer to a domiciliary medicines support team who can visit patients in their homes. This is nothing to do with community pharmacy, but there is a pharmacist and technician who support them. However, it is feasible in certain circumstances for community pharmacists to do home visits or home MURs, but they need the resources in place to enable them to leave the shop, and they have to fill out a form to allow them to do it.” 

Avoiding readmissions 

All of this helps to avoid readmissions. “A better understanding of how to take their medicines keeps people healthy”, says Alistair, “and these interventions also pick up on early adverse drug reactions and allergies, so you can intervene much earlier to prevent readmission.”

Another advocate of community pharmacy’s role here is Lelly Oboh, consultant pharmacist at Guy’s and St Thomas’ NHS Foundation Trust specialising in the care of older people. She says patient advocacy is another benefit of pharmacy involvement after discharge. “Community pharmacy is the one-stop place for queries on medicines use in community to triage, refer or intervene as appropriate. Offering education and training for patients, relatives and paid carers on medicines handling and administration reduces the risks and improves outcomes for patients,” Lelly explains. “As primary healthcare professionals who have a lot of contact with older people – especially frail older people – there is also a big opportunity for monitoring the use and outcomes of new medicines, both from the patient perspective and so we can feed back to their GP,” says Lelly.

“In addition, addressing patients’ concerns about medicines use gives them a better understanding of what the medicines are for, the benefits and common side effects that impact on their daily functioning, and helps them to make informed decisions about whether or not to take their medicines.”

Alistair says evidence from an NHS Wales study into the R2P process showed a three-fold return on investment, thanks to less medicines waste and problems being identified earlier on. “We’ve also been doing topline feedback on readmission rates, which enables us to drill down to readmissions for the same diagnosis,” says Alistair. “Data from the first four months of the year shows a drop from four per cent to 2.5 per cent, which equates to about 70 fewer patients being readmitted. So with Lord Carter estimating it costs £3,500 to host a patient’s hospital stay, if someone is eligible, it makes sense for
us to refer them.” 

More work to do

Nonetheless, both Lelly and Alistair think not enough is being made of the potential of community pharmacies to improve patient safety at the point of hospital discharge at present.

In terms of R2P, Alistair admits there is more work to do. “It’s still a learning period for us,” he says. “For it to work, we are reliant on 150 pharmacies using the system properly all the time and at the moment we cannot be sure that this is happening, but we will know soon.

“It took us three years to get from concept to delivery, and we are still making some changes to make it better. We are looking at a tweak to the software this month that will make it easier for community pharmacists to manage their referrals and the outcomes, so the technology can then identify who has a problem and how it’s going. The system also needs to be very fast and user friendly because if it doesn’t work at the hospital end, it’s not going to work at all.”

Alistair believes that R2P should be a national standard. There is a similar service called PharmOutcomes already in operation. This is a web-based system that transfers information about patients from hospital to community pharmacy via an e-form that is manually completed after patient discharge, but Alistair says it’s not as fast. “They do about 120 referrals a month, but we do more than that in a week,” he adds. “Ultimately, what needs to happen is that anyone eligible is referred.” 

Not just dosette boxes 

Lelly says the R2P service is “great as it shows that there is a need for this, but more than two-thirds of the referrals to community pharmacy are about dosette boxes”. And while she stresses that it is “certainly good news that pharmacy is in the loop”, she says she wants to “dispel the myth that all we do is dosette boxes, which is what GPs and social services seem to think. That is such a waste of our pharmacy profession because we know that the evidence shows that these are not a good solution most of the time. In fact, we know that 70 per cent of medication errors will be due to miscommunication, so how does the dosette box fix that problem? What we need to focus on is what is really causing those errors and what pharmacists can do about that.”

She puts part of the miscommunication down to the fact that many people are prescribed new medicines in hospital, which they don’t really understand enough about. “Lots of older people are admitted to hospital with an acute illness along with a long-term condition,” she explains. “The acute illness is resolved, but then they have to come out and live their lives, and quite often no one has told them what their new medicines are for, how long they should take them for, if they need weekly checks and so on. We see people all the time who have come out of hospital, feel better and so don’t take the medicines they were given in hospital.” 

Lelly’s solution is that there should be “clearer messaging” to patients when they come out of hospital. “They should ring their community pharmacy and we can answer any questions or worries that they have, and help them take their medicines properly, change formulations if necessary, and keep them out of hospital,” she says. “Who else has the experience in medicine, who knows that patient and delivers their medicines, but the community pharmacist? We should be talking to people as proper professionals, not just filling out dosette boxes. I think we are underselling ourselves. Going forward, we really need to be promoting ourselves as the medicines experts otherwise we are doing the profession – and the public – no favours.”