Working at system level on care homes

by Wasim Baqir, National pharmacy lead on care homes, NHS England

NHS England has announced 180 new jobs for pharmacists and 60 for pharmacy technicians as part of the drive to improve patient care and the use of medicines in care homes.  At a system level, here’s how it will work – and I promise, it’s not as hard as it sounds!

STPs/ICS

The NHS and local councils came together in 2016 to form 44 Sustainability and Transformation Partnerships (STPs) with a vision to improve health and care for local people across whole areas rather than individual organisations. Following on from the Vanguard programme, the NHS announced 10 Integrated Care Systems (ICS) that have been given greater operational and financial autonomy to manage their services.

The Medicines Optimisation in Care Homes Programme is being launched at STP/ICS level so that the local systems can decide where best to use this resource for their care homes.  STP/ICS areas will be allocated funding based on their indicative care home population.  The STP/ICSs will then work with the NHS England regional offices to support discussions with local providers of clinical pharmacy services to agree how best to use the funding to support care homes and their residents.

System Leadership

This is an ideal opportunity for pharmacy across the different sectors to come together and work in a more integrated way.  Some areas are already working well at STP/ICS level. Here are some tips about how hospital, primary care, general practice and community pharmacy can work together to  support this programme:

  • Find out what your care home population is and what their needs are. Are there specific care home types? (e.g. mental health, dementia); see what medicines optimisation services they are already getting and identify the gaps.  Speak to current providers and see what they are doing; are there opportunities for you to work together?
  • What are your ICS/STP’s plans for care homes and are they implementing the Enhanced Health in Care Homes framework? Find out who’s leading this and what their plans for medicines optimisation are? You may be able to help shape those plans.  Also find out what your STP/ICS’s medicines optimisation plans are where they align to care homes.
  • Get together with all pharmacy stakeholders: hospital, mental health or community services trusts, GP federations or GP practices, CCGs, primary care pharmacists (working for non-CCG organisations), community pharmacists – it can sound difficult but all it takes is a little time, a few good conversations to find some common ground.
  • Develop your plan with care homes, patient and other healthcare professionals
  • Agree a plan on how you will deliver an integrated approach to medicines optimisation in care homes. Don’t get too bogged down by who hosts the actual pharmacists and pharmacy technicians; the key is that these professionals are enabled to work across organisational boundaries to support care homes.  Make sure your plan aligns to STP/ICS plans for care homes and medicines optimisation

Sometimes it can be hard to visualise what this actually looks like in practice.  Here are some case studies:

Hospital Pharmacy

Pharmacists and pharmacy technicians are employed the by the local NHS Acute Trust and work within their elderly support service. Each pharmacy professional reaches out to care homes 2-3 days per week.  They have established a relationship with hospital consultants (e.g. Care of the Elderly), local GPs, GP pharmacists, community pharmacy and other local health and social care professionals. They have access to the hospital and GP clinical systems and work autonomously.  Residents are stratified by risk and need, with priority cases being seen first.  Technician caseloads include new and recently discharged residents, swallowing or other adherence problems. Pharmacists cases include complex patients, often within a MDT setting, high risk (e.g. high eFI), high users of hospital services and end of life patients. Good relationships with GP practices and community pharmacy allow them to rapidly discharge patients and ensure there is follow up.

Community Pharmacy

Community pharmacists and pharmacy technicians are commissioned to provide clinical support for care home residents. They undertake medication reviews for all care home residents, stratifying residents to those they can manage, those who they need additional help with (from hospital or GP pharmacists) and complex residents that are referred to their hospital/ GP colleagues). In some cases pharmacists have access to clinical systems and can record their consultations and make changes. Where they don’t have this, they can work with practice based pharmacists or make recommendations to GPs. Community pharmacy technicians work with homes to support medicines management systems (e.g. ordering and storage) and help reduce medicines waste.

CCG and other primary care based Pharmacy Services

Primary care pharmacy professionals work out of GP practices supporting care homes residents registered with that practice. They have close working relationships with hospital teams and the local community pharmacy. Pharmacists will autonomously review a range of care home residents, with more complex patients being discussed in a multidisciplinary meeting or working in conjunction with hospital based elderly care or mental health teams. Pharmacy technicians undertake a range of clinical and medicines management tasks to support residents and homes with medicines optimisation and management.

Relationships

In all these cases (which I have adapted from real life situations) relationships between different organisations and pharmacy sectors are very important; once you have a good relationship, you can start co-developing bespoke solutions to everyday issues.

To enable pharmacy professionals to work more collaboratively, we need system leadership and leaders to think beyond the walls of their organisations.  Chief and senior pharmacists (e.g. primary care and community pharmacy) and other senior leaders (e.g. CCG, GP medicines optimisation leads) having a shared vision can enable clinical pharmacists and pharmacy technicians to create local communities of practice where sharing and learning across the system is encouraged.  By doing so, pharmacy teams will work more effectively with each other as well as with their colleagues across the health and social care system.

Collaboration

There will be other good examples of working across the system and collaboratively within pharmacy and with other health and social care professionals, as well as patients.  This blog is intended to get you thinking about how you do this in your area.

We must not forget that as we develop collaborative practices, residents and families co-develop solutions; let’s stop ‘doing to’ and start ‘doing with.’  We know we make better decisions when we work together.

Medicines optimisation in care homes works.  It is most effective when pharmacy professionals work across the health and care system, using their unique skills to ensure that care home residents, care home and the wider system get the best value from medicines.

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