The NHS Long Term Plan, published in January 2019, outlines the ambitions for the NHS for the next 10 years.
To provide some insights into what it means for those working in pharmacy and medicines optimisation, the Chief Pharmaceutical Officer Keith Ridge asked national colleagues to write about their specialist areas:
‘It needs each of us to change the ways that we think and behave’
Unlike my parents, I cannot remember a time when effective antibiotics were not available.
I, like most people, have been able to lead my life comfortable in the knowledge that when I’ve needed to go into hospital for an operation, or been unwell because of an infection, I’ve been able to rely on antibiotics to protect me or make me better.
But this is no longer the case.
The way that we have relied on and used antibiotics, often inappropriately, means that we have allowed the widespread development of antimicrobial resistance. Many of our antibiotics no longer work as they should and we have been too slow to develop new ones.
Tackling this issue is not going to be easy and will need each of us to change the ways that we think and behave.
The NHS Long Term Plan acknowledges the need for further progress on antimicrobial resistance and refers to the recently published 20 year vision and five year action plan for tackling it. It talks about optimising the use of and reducing the need for antibiotics, and supporting the development of new antibiotics, and it promotes a greater focus on preventative measures, such as vaccination and infection prevention and on tools such as electronic prescribing and improved diagnostics.
The pharmaceutical industry will be expected to take more responsibility for antibiotic resistance. NICE and NHS England will explore a new payment model that pays pharmaceutical companies based on how valuable their medicines are to the NHS, rather than on the quantity of antibiotics sold. This will incentivise companies to invest in the development of drugs that will treat high priority resistant infections.
However, if you read into it more deeply, the plan also opens up a wide range of exciting, new opportunities for tackling antimicrobial resistance.
Imagine these scenarios.
- A call adviser in a local urgent care centre refers a patient with a sore throat for a consultation with a community pharmacist who is also able to provide opportunistic advice on infection prevention and offer a flu vaccination.
- A clinical pharmacist in a primary care network working as part of a multidisciplinary team providing expert advice on antimicrobial stewardship in care homes.
- A pharmacist prescriber in general practice who reviews and optimises a patient’s COPD medication to prevent an exacerbation and the need for antibiotics or a hospital admission.
- A consultant antimicrobial pharmacist running an integrated parenteral antibiotic therapy service across local healthcare organisations.
- A pharmacist at a STP / ICS using open-access databases to analyse local resistance patterns and to identify and reduce unwarranted variation in the implementation of antibiotic prescribing guidelines.
All seven chapters in the plan can be linked in one way or another to tackling antimicrobial resistance; the challenge for all of us is to use the opportunities it provides to get on with it!
Regional Pharmacist (Midlands and East), NHS England and NHS Improvement
‘Digital technology is the enabler to deliver the long term plan’
It is clear from the NHS Long Term Plan that digital transformation remains a key priority. What is different from previous documents is that digitally-enabled transformation is woven throughout the whole plan and that technology will play a key part in realising the core aims.
The focus is now on ensuring that everyone that needs to access information can do so using digital means in every location in which they need it – medicines has been identified as a priority for this in every survey conducted over the last few years in every care sector.
In hospitals this is being enabled by accelerating the use of ePrescribing systems. The use of more mature functionality to support improved prescribing and medicines administration is also underway with the global digital exemplar sites. The first sites to undertake closed loop medicines administration are now live and key interfaces to other systems are in development.
The use of standards is critical if information is to be available across the system – identified in both the long term plan and the Department of Health and Social Care’s technology vision. The dictionary of medicines and devices (dm+d) is the key that is now being augmented with messaging standards for the rest of a prescription. The definition of these standards will be complete in the Spring, opening new possibilities for accessing and transferring prescription and related information.
These message standards will provide a raft of opportunities that can support the transformation of services and provide improvements to patient care across all care sectors. In tandem with this, and using this information, an additional set of standards for the capture and communication of structured (and coded) clinical data by pharmacy practitioners during patient consultations has been produced and used to inform the development of functionality to support care transfer. These provide the basis to underpin future developments supporting integration of pharmacy across the system and ensuring that relevant data is made available to the wider clinical record to support referral and clinical documentation in primary care.
Another longer term focus is ensuring the smooth digital transfer of prescriptions for all medicines and providing patients with the ability to track their prescriptions – work to support this via the NHS App is already underway.
We are also looking to make better use of the data that systems can provide to allow us to better understand the way in which medicines are used, to help inform and drive improvements in prescribing quality and antimicrobial stewardship.
All of this has to be underpinned by appropriate approaches to medicines safety – realising the true benefits of digitisation means that all systems will need to adopt standards and optimise systems on an ongoing basis. Central to this will be having a workforce that is trained and skilled in clinical informatics – there are now many opportunities to pursue for training and support yet, as a profession, pharmacy is not leading the charge, despite our long history in adopting digital systems. The Faculty of Clinical Informatics provides professional support and the Digital Academy (extended as part of the plan) is open to pharmacy. Applications open again later this year – it would be great to see more pharmacy staff becoming involved and their expertise developed and recognised. The recently published Topol report also heralded the introduction of Topol fellowships.
The plan offers up many opportunities and provides continued focus on the use and acceleration of technology to reshape and underpin the way in which we work – if you haven’t thought about how you are going to use systems and shape the way in which you support patients now is a good time to get involved.
Associate Chief Clinical Information Officer (Medicines), NHS England
‘The development of ICSs is critical to help build relationships to support care’
As medicines, nutrition and public health have improved, the number of older people has increased, with those over 85 years of age projected to reach 2 million, from the current 1.3m, within the next 10 years. We all want to grow old and remain well, but for many people living with multiple long-term conditions and increasing frailty become the reality of their later years.
Because many long-term conditions are now treatable with medicines, polypharmacy is very common in the older population. Polypharmacy, when appropriate, maintains health and prolongs life. However, polypharmacy can also occur when medicines that were previously beneficial are continued when no longer required, are prescribed to manage the adverse effects of other medicines, or when the risk of a previously prescribed medicine in an individual has changed to outweigh the benefit.
This inappropriate polypharmacy requires regular, structured medication review. People who could benefit from this type of review can be identified through evidence-based tools, such as PINCER. Successful review can improve medicines safety and patient well-being, through prescribing clinically appropriate medicines that the person wishes to take.
Effective, structured medication review will involve shared decisions and requires both time and trust between the clinician and the patient. Clinical pharmacists, as medicines experts, are ideally placed to lead these and, with the investment in clinical pharmacists working within primary care networks, pharmacists will be available and will have appropriate time to deliver this important intervention.
Some older people choose to spend their latter years in an environment where care is provided for them. Others, who are less well, may be unable to live independently and require nursing care. Providing good quality care in a care home environment is challenging and unmet health-related needs for residents can lead to unnecessary hospital admissions, as well as reduced quality of life for the individual and concern for their family and friends.
With up to 10% of hospital admissions being medicines-related, there is an opportunity to address preventable medicines-related hospital admissions from care homes. The announcement of further pharmacy professionals working within a GP-led multidisciplinary team to support medicines optimisation, though regular, structured medication review in care homes, is very welcome, as is the Government’s review into over-prescribing in the NHS, and both will reduce the risk of vulnerable citizens coming to harm from medicines.
The development of integrated care systems is critical, these will facilitate flexible working across the different health care sectors and build relationships to support patient care. This is just one of many foundations which will support clinical pharmacists working within the primary care network. Others include the shared clinical record, visible to all health care professionals to ensure appropriate communication, and use of technology including video consultations to facilitate specialists, such as consultant pharmacists, to support decisions when required.
Regional Pharmacist (London), NHS England and NHS Improvement
Consultant Pharmacist, Care of Older People, London North West Healthcare NHS Trust and NHS Specialist Pharmacy Service
‘Exciting opportunities for the pharmacy workforce to play an integral role in new models of care’
The publication of the NHS Long Term Plan represents an exciting opportunity for the pharmacy workforce. It provides opportunities for people to play an integral role in the delivery of new models of care, disease prevention and improving patient outcomes. We know from practical experience, the impact of pharmacy on patient care as part of multidisciplinary teams in care homes, urgent and emergency care and GP practices.
The Pharmacy Integration Fund has been instrumental in helping pharmacists and pharmacy technicians upskill and transform their practice. The challenge now is ensuring sustainability and consistency across the country for services we know have demonstrable impact, whilst ensuring workforce supply and development, so people can undertake these roles.
Underpinning workforce development is a model of education and training that delivers the right pharmacy workforce. A workforce that can adapt to the increasingly complex health and care system, and respond to technological advances and changing patient needs. To ensure we have the model right, HEE is undertaking a review of the current model of education and training for the pharmacy workforce. As part of this review, we will be working with partners to consider:
- The initial education and training pathway for pharmacists and how this could be delivered differently
- Foundation training across primary, community and secondary care for clinical pharmacists and how this could be standardised to build on the initial education and training and to meet the future requirements of service
- A review of the training of pharmacy technicians to ensure they are competent and confident to advance their practice across primary, secondary and community settings.
Pharmacy Dean (North), Health Education England
Pharmacy Dean (London), Health Education England