One of the biggest dates in Northern Ireland's agricultural calendar has to be the Balmoral Show, held annually at the King's Hall in Belfast.

Lisburn’s popular Bow Street is not just home to some big brands, it is also where some big developments in community care are being made. Staff at Boots, based at the heart of the city’s main shopping area, recently opened a new area within the pharmacy, dedicated to harmonising pharmaceutical service deliver for the surrounding care homes. The newly extended room has a separate drugs room and each nursing home has its own work station and dedicated staff member working on that home resulting in a smoother, well-organised service.

Jayne McCutcheon, who manages the store, was joined by Marie Smith, regional pharmacy manager, for the occasion. “The Care Home Room enables the team to work in a new way delivering fantastic patient care and an efficient service to our care homes,” Jayne explained. “We receive the information from the nursing home, put the prescription together for each individual patient into a MDS system and deliver it to the care homes. The nurses don’t have to organise medication for individual patients – it is all done for them. Our pharmacy services homes in Lisburn and surrounding areas such as Lurgan and Portadown and this investment to the Care Home Room will enable us to offer an even more comprehensive and valued service.”
 
Marie said that the Care Home Room in Lisburn is the third to be rolled out in Northern Ireland. “We already have this style of room in Belfast and Bangor and we are looking at further sites in Northern Ireland in the next year. Boots also provides Training Days to nursing home staff which facilitates up-skilling them on medications and other clinical areas. This also builds up great relationships between the staff members of the care homes and staff within Boots.”

Even the largest pharmaceutical companies will soon need to step outside their sector and collaborate with other organisations, according to new research by Price Waterhouse Coopers (PwC). Recently announced activity such as GSK and Pfizer’s new HIV-focused venture confirms that pharmaceutical companies are exploring new ways to collaborate.

At the same time, a flurry of merger and acquisition deals have been triggered, including Roche and Genentech, Pfizer and Wyeth, GSK and Stiefel and Merck and Schering Plough. While such arrangements will continue to be made there are alternatives, such as collaboration, that PwC believes will actually be more flexible and value-enhancing in the long term.

According to the report, PwC believes that the financial crisis may force many more companies into collaboration. In fact the government’s response to the economic climate has allowed collaboration outside the pharma sector that would have been unthinkable before, such as waiving competition issues for mergers. “Collaboration could address the current funding crisis for biotech firms but this requires an immediate response,” explained a spokesperson from the think tank. “In fact the pressure to change to new business models could come from outside the pharmaceutical sector, perhaps triggered by regulators, investors, and healthcare payers.”

There is certainly no shortage of evidence to suggest that there are significant benefits from a collaborative approach with longer term aims. A study by the RAND Corporation estimated the financial savings from having 100 per cent participation in disease management programmes for four diseases (asthma, chronic obstructive pulmonary disease, diabetes and congestive heart failure) in the US. They estimate the net savings to the health system to be $28bn (around 2 per cent of total US health expenditure), with additional benefits to the economy in terms of working days saved.

Furthermore, time waits for no pharma firm so sharp action is paramount, since several non-pharmaceutical companies have already entered the arena. Vodafone has, for example, joined forces with Spanish telemedicine provider Medicronic Salud and device manufacturer Aerotel Medical Systems to offer a wireless home monitoring service. Similarly, Prudential is collaborating with Virgin Active Health Club to offer a critical illness policy that provides subsidised gym membership and rewards people who exercise regularly by reducing their premiums.

Simon Friend, global pharmaceutical and life sciences leader at PwCs, summarised the findings. “Most large pharmaceutical companies use external contractors to supplement their in-house resources, but very few firms have taken the next step,” he said. “Yet there is no reason why many companies could not outsource R&D, manufacturing and promotional activities. This would allow them to focus on their main value-adding functions – project management, business development, regulatory affairs, intellectual property management, pharmacoeconomic analysis and the formation of good relationships with key opinion leaders and healthcare payers. The world is changing fast and those who are flexible and can adapt will reap the benefits.”

The changing face of the wider healthcare model globally, the demands from different stakeholder communities, including the patient, will demand that pharmaceutical companies provide holistic solutions not narrow treatments. In tomorrow’s world this means that pharmaceutical companies must work more with other parties. To do so they will have to ‘profit together’, by joining forces with a wide range of organisations, from academic institutions, hospitals and technology providers to companies offering compliance programmes, nutritional advice, stress management, physiotherapy, exercise facilities and health screening.

A new model to the pharmaceutical industry is the federated model, whereby a company creates a network of separate entities with a common supporting infrastructure. These might include universities, hospitals, clinics, technology suppliers, data analysis firms and lifestyle service providers based in numerous countries.

One of the most valuable opportunities for an insight into arguably the most important year for budding pharmacists was taken by over 130 third year students from universities across the UK and Ireland, recently. The annual Ulster Chemists’ Association Pre-registration and Tutor Evening welcomed speakers from across the pre-reg spectrum, including current students, tutors and recently qualified pharmacists, to talk about their experiences.

Hilton Templepatrick, 16 September 2009 - Thank You!

A rapid, exponential rise in diagnosed patients is a key sign of a pandemic and last month, there was a fifty per cent increase in the number of reported cases of H1N1 within Northern Ireland, in just one week. However, following extensive discussions among healthcare professionals in pandemic management, it would appear that for pharmacy, the risks are not only health-related.

If modern therapeutics continue to stem from accurate and methodical prescribing, will pharmacists be the ones to blossom? All rather saccharine, botanic metaphors aside, the increase in pharmacy prescribing brings significant opportunities for the profession at all levels. At a conference hosted by NICPLD in Belfast last month, the latest cohort of independent prescribers in Northern Ireland to qualify, joined past course graduates to share their experiences of how prescribing has changed their daily working.

Delegates discussed issues surrounding prescribing, including funding, the creation of a support network for prescribers and special areas of clinical interest and how prescribing can help to refine and develop these. Chief pharmaceutical officer Dr Norman Morrow opened the day and commended the progress since the first supplementary prescribers completed their training.

“Prescribing pharmacists are very unique and certainly within the UK and Europe you will find yourselves as leading edge practitioners on a world stage,” he said as he addressed the group. “The associated issues include medicines management, compliance and reducing overall costs and these are things you ought to keep in mind when deciding how best to use your qualification. When the Department campaigned for independent rights across the formulary and for them to not be limited to certain medicines, we were pleased to have won this argument and independent prescribers are not restricted.

“However, we need to consider the future. Have we reached the pinnacle of professional aspiration? It would be very limiting if we thought of it in this way. We began small and we have now built a tremendous facet to the pharmacy profession. We have gained the endorsement of others and learned along the way. We have since established roles for heads of pharmacy and medicines management in the new Trusts Medicines account for around £400 million of the HSE’s expenditure, second only to salary expenditure.”

It is important to make the distinction between doctors and prescribing pharmacists, which lies in diagnosis. The strengths of prescribing pharmacists have been and will continue to be found in therapeutics, management of long term treatment and perhaps remote care, as well as early public health screening and interventions. “I want to encourage you to have a vision of what you want to achieve with this,” Dr Morrow said.

The majority of NICPLD’s independent and conversion course graduates are hospital pharmacists, although the interest levels among primary care and community pharmacists is increasing, with clinical areas such as hypertension, asthma and COPD. hypercholesterolaemia, diabetes, benz reduction and ace inhibitors making regular appearances in Northern Ireland. Elsewhere in the UK however, pharmacists are already prescribing in substance misuse, palliative care, antimicrobial chemotherapy and more, proving that the scope for development is considerable.

Rosemary Donnelly, who has been a qualified pharmacy prescriber since 2004, works within the Ulster Hospital. She prescribes in the hospital’s diabetes and cardiovascular clinic and notes that the clinics have been easily transferred to primary care. “Before beginning the course, I approached the consultant I worked with who was very interested in mentoring me,” Rosemary said. “At the time it was exclusively a supplementary course but it was a great grounding. There had been an audit carried out in 2000 which indicated that only 26 per cent of the clinic’s patients were on lipid lowering treatment and that a medicines management programme was needed.

“The clinic practitioners wanted to recruit a nurse that would run this clinic for him. But I told him about becoming a supplementary prescriber and he changed his mind about a prescribing nurse! The need had been identified for me, then the scope of the clinic was defined. I was very fortunate in this sense but it is important for prescribing pharmacists to identify where their skills can be best used. We looked at lipids, blood pressure, microalbuminuria, blood sugar with oral hypoglycaemics and insulin titration.

“I did the conversion course in 2006/07 and was mentored further and took part in virtual clinics. I also worked with a diabetes specialist nurse, but there was no conflict since we had jointly established this clinic and each trained together. The virtual clinic was helpful – it allowed us to examine case studies of each patient who had visited the previous week and we gave our opinions about how to treat them. They had already been diagnosed, so we were there to help manage their condition. We then found it easier to evaluate our progress. I did not see patients for the first nine months but it was excellent preparation for when I did see them in the clinic.”

To prevent inefficiencies and to promote closer working between pharmacy and nursing, Rosemary and her colleagues defined which areas would be best managed by the pharmacist and nurses independently and which areas would overlap. “I took care of concordance with medicines, drug histories, medicine reviews, side effects and protocols, while the nurse did physical assessments, social issues, psychology and also dealt with carers. Titration or therapies and monitoring outcomes was something we each had responsibility for. Prescribing is an excellent way of harmonising professions and is not something that should be repelled or underestimated.”

Two years ago, the hospital carried out another audit on the clinics, this time concentrating on patient satisfaction. “77 per cent were very satisfied and 23 per cent were satisfied so having no complaints was hugely encouraging,” continued Rosemary. “The opportunities afforded to me include prescribing at ward level, an extension to my primary care remit and telehealth, where we remotely monitor our patients, particularly with BPM. They can upload information about their blood pressure or glucose and their weight, which allows us to titrate without asking the patient to visit us as often.”

Caitriona Donnelly, a renal pharmacist at Belfast City Hospital, started an erythropoietin or EPO clinic, after having identified a need at a regional level. “We intended to see non dialysis patients who needed EPO but there were some immediate, practical issues to overcome,” she began. “There is no room within the pharmacy and outpatients was very busy. So we set it up in the renal unit where there was a treatment room and refrigerator, and got administrative support from PAS as well as nursing support.

“When first selecting patients, we received a referral letter from their consultation nephrologist with a signed prescription, and then we contacted the patient directly to arrange their appointment. PAS then confirmed this in writing with the patient and continued to manage appointments. The nurse’s duties included BPM and obtaining blood samples, then determining with the use of an hemacue machine the estimation of haemoglobin and documenting any patient concerns.
“My role was to check recent bloods, review BP and Hp estimations, review their EPO dose and contact the doctor if necessary, run a medication review and eMed update, issue EPO supplies, indicate the next clinic appointment and to check the lab results.”

Although the main diagnosis has already been made with both Rosemary and Caitriona’s patients, clinical judgement is very important and if a suggestion of an associated or developing condition is made by the pharmacist, action must of course be taken. And it is the same in community. Pharmacy contractor Raymond Anderson has been involved with his local GP surgery as a prescribing advisor for some years and is also a product of the independent course. He is confident that expertise within medicines and informed clinical decision making is what will make pharmacy a valuable component of the prescribing model.

“Pharmacy is very dependent upon evidence based reporting and whenever pharmacy is involved in something relatively new, the professional expertise and input of pharmacists needs to be recorded,” he said. “Management is very different from diagnosis, so if we receive anomolies in blood results then occasionally we will request a second test as blood often comes back with abnormalities reported, but more often than not we will refer immediately. We are not here to diagnose and once that has been made clear, we can start to overcome some of the barriers to progress, which include the need to practice in a GP setting, the necessity of appointments, the lack of IT links and infrastructure in community and the imperative for continued funding.”

Surprisingly, apathy or opposition from other healthcare professions, particularly doctors and prescribing nurses and clinicians, was not cited as one of the biggest obstacles and when it did arise, was easily managed. “Most nephrologists were in favour of pharmacy prescribing although we did encounter a little opposition from those who were not so keen,” Caitriona said. “However, the real challenges were getting adequate cover for pharmacist prescribers and nurses, contacting doctors, dealing with acutely unwell patients and deciding how to work together for the best outcomes for patients. Additional indemnity insurance for hospital prescribing pharmacists is still needed and regular auditing can be demanding.

“My advice is to keep the numbers of patients realistic and to forge good communication levels with colleagues and patients. Management support for pharmacy, medical and nursing divisions is also vital.”
Raymond said that whether hospital or community, a grasp on what you want to do with the qualification is essential. “Shortly before qualifying, I needed to plan. I had to decide on objectives, what I wanted to achieve, obtain funding, discuss possible areas of practice with GP surgery - I began these discussions mid way through my course. I talked to the prescribing nurse too and assured her that any prescribing practice I became involved in was not a threat to her existing services.

"So what next after the decision is made? Meet with senior GP and/or practice manager, confirm patient base for selection, search hypertension and cholesterol registers and check those needing review by monitoring blood pressure, cholesterol etc. It is about giving a more wholesome package. I explained in the letter to patients that because the practice was introducing a new CVD review clinic, they were invited to come along. I also knew I had to make sure that a nurse was available for each appointment.”
As an anticoagulant pharmacist in the Southern Trust, Sinead O’Doyle’s first challenge was to tackle the practicalities of changing a clinic from medical to pharmacist-led. “The transition was made while I was doing my supplementary course and we had lots of planning over this period,” she said. “I began to visit all three anticoagulant clinics in the area, informing the local GPs by letter about what we were proposing and meeting patients in person at the clinics. Guidelines for clinics and standard clinical management plans were also compiled.

“There was not much of an increase in uptake at any of the three clinics but each are much better managed and a recent audit indicated there has been an improvement in the quality of care.” Sinead routinely prescribes warfarin, or acebocoumarol and phenindione for those who are intolerant of warfarin.

“You can be as clinically confident as anyone but it is essential to have administrative back up. Audits are paramount but particularly important for new clinics or existing ones with a transferring lead. How do you make a pharmacist led clinic successful? You definitely need a supportive consultant, who will support you and promote the service, support from senior pharmacy management, regular audits and regularly and accurately updated patient record. Secondary to improving patient outcomes, it has to be a role that can relieve the burden on doctors.”

Cathy Harrison, principle pharmaceutical officer at the Department looked at the developments within primary care. “First of all, we need to start with a really strong leadership and vision for pharmacy which is what we still need to decide upon,” Cathy said. “We then need to influence change and health policy. Key leadership issues include whether all pharmacists should ultimately prescribe, whether prescribing is critical to the future and whether patients will accept pharmacy prescribing.

“You will still face the same start up practicalities and hurdles as you do with regular pilot services. The DHSSPS still needs to look how we can support pharmacists in primary care. We are ahead of the curve in many ways in Northern Ireland and the UK as we are one of the few countries globally that permits and supports pharmacy prescribing. We will be learning from your experiences and they will inform policy change in the future.”