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Review of Medicines Optimisation in Primary Care

The Regulation and Quality Improvement Authority (RGIA) has published the report of its Review of Medicines Optimisation in Primary Care.


orthern Ireland has an ageing population, which is likely to increase the number of people

with multiple medical conditions, leading to greater use of complicated medicines regimens. RQIA assessed present medicines optimisation processes in here, aligned to DHSSPS’s Medicines Optimisation Quality Framework, and this report makes 16 recommendations to improve medicines optimisation processes in primary care.

An effective medicines optimisation process in primary care requires a multidisciplinary approach, involving both medical practitioners and community pharmacists.

A robust system of oversight of prescribing practice is also important, to ensure that it is in line with medicines optimisation principles, in terms of safety, quality and effectiveness of prescribing, to deliver better outcomes for patients. DHSSPS is developing a Medicines Optimisation Quality Framework, due for publication in 2015.

To gain assurance as to present medicines optimisation processes in primary care, DHSSPS has commissioned RQIA to conduct this review.

Although individual clinicians have responsibility for medicines optimisation, the Health and Social Care Board (HSC Board) has responsibility for including in its commissioning arrangements, processes to ensure the quality and safety of medicines optimisation in primary care.

The review examined those processes. The review examined the links between secondary care and primary care (general practice and community pharmacy), and also assessed the service user and carer experience of managing their medication.

“Transforming Your Care (TYC) sets the strategic direction for health and social care in Northern Ireland,” states


the Report. “The focus for healthcare should move from inpatient services to provision of care in the community and in people’s own homes.

“TYC outlines that community pharmacists have a greater role to play in managing patients with long-term conditions, who are taking multiple medicines. The pharmacist should form part of a multi-disciplinary approach to managing long-term conditions, keeping the focus on the patient, providing alternative options to being admitted to hospital, and to prevent such occurrences whenever possible. This shift in emphasis to primary and community care strengthens the need for robust optimisation of medication in these areas.”

From a financial aspect, HSC medicines expenditure equates to £550m per annum in Northern Ireland, representing 14% of the total HSC budget and is the second largest cost after salaries. Each year community pharmacies in Northern Ireland dispense in excess of 38 million prescription items, for medicines costing £375m. In addition, some £175m of medicines are dispensed in the hospital setting.

The review team acknowledged the enthusiasm and commitment of HSC Board medicines management teams, but identified a number of factors preventing achievement of optimal processes in primary care.

“Negotiations regarding a new contract for community pharmacy have been proceeding at a slow pace and are still ongoing. The review team considers that the lack of a definitive contract is helping to prevent further development of an extended role for community pharmacy in medicines optimisation, and was potentially preventing better outcomes for patients,” they say.

The review team makes 16 recommendations to improve medicines optimisation processes in primary care, detailed below. 

RECOMMENDATION 1 - In its review of medicines management structures, the HSC Board must take account of the medicines optimisation quality framework and other relevant system changes. The review must also rationalise supporting structures where possible.

RECOMMENDATION 2 - The HSC Board should consider how, in the absence of QOF medicines management indicators, meaningful assurance regarding the safety of prescribing/medicines optimisation in GP practices can continue to be achieved.

RECOMMENDATION 3 - The HSC Board should review the impact of removal of the QOF medicines management indicators, to determine whether they were a positive driver for prescribing safety and quality.

RECOMMENDATION 4 - The Integrated Medicines Management Service should be available to a consistent level in all trusts and include a standard process for communication with General Practice and Community Pharmacy.

RECOMMENDATION 5 - Community pharmacy should be provided with access to the electronic care record.

RECOMMENDATION 6 - A more robust integrated medicines management model should be established for complex patients post discharge, which would include a defined role for community pharmacy.

RECOMMENDATION 7 - The HSC Board should establish consistency of prescribing practice where appropriate and with consistent data analysis across both secondary and primary care. This should be set out in commissioning requirements.

RECOMMENDATION 8 - The HSC Board should develop a robust and effective system of incident reporting and dissemination of learning from incidents in primary care, taking account of regional developments in this area.

RECOMMENDATION 9 - The HSC Board should develop a robust system for dissemination of alert letters to community pharmacies.

RECOMMENDATION 10 - Greater priority should be given to dealing with antimicrobial stewardship. The action plan and outcomes already developed for primary care should be progressed as soon as possible.

RECOMMENDATION 11 - The HSC Board should ensure that the Northern Ireland Formulary is completed with appropriate processes in place for regular updating.

RECOMMENDATION 12 - The HSC Board should make the Northern Ireland Formulary available electronically in GP practices and in community pharmacies and also in different formats such as an App.

RECOMMENDATION 13 - All parties involved should continue as a matter of urgency to progress the development of a new pharmacy contract.

RECOMMENDATION 14 - The HSC Board should standardise medication review and the role of pharmacists in the review process. The HSC Board should also explore alternative methods of pharmacist involvement in medication review, without contractual arrangements, if necessary.

RECOMMENDATION 15 - The HSC Board should work with prescribers to ensure that the principles contained in NICE Guideline 76 are being implemented, to ensure appropriate engagement with service users when prescribing medication.

RECOMMENDATION 16 - As part of its restructuring, HSC Board should consider enhanced service user involvement at a strategic level of its medicines optimisation structures.

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