The message could not have been starker –how health and care is delivered in Scotland is changing and, this time, it’s really going to happen because the pressures on the system leave no alternative.
‘We have to be clear the difference that health and social care integration is going to make,’ said Vicky Irons, Chief Officer of the Angus Health and Social Care Partnership. ‘If we are passive about this or even resistant, there is a chance that we won’t make any difference at all and that would be a wasted opportunity. The emphasis now is genuinely about seizing some of these opportunities.’
Vicky Irons was speaking at the recent Pharmacy Management Forum in Scotland, which focused on how the pharmacy profession delivers its full potential in the new world of integrated health and social care partnerships, where each professional is expected to practice what is being termed ‘Realistic Medicine’.
‘When I reflect on the passage of change in primary care over the last 20 years there is some consistency among the drivers of change,’ Ms Irons told her audience meeting in Dunblane. ‘Each of the reforms was seeking greater integration of services, more continuity, proactivity in care planning, less unscheduled care, more effectiveness, more community capacity, delegation of power and a shift in the balance of care. The spirit of the reforms was very similar, the intent similar, the objectives similar. Unfortunately, the results in the past were pretty similar too.’
This time, she told her audience of pharmacists, there is a determination that reform will happen, not least because the challenges are simply too big for previous delivery models to cope.
‘Take workforce, for example. The workforce that we require now does not exist, and it is getting scarcer. So we need support from the wider partnership, you guys, to help us extend our view to the very periphery of our current vision when it comes to workforce, because this is possibly one of the biggest risks to our being able to sustain a good future.’
The principle of partnership in decision making, both across professions and between carers and people, is at the heart of integrated health and social care. It is also a pillar of the move to Realistic Medicine being championed by Scotland’s Chief Medical Officer, Dr Catherine Calderwood.
Realistic Medicine seeks to ensure the healthcare people receive is of the greatest value to them as individuals, is most in line with their wishes and has the least potential to harm them. It asks professionals to reduce wastage, to challenge variations in practice and outcomes, to treat illness rather than risk, and for each to take her or his own practice up a level as improvers and innovators.
Dr Calderwood told the Pharmacy Management Forum that pharmacists have been one of the single biggest professional groups to comment on Realistic Medicine, and their reaction had been overwhelmingly positive:
‘We are changing our thoughts, we are moving treatment out into communities, away from hospitals and, in doing that, I would say pharmacists are absolutely ideally placed at the right time to become more involved and I think we need, as has been the commitment of Prescription for Excellence, to really invest and develop the pharmacy profession.’
The chairman of the Scottish Pharmacy Board of the RPS, Dr John McAnaw, suggested to the conference that there was much in the changing working environment of Scotland’s pharmacists that is good for the profession:
‘Realistic medicine supports professionalism and is a good anchor, with a clear focus on patients. We should use it to reflect on some of the helpful, and sometimes unhelpful, habits that we have.
‘There is a clear need to make sure the role of pharmacists in patient care is clear and understood and perhaps we need to do more to engage with the integration agenda so that others are aware of the knowledge skills and expertise that pharmacists bring, so they understand the values and behaviours that underpin our professionalism and see what we can bring to the table to ensure patients get the right medicine at the right time to have the right response.
‘We need to be influencing strategic planning groups in the health and social care partnerships to ensure that the pharmacist role and expertise can be deployed in the right way. We need to look at stronger care networks being developed locally to benefit patients and the public. We also need to think of integrated pathways, the journey from home into hospital and back out, because there is a clear and important role for pharmacists to play in these pathways.’
One person already won over to the work of pharmacists, pharmacy advisers and wider pharmaceutical services, is Angus Chief Officer, Vicky Irons. She often visits community pharmacies in her patch and believes the role of pharmacy is well developed and growing ‘at pace’:
‘There is an opportunity for us to build interdependences across all of our partners and break down unnecessary barriers in care and we are seeing that emerge in Angus in the enhanced care service model centred on our GP practices. It is a simple concept that develops multi-disciplinary team working, predominantly at the moment around older people although we are looking to expand that. It ensures that we have early coordinated interventions that improve outcomes in people’s lives.
‘We are enabling locality and community pharmacists to work together to deliver the pharmaceutical care of patients as part of this and are seeing a significant change in the use of institutions as a result.
‘And the other intended consequence, that you cannot put a value on as it is immeasurable, is the development of the relationships across the professional groups. It is exciting to see professionals around a table talking about the care of a person, where they all contribute and also expand their knowledge of what other professionals do. It reduces duplication and it improves the standard of care being provided.’
Scotland’s Chief Medical Officer cited work in NHS Forth Valley where community pharmacists have become the first port of call for some people who would previously have sought a GP appointment.
Dr Calderwood presented interim findings from a programme that has signed up almost every community pharmacy in Forth Valley to manage the treatment of urinary tract infections, impetigo and exacerbations of COPD, backed with face to face and online training opportunities.
In the first 22 weeks, 897 people were seen after coming to the pharmacies with UTIs. Of these, pharmacists treated and discharged 682 of them, with only 139 needing onward further referral. Similar numbers of people with impetigo and exacerbations of their COPD were being treated and completely discharged through community pharmacy. In all, almost 1200 people were seen in first 22 weeks of the programme, which is being formally evaluated for its potentially to be rolled out to other areas.
‘That is innovation,’ said Dr Calderwood, ‘person-centred, personalised care and it is freeing up time for the GPs who are very much under pressure. And, there has been amazingly good feedback from patients.
‘Your expertise, your training, your knowledge and the ability to provide care as we are seeing demonstrated: this is the right time to be doing this.’
John McAnaw, while celebrating the opportunities that change is bringing, also acknowledged that pharmacists can find themselves pulled in all directions:
‘We’ve had things thrown at us constantly. As we are trying to grasp what one things means and whether we perhaps need to reset the direction, another comes along. We are living, at a policy level, in a constantly changing environment.
‘The lasting constant in times of change has to be professionalism. We have to maintain that professionalism whatever. It is the constant that we have, making sure we can practice according to our core values, beliefs and behaviours and around the duties of integrity, honesty and clinical competence.’
‘At the moment, the possibilities are infinite and so are some of the expectations,’ admitted Vicky Irons. ‘It is really important for us to develop a sense of priority and stick to it. We can do loads of things but we actually need to do a few things really well. But we can’t be dragged back into what we used to know and do, because it doesn’t work anymore.’
Integration – what could pharmacists do to assist our carers?
A practical example of integrated care showcased at the Pharmacy Management National Forum for Scotland described how the daily medicines needs of elderly people in and around the towns of Moffat and Lockerbie are being managed by one care at home provider.
Dumfries and Galloway has in place Guidelines for Home Care Workers Assisting Older People with Medication, which have been developed and agreed by a multidisciplinary team, including representatives from health, social work, commissioning and care agencies. The guidelines are followed by all care providers working in the area.
Gayle Lamont, care co-coordinator at one of the providers, Annandale Bed and Bath Services (ABBS), explained how the partnership between ABBS, community pharmacists and primary care pharmacists is seeing care visits to some of the elderly people they support being combined with administering prescribed medication in the right way at the right time.
‘Our carers are not healthcare professionals but can, with the right training and support from pharmacists, manage the administration and recording of administration of medicines safely. This is often the key to helping the older person to remain in their own home for longer.
‘Every four weeks, the carers visit the clients’ community pharmacist to collect both the medicines needed for the coming month and medicine administration record (MAR) charts that, when completed and countersigned, become part of the clients’ care records. Systems are also in place to ensure medicines are ordered correctly and at the right time.
‘I would say that the most important relationship for my carers, after that with the clients, is with our local community pharmacists who they can easily turn to at any time for advice about medicines, without having any concerns about asking silly questions. The pharmacists know our carers and work well with them.’
Overseeing the programme is NHS Dumfries and Galloway Service Development Pharmacist, Catherine Smith:
‘Some elderly people living at home with the support of home care workers may require assistance to take their medication correctly. It is important to ensure that these people are enabled to manage their own medication for as long as is possible but, in some cases, once all other options have been explored, the person may be assessed as needing a carer to administer and manage their medication. We would refer to this as Level C care, also known as Level 3 in other parts of Scotland. It is important that carers are appropriately trained to provide this level of care.
‘The links and close working relationships developed between providers like ABBS, the local community pharmacists and the primary care pharmacists highlight how pharmacy can be central to the wider relationship between the client, their family, the GP and social work team.’
John Macgill is Director of Ettrickburn, a communications and government relations consultancy specialising in Scottish healthcare and lifesciences. www.ettrickburn.com