Medicines management[


Updated July 2006 As people get older, their use of medicines tends to increase. Taking into consideration how the ageing process affects the body’s capacity to handle medicines becomes increasingly challenging when attempting to ensure that medicines are prescribed and used effectively. Multiple diseases or complicated medication regimes may affect a patient's capacity to manage their own medication. This may cause confusion, and is often related to such factors as adverse drug reactions, missed medication or repetition of prescription. Self medication, or medication by relatives or friends/carers is common practice and administering prescription drugs to the older person by non-medically qualified persons is a serious hazard. Non steroidal anti inflammatory drugs (NSAIDs) such as painkillers are often taken for rheumatoid disease by the older person, who can later become reliant on them. This dependence on the drug for mobility can be a result of poor medicines management which can seriously affect the health of the individual. These drugs are extremely toxic to kidneys, especially those of the older person.

Medicines management is a term that has been used to describe methods to overcome these problems and encompasses the entire way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes of patient care. The components of medicines management should be:
  • optimising a medication regime (right drug at right time)
  • facilitating adherence to medication, including beliefs and fears as well as physical problems
  • organising supply and administration support, such as repeat dispensing systems
  • provide monitoring and feedback systems.[see reference 1]
As one of the primary health professions in the NHS, pharmacy has a vital role in delivering healthcare to the individual. A key theme of the NHS Plan is empowering patients to take an active role in managing their own pharmaceutical care. Patients are not merely passive recipients of prescribing decisions. The older person is especially important in this respect as we know that 80 per cent of over 75s take one or more medicines and 36 per cent of over 75s take 4 or more.[see reference 2] Those aged 60 and over receive more prescription items per head than any other group. In England in 2005, the average was 14.3 prescription items per head of population with 3.8 items on average to children under 16, 9.1 for persons aged 16-59 and 38.4 items to those 60 years and over.[see reference 3]

Effective medicines management is essential for independent living for most older people. It is recognised as no longer effective or appropriate to merely provide the older person with a ‘Dosett Box’ (a pill box with times/days marked on it, which helps people take their medications at the correct time).
In order to provide effective treatment it is important that patients adhere to the doctors’ instructions and take the medicines prescribed, and that the need for the medication is reviewed at appropriate intervals, however:
  • up to 20 per cent of prescriptions are not ‘cashed’
  • around 50 per cent of people do not take their medicines as intended
  • 80 per cent of drugs prescribed are repeat prescriptions without consultations[see reference 2]
Medication review is usually conducted by the GP with the patient. 'Medicines and older people', the NHS document dealing specifically with implementing medicine's related aspects of the National Standards Framework, recognises that pharmacists and nurses play a part in medicines advice. Evidence from the US shows that pharmacists could improve patient care by reviewing drug treatment and a study in Britain found that consultations with a clinical pharmacist were an effective method of reviewing the drug treatment of older patients.[see reference 4]

Medicines management policy initiatives in Britain are summarised below.

National service framework for older people – Medicines management (Department of Health)
A national service framework to define standards for health and social services for older people was published by the Department of Health in March 2001.

Milestones in the document include:

  • all people over 75 should normally have their medicines reviewed at least annually, and those taking four or more medicines every six months
  • all hospitals should have ‘one-stop dispensing/dispensing for discharge' schemes, and where appropriate, self-administration schemes for medicines for older people
  • by April 2004, every primary care group or primary care trust will have schemes in place so that older people get more help from pharmacists in using their medicines
Also highlighted within this national service framework:
  • the acknowledgement that the ageing process affects the body’s capacity to handle medicines
  • that multiple illness and polypharmacy (taking more than one drug) can affect patients’ capacity to manage their own medicines
  • that some medicines are under-used and
  • that many are not even taken
In conjunction with this particular national service framework, a booklet entitled ‘Medicines and Older People: implementing medicines-related aspects of the NSF for older people’ was produced due to the high number of older people who are taking prescribed medicines in conjunction with other remedies they buy themselves.

The booklet advocates the development of appropriate medicines management systems so that the medication needs of older people are regularly reviewed, discussed with older people and their carers, and that information and other support is provided to ensure older people get the most from their medicines and avoidable adverse events are prevented.

National service framework for older people, a report of progress and future challenges, 2003

The report states that initial progress has been slow against the objectives, although there is evidence that the number of medicines reviews undertaken has increased significantly. Further, only 54 per cent of hospitals had 'one-stop dispensing/dispensing for discharge' schemes.

Pharmacy in the future - implementing the NHS plan – a programme for pharmacy in the health service (Department of Health)
As one of the primary health professions in the NHS, pharmacy has a vital part to play in delivering the NHS plan.

Pharmacists are an integral part of most people's experience of NHS care, and in order to meet the changing needs of patients this paper called for the following:
  • making sure that people can get medicines or pharmaceutical advice easily and, as far as possible, in a way, at a time and at a place of their choosing
  • more support in using medicines. Extra help for those who need it to get the best out of their medicines – help which will mean fewer people being ill because they are not using their medicines properly, and which will cut the amount of medicine which is simply wasted
  • giving patients the confidence that they are getting good advice when they consult a pharmacist
The document goes further to put forward recommendations in:
  • medicines management services – targeted support for patients
  • spreading expertise – medicines management action team
  • patient partnership in medicine taking.
A spoonful of sugar - Medicines management in NHS hospitals (Audit Commission)
The Audit Commission report acknowledges that medicines management is central to the quality of healthcare, and underpins many of the specific objectives set out in the NHS Plan. However, a combination of factors means that hospitals do not always manage their medicines to best effect. This report addresses the main strategic challenges and issues facing hospitals in improving the effectiveness of their medicines' management, and suggests ways in which potential barriers can be met and overcome.

This report has two aims:
  • to raise the profile of medicines management in hospitals; and
  • to make the case for providing adequate investment to enable standards to be raised
The document goes on to highlight strategic challenges, obstacles to progress and how to overcome them. It further makes recommendations for:
  • Department of Health
  • National Assembly for Wales
  • Royal Pharmaceutical Society of Great Britain
  • NHS Purchasing and Supply Agency
  • NHS trust boards
  • Commissioners.
Medicines partnership
Medicines partnership is an initiative supported by the Department of Health. It enables people to get the most out of their medicines by involving them as partners in treatment decisions. It works with others to integrate this model throughout the healthcare sector. It promotes the concept of concordance, as opposed to compliance, which emphasises a partnership-based process of prescribing and medicine taking. Its essential elements are:
  • Patients have enough knowledge to participate as partners
  • Health professionals are prepared for partnership
  • Prescribing consultations involve patients as partners
Medication review
Medication Review is a section within the Medicines Partnership website which provides information to patients and health professionals on Medication Review.

References:
[1] Managing medicines (2002). History and development. London: Managing medicines - A Resource Centre for Medicines Management and Pharmaceutical Care.
[2] Rayer T (2002) Medicines Management – Independent living for older people [paper for conference]. London: University of Leeds.
[3] NHS Information Centre (2006) Prescriptions dispensed in the community statistics for 1995 to 2005: England. London: Information Centre, Government Statistical Service.
[4] Zermansky AG & Petty DR et al (2001) Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. British Medical Journal 323:1340-1344.

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