newmedicinese rvice - cppe · newmedicinese rvice deliveringquality andmakingadifference developed...

An open learning programme forpharmacists and pharmacy technicians

DLP163

MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION � COMMUNICATION � CONSULTATION �

INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE

� INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK � MEDICINES �

PATIENT-CENTRED CARE� ADHERENCE � INTERVENTION � COMMUNICATION � CONSULTATION

� INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE�

INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED

CARE � ADHERENCE �INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE

� TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION � COMMUNICATION � CONSULTATION �

INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � ADHERENCE � ADHERENCE � INTERVENTION � COMMUNICATION

� CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE �

INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK �

MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION � COMMUNICATION �CONSULTATION� INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION �

COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK

� MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION

GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE � ADHERENCE � INTERVENTION � COMMUNICATION �

CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK � MEDICINES � PATIENT-CENTRED CARE

� ADHERENCE � INTERVENTION � COMMUNICATION � CONSULTATION � INFORMATION GOVERNANCE � TEAM WORK

New medicine serviceDelivering quality

and making a difference

Developed in partnership

An open learning programme forpharmacists and pharmacy technicians

New medicine serviceDelivering quality

and making a difference

Educational solutions for the NHS pharmacy workforce

© Copyright controller HMSO 2011

Developed in partnership

ii Acknowledgements

CPPE writers and reviewers

Christopher Cutts, director

Lesley Grimes, senior pharmacist, learning development

Matthew Shaw, deputy director

Michelle Styles, regional manager, London

The School of Pharmacy, University of London writers and reviewers(Section 2)

Nick Barber, professor of pharmacy practice

Sarah Clifford, lecturer in medicines in health

Project team, contributors and reviewers

Alison Blenkinsopp, professor of the practice of pharmacy, Keele University

Alastair Buxton, head of NHS services, Pharmaceutical Services NegotiatingCommittee

Richard Dyson, senior policy officer, primary care workforce and contractingteam, NHS Employers

Lucy Gate, health psychology specialist, Atlantis healthcare (Section 4)

Sally Greensmith, NHS Employers Community Pharmacy NegotiatingTeam andCPPE local pharmacy tutor

Taryn Harding, deputy head, primary care workforce and contracting team,NHS Employers

Mimi Lau, director of pharmacy services, Numark

This programme was piloted by all the attendees at the new medicine servicestakeholder event on 19 July 2011.

Thanks

CPPE would like to thank all the attendees at the July 2011 new medicine servicestakeholder event for their contributions to the content of all the new medicineservice learning materials.

A U G U S T 2 0 1 1

iiiContents

About CPPE open learning programmes v

About this learning programme viii

Preparing yourself for the new medicine service x

Section 1 Background to the new medicine service 1

1.1 The key drivers for a new medicine service 1

The importance of the service to pharmacy 2

A new advanced service 3

1.2 The current NHS agenda: QIPP and medicines optimisation 4

1.3 It’s now or never! 5

1.4 Research to support the development of the service 6

1.5 New medicine service and medicines use reviews 9

1.6 Outcomes of the service 10

Exercises 4, 10

Practice points 6

Summary and intended outcomes 11

Suggested answers 12

Section 2 Supporting medicines adherence 14

2.1 A new medicine – the patient journey 14

2.2 The problems patients face 15

2.3 Adherence 17

2.4 Non-adherence: how common it is and what it means 19for the patient

2.5 Unintentional and intentional non-adherence 20

Internal and external causes of non-adherence 21

2.6 What we are trying to achieve with the new medicine service 21

Exercises 16, 18

Practice points 19

Reflective questions 18, 21



Section 3 Planning and preparing for the 25new medicine service

3.1 Self-assessment of readiness for community pharmacists 26

3.2 Delivering the service within the NHS community 26pharmacy contract

A U G U S T 2 0 1 1

C O N T E N T S

3.3 Preparing your pharmacy 28

Preparing your resources 28

3.4 Optimising team work and leadership in your pharmacy 31

3.5 Communication with GPs, their practices, other prescribers, 36healthcare professionals and local pharmacy colleagues

3.6 Further considerations when preparing for the service 39

Organising patient appointments 39

Information governance 40

3.7 Challenges 41

Practice points 27, 28, 29, 31, 32, 33, 34, 37, 38, 39, 41, 42

Reflective questions 25, 35, 36


Section 4 How to deliver a quality new medicine service 44

4.1 Communication skills – a patient-centred approach 44

4.2 The new medicine service – the three key stages 47

Patient engagement 47

Intervention stage 51

Follow-up stage 60

4.3 Data recording and record-keeping 61

Exercises 55, 56

Practice points 46, 48, 49, 54, 58

Reflective questions 45, 50, 51



Your personal action plan 64

Reflective questions 64

References 65

Figure 1 Interview schedule for the new medicine service 53Intervention stage

Figure 2 Interview schedule for the new medicine service 60Follow-up stage

Table 1 Key strategies to support adherence 22

Appendix 1 Self-assessment of readiness for community pharmacists 67

New medicine service flowchart 70

iv

A U G U S T 2 0 1 1

vAbout CPPE open learning programmes

Learning with CPPE

The Centre for Pharmacy Postgraduate Education (CPPE) offers a wide range oflearning opportunities for the pharmacy workforce.We are based in the Universityof Manchester’s School of Pharmacy and Pharmaceutical Sciences and are fundedby the Department of Health to provide continuing education for practisingpharmacists and pharmacy technicians offering NHS services in England. Forfurther information about our learning portfolio, visit: http://www.cppe.ac.uk

Themes

We have allocated themes to all our learning programmes.There are 30 themes intotal and they allow you to navigate easily through our full learning portfolio. Eachtheme has been assigned a different colour, and this is used to identify the theme innews@CPPE, on our website, and on the covers of all the learning programmes.

This learning programme is part of the Core NHS services and regulations theme.You may find additional learning programmes within this theme in our prospectusand on our website.

This programme can be downloaded in PDF format from our website:http://www.cppe.ac.uk

We recognise that people have different learning needs and not every CPPElearning programme is suitable for every pharmacist or pharmacy technician.Some of our programmes contain core learning, while others deliver morecomplex learning that is only required to support certain roles. So we have createdthree categories of learning – CPPE 1 2 3 – and allocated each programme to anappropriate category.

The categories are:

Core learning (limited expectation of prior knowledge)

Application of knowledge (assumes prior learning)

Supporting specialisms (CPPE may not be the provider and willsignpost you to other appropriate learning providers).

This is a learning programme.

Continuing professional development

You can use this learning programme to support your continuing professionaldevelopment (CPD). Consider what your learning needs are in this area. Use yourCPD record sheets to plan and record the actions you have taken.

A U G U S T 2 0 1 1

vi A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

Activities

Exercises

We include exercises throughout this programme as a form of self-assessment. Usethem to test your knowledge and understanding of key learning points.

Practice points

Practice points are an opportunity for you to consider your practical approach tothe effective care of patients or the provision of a service.They are discreteactivities designed to help you to identify good practice, to think through the stepsrequired to implement new practice, and to consider the specific needs of yourlocal population.

We have designed the practice points in this programme to help you and yourteam to make links between the learning and your daily practice and to co-ordinatewith other healthcare professionals.

Reflective questions

We have included reflective questions in this programme to give you anopportunity to reflect on what you already know, or on what you have read so far,to reinforce your learning.Thinking about these questions will help you to meetthe objectives of the programme.

Assessment

There is no CPPE or other independent assessment for this programme. However,before you can provide the new medicine service you need to complete theself-assessment form included with this programme (see Appendix 1).

References and further reading

References for all the books, articles, reports and websites mentioned in the text, atthe end of the programme. References are indicated in the text by a superscriptnumber (like this3 ).

Programme guardians

CPPE has adopted a quality assurance process called ‘programme guardians’.A programme guardian is a recognised expert in an area relevant to the content ofa learning programme who will review the programme every six months. Anycorrections, additions, deletions or further supporting materials that are neededwill be posted as an update to the programme on the CPPE website.Werecommend that you refer to these updates if you are using this (or any other)learning programme significantly after its initial publication date. A full list ofprogramme guardians is available on our website.You can email your commentsabout this programme to them at: [email protected]

A U G U S T 2 011

A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

Brand names and trademarks

CPPE acknowledges the following brand names and registered trademarks whichare mentioned in this programme: Champix®

External websites

CPPE is not responsible for the content of any non-CPPE websites mentioned inthis programme or for the accuracy of any information to be found there. The factthat a website or organisation is mentioned in the programme does not mean thatCPPE either approves of it or endorses it.

Disclaimer

CPPE recognises that local interpretation of national guidance may differ from theexamples used in this learning programme and you are advised to check with yourown relevant local guidelines.You are also advised to use this programme withother established reference sources. If you are reading this programme significantlyafter the date of initial publication you should refer to current published evidence.CPPE does not accept responsibility for any errors or omissions.

Feedback

We hope you find this learning programme useful for your practice. Please help usto assess its value and effectiveness by completing the online feedback formavailable on our website. Visit: http://www.cppe.ac.uk/mycppe and then selectmy CPPE record from the menu and log in; scroll down to find the learningprogramme title, and click on the Tell us what you think icon. CPPE may email youa reminder to do this.You can also email us direct if you think your comments areurgent, using the email address: [email protected]

vii

A U G U S T 2 0 1 1

About this learning programme

Welcome to this open learning programme. This programme is part of a range oflearning materials which have been developed collaboratively by pharmacyorganisations to support the introduction of the new medicine service (NMS).The learning materials consist of this open learning programme, a new medicineservice CPPE local solutions workshop and a new medicine service CPPEe-learning video wall. All the materials have been designed to help you become apharmacist leader in the setting up of a new medicine service in your practice,offering consistently high levels of patient care.

Accessing the associated learning programmes

� For the new medicine service CPPE local solutions workshop materials, visit:http://www.cppe.ac.uk/localsolutions

� To access the complementary video-based e-learning programme, visit:http://www.cppe.ac.uk/e-learning

The study time will depend on you, but we estimate that the reading and activitiesfor this open learning programme will take a total of four hours.

Target audience

This programme is aimed primarily at pharmacists and pharmacy techniciansworking in community practice. It is also relevant to primary care pharmacistswho might be involved in implementing such a service. Hospital pharmacists andpharmacists working in other sectors will find this of interest.

Learning style adopted in this programme

The programme is split into four sections. In Section 1 we look at why the newmedicine service is needed, addressing the context for its development andconsidering some of the research evidence which supports it. In Section 2 we lookat what the service is trying to achieve, and more specifically at the concept ofadherence. We move on in Section 3 to look at what you need to do to plan andprepare to deliver the service, and finally in Section 4 we focus on each stage of theservice in detail and highlight ways in which you can ensure you provide a highquality service for your patients.

Watch this space!

Some of the details of the new medicine service were notavailable when we prepared this learning programme. Watchout for this image as you work through the programme; wehave used it to highlight areas where more recent informationmay be available. We recommend you regularly check thePSNC website for the latest guidance:http://www.psnc.org.uk/pages/nms.html

viii

A U G U S T 2 0 1 1

WATCHTHIS SPACE!

A B O U T T H I S L E A R N I N G P R O G R A M M E

Aim of this programme

When you have worked through this open learning programme you will have anunderstanding of the purpose and scope of the service and will have translated thatto a personal action plan to support you and your pharmacy team in delivering apatient-centred, effective new medicine service, as part of your day-to-day practice.

Learning objectives

At the end of this open learning programme you will be able to:

� describe the background and expected outcomes for the new medicine service,including the evidence base

� explain the key role the pharmacy team has in supporting patients withadherence and helping them to make decisions about their medicines

� undertake a patient-centred approach to support individuals with theirmedicines

� implement and deliver a high-quality new medicine service.

Working through this programme

We would advise you to work flexibly with the materials to suit your own style oflearning. There is no right or wrong approach, but remember that the aim of yourhard work is to enable you to feel confident to meet the challenges facing you. Bearthis in mind as you work through the programme – it will help you to decide ifyour approach to study is working.

We have designed the programme for self-study, but as you progress through thesections it will be essential for you to talk through some of the issues with yourstaff and colleagues.

Online resources

Some of the references in this programme are to material which is only availableonline, and we assume that you have access to a computer connected to theinternet. If you do not wish to retype all the web addresses into your browser youmay find it helpful to download this programme from the CPPE website as a PDFdocument containing ‘live’ web links. Log on to:http://www.cppe.ac.uk/openlearning

Where we think it will be helpful we have provided the URL to take you directly toan article or specific part of a website. However, we are also aware that web linkscan change (eg, the Department of Health links) so in some cases we haveprovided the URL for the organisation’s home page only. If you have difficultyaccessing any web links, please go to the organisation’s home page and useappropriate key words to search for the relevant item.

Note on articles: If you have difficulty locating an article on the internet, searchvia: http://www.google.co.uk by typing in the title, author, date and name of thejournal. It can also be helpful if you add in, at the end of the search criteria, thewebsite where you think the information may be, eg, dh.gov.uk

All URLs were accessed 15 August 2011.

ix

A U G U S T 2 0 1 1

x

Preparing yourself for the new medicineservice

Before you can provide the new medicine service in your pharmacy you need tocomplete a self-assessment form. This self-assessment form has been developed toprovide you (the pharmacist) with a framework to assure yourself, your employer(where appropriate) and the NHS that you have reflected upon the skills andknowledge necessary to deliver the new medicine service and that you candemonstrate them.

Before starting to work through the programme, take a detailed look at the self-assessment form, which is included in Appendix 1. Then look through thequestions below to help identify your learning needs, so that you can plan andstructure your learning.

Reflectivequestions

1. Are you accredited to provide medicines use reviews (MURs)?

2. How much do you know about the background and purpose of the new

medicine service?

3. What sort of problems do you think patients might experience when they

start a new medicine?

4. What do you anticipate will be the intended outcomes of this new service?

5. How comprehensive is your knowledge of the conditions, therapies and

medicines that are to be included in the new medicine service?

6. How confident are you with your communication skills?

7. Are you aware of the key strengths of each member of your pharmacy

team?

8. How would you go about developing closer links with your local

prescribers?

9. What arrangements could you put in place to develop closer links with your

local pharmacy colleagues?

At the end of this programme you will be able to revisit these questions to see ifyour learning needs have been met, before finally completing the self-assessmentform.

A U G U S T 2 0 1 1

Section 1Background to the new medicineservice

Objectives

On completion of this section you should be able to:

list the key drivers for the new medicine service and its importance forthe pharmacy profession

describe the evidence that supports the new medicine service

describe the key outcomes of the service for patients, the NHS and thepharmacy profession

outline the link between the new medicine service and the quality,innovation, productivity and prevention (QIPP) agenda for medicinesoptimisation

compare the new medicine service to the MUR service.

This section will look at the background to the new medicine service to help youunderstand its origins, the evidence it is based upon and how it fits in with thecurrent NHS agenda. This section will also encourage you to think and reflect onthe opportunity presented to pharmacy through this new service.

1.1 The key drivers for a new medicine service

In England, around 15 million people have a long-term condition (LTC).Long-term conditions are conditions that cannot, at present, be cured, but can becontrolled by medication and other therapies. Although it can be difficult for somepeople to adjust to life with a long-term condition, there is often a great deal thatcan be done to manage symptoms and maintain quality of life.

The prescription of a medicine is one of the most common interventions inhealthcare. In England there were over 813.3 million NHS prescriptions dispensedby community pharmacies in 2009/2010. The optimal use of appropriatelyprescribed medicines is vital to the self-management of most long-term conditions,but reviews conducted across disease states and countries are consistent inestimating that between 30 percent and 50 percent of prescribed medicines are nottaken as recommended. This represents a failure to translate the technologicalbenefits of new medicines into health gain for individuals. Sub-optimal medicineuse can lead to inadequate management of the long-term condition and a cost tothe patient, the NHS and society.

It is therefore clear that non-adherence to appropriately prescribed medicines is aglobal health problem of major relevance to the NHS. It has been suggested thatincreasing the effectiveness of adherence interventions may have a far greaterimpact on the health of the population than any improvement in specific medicaltreatments.

1

A U G U S T 2 0 1 1

S E C T I O N 1

Non-adherence is often a hidden problem: undisclosed by patients and unrecognisedby prescribers. People make decisions about the new medicines they are prescribedand whether they are going to take them, very soon after they are prescribed.

Proof of concept research has shown that pharmacists can successfully intervenewhen a medicine is newly prescribed, with repeated follow up in the short term, toincrease effective medicine-taking for the treatment of a long-term condition.1

The importance of the service to pharmacy

The new medicine service is a community pharmacy-based service, but it will haveimplications for everyone involved in pharmacy, regardless of the sector you workin, or the role you play.

Reflectivequestions

We have noted some thoughts below about the way that different pharmacy

professionals will be involved in this new service. Can you think of any others?

Pharmacy technicians

There are many elements of the service that pharmacy technicians can be involvedwith to ensure the service is provided efficiently and effectively. Team work will beessential in delivering a successful service.

Hospital pharmacists

When a hospital initiates a new medicine for a patient being discharged fromhospital, the prescriber or hospital pharmacist can make a referral into the newmedicine service. This provides reassurance that any information they provide topatients is reinforced by community pharmacy colleagues and that any problemspatients experience will be addressed and discussed. Providing the right support topatients when they are taking newly-prescribed medicines could help to reducehospital admissions. Hospital chief pharmacists are encouraged to contact theirlocal community pharmacy leader colleagues to consider how best these systemscould work.

2

A U G U S T 2 0 1 1

B A C K G R O U N D TO T H E N E W M E D I C I N E S E R V I C E

Primary care pharmacists

The new medicine service will help to reinforce medicines management messagesfrom GP practices and other prescribers, as well as contribute to the wider agendaof QIPP in reducing medicines waste and supporting patients with long-termconditions.You can help support your community colleagues by talking to GPpractices about the service and encouraging referrals.

Industrial pharmacists

Think about the investment you make in developing and marketing medicines. Thenew medicine service will provide reassurance that patients are given theappropriate support to take these medicines in the right way.

A new advanced service

For the last six years pharmacists have been offering medicines use reviews(MURs) to help people understand their medicines and support them in gettingthe most from the medicines they have been prescribed. Now, through the newmedicine service, the NHS is funding pharmacists to offer this support to peoplewho are started on certain new medicines – focusing funding on those medicineswhere the most benefit is likely to be seen.

The new medicine service will be implemented on 1 October 2011 andwill provide support with medicines adherence for patients being treatedfor four conditions/therapy areas.These are:

� asthma/chronic obstructive pulmonary disease (COPD)

� type 2 diabetes

� antiplatelet/anticoagulant therapy

� hypertension.

This is just the beginning for this new service; if pharmacy can demonstrate that itcan deliver a successful service then the list of medicines the new medicine servicecovers could expand.

The outline service specification has been published by NHS Employers and thePharmaceutical Services Negotiating Committee (PSNC) and details each stage ofthe service, ie, patient engagement, intervention and follow-up. The specification isavailable at: http://www.psnc.org.uk/pages/nms.html

If you have not yet read the outline service specification then you shoulddo this now to ensure you are familiar with each of the three stages of theservice. Refer to the service flowchart (see final page of this programme)as you read through the specification, to help clarify the steps within eachstage.

The new medicine service is an advanced service and is supported by a maximuminvestment of £55 million per annum in 2011/2012 and 2012/2013. Pharmacies canchoose whether to provide the service but those that do will be required to ensuretheir premises meet the required standard (further details are available via the PSNCweb page at:http://www.psnc.org.uk/pages/mur_premises_requirements.html)and that all the pharmacists delivering the service have completed the self-assessment form provided in Appendix 1 at the end of this programme.

3

A U G U S T 2 0 1 1

S E C T I O N 1

1.2 The current NHS agenda: QIPP and medicinesoptimisation

We know that we need to make sure we support people who take medicines. Asignificant part of this is helping people to understand why they need to take themand preparing them for any adverse effects they may experience.

We also know that the NHS, as a service funded by tax payers, needs to show thatit offers not only a high level of quality, but also value for money. Quality,innovation, productivity and prevention (QIPP) is a national programme whichmaps out many elements of the future NHS. One of the QIPP workstreams looksat medicines use and procurement or ‘medicines optimisation’ and highlights therole of the pharmacy team in helping people to get the most from their medicines.The new medicine service is a key contributor to the QIPP programme as it mayhelp improve health outcomes for patients, reduce hospital admissions and reducethe amount of waste medicines.

Exercise 1

Find out more about QIPP by accessing the Department of Health website at:

http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPP/index.htm

Think about the different community pharmacy services which can contribute

to QIPP and list them here.

We have also seen in the governmentWhite Paper Equity and excellence: liberatingthe NHS that we need to put patients at the heart of everything the NHS does;neatly captured as ‘no decision about me without me’.2 Helping the people who useyour pharmacy to understand their medicines and supporting them in makingpositive choices about their medicines is an important step in patient-centred care.

4

A U G U S T 2 0 1 1

http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPP/index.htm


1.3 It’s now or never!

You may already be wondering about the challenge of introducing another newservice into your pharmacy, but take a moment to reflect on the opportunities thenew medicine service can offer community pharmacy and the wider profession.Helping patients with their medicines is something pharmacists do on a daily basis.However, this service acknowledges the pharmacist as the expert in medicines andfocuses on the contribution you can make in supporting patients with long-termconditions. The new medicine service is currently funded until the end of 2013. Ifthe service is unsuccessful because of low uptake or an inability to demonstratethat pharmacy can make a beneficial impact, then future funding for the service isunlikely. By delivering a high-quality service you will help provide evidence thatpharmacists can reduce non-adherence and improve outcomes for patients and, atthe same time, help to secure future funding for this and other services.

Felicity Cox, lead negotiator for the NHS Employers organisation, said ‘We aredelighted with the changes to the community pharmacy contractual framework that willdeliver improved outcomes for patients.They will also support better utilisation ofcommunity pharmacy expertise and resources and provide value for money for the NHS.It is an important step for community pharmacy and we look forward to working withthe PSNC and other stakeholders over the coming months to ensure the success of theseservice developments, especially the new medicine service.These changes deliver on theGovernment's priorities for health as outlined in “Equity and excellence: Liberating theNHS” and will contribute to the Quality Innovation Productivity and Prevention(QIPP) programme’.3

Sue Sharpe, chief executive of the PSNC, recently sent a letter to contractors tooutline the opportunities for the new medicine service, highlighting the importanceof making it a success. The letter states: ‘If we fail – either because we demonstratefrom low uptake that we are not interested in the role, or because the interventions do nothave a beneficial impact or are not valued, then the outlook is not good, and the service isunlikely to be extended beyond 2013.The pressure on NHS resources will be there for thelong term, and all significant areas of spend will come under critical scrutiny.The cost ofmedication, including the associated cost of dispensing, is the largest single budget spendin primary care. So, if we demonstrate that we can improve its efficacy, then we have acompelling case that will secure community pharmacy’s future’.

These comments show that the service is not just about money and demonstratingservice delivery; pharmacy has an opportunity to make a really valuablecontribution to patient care, by delivering a quality service that contributes to thewider NHS agenda.

We also asked some community pharmacists and some leaders in the pharmacyprofession what they thought about the new medicine service.

5

A U G U S T 2 0 1 1

‘This is our chanceto shine, when we did this

in our pharmacy as a serviceit was a great success... the patients loved it.’

‘We can’t stickwith dispensing.’

‘Pharmacy is thebest place for this serviceand we have confidence

to deliver it.’

‘It’s time tochange our role.’

‘We all need tomove forwards, with our

hearts and minds.’‘Medicines optimisationis a key element of QIPP.’

‘Pharmacy offer themedicines optimisation solutionthrough targeted MURs and the

new medicine service.’

This is the future,this is the visionfor pharmacy.’

‘This is our burningplatform – if we get thiswrong this could be the

end of new services.’

S E C T I O N 16

Practice point

Reflecting on the statements from Felicity Cox and Sue Sharpe above, as well as

the comments from the pharmacists, what do you consider are your

responsibilities to community pharmacy and the wider profession with regard

to delivering a high-quality new medicine service to your local community?

1.4 Research to support the development of the service

The new medicine service builds on research that sought to identify:

� the problems people had with their medicines

� if, when and why non-adherence emerges from the start of a new medicine

� the evaluation of a pharmacy-led intervention developed to support adherence.

The initial stage of the research involved a survey of 258 patients who had justreceived a prescription for a new long-term medicine. Patients were eligible to

They said:

A U G U S T 2 0 1 1

B A C K G R O U N D TO T H E N E W M E D I C I N E S E R V I C E 7

The patient had stoppedtaking his new bloodpressure medicine (and allhis others) because ofheadaches. Also, he didn’tlike taking any tablets andhe wanted to clean hissystem of the medicines.

In-depth discussion with thepatient revealed a previous badexperience with the medicalprofession and very strong beliefsagainst taking any medication. Thepharmacist explained why themedication was important to helphis condition, especially in light ofthe fact that the patient hadpreviously had a heart bypass. Thepharmacist recommended that thepatient start taking the medicationagain and to return to the GP todiscuss the side-effects.

The patient had started taking hismedication again and had beenback to his GP. The patientreported that he found speaking tothe pharmacist very useful as “itwas the right information at theright time” and it helped himunderstand why the medicationwas necessary. He alsocommented that he found it goodto talk to the pharmacist as he livesalone and does not have anybodyto discuss these issues with.

Patient had concernsabout taking hispreventative inhaler if hewas going out drinking forthe evening, so on theseoccasions he missed adose.

The pharmacist advised him that itwas fine to take the inhaler beforehe went out drinking anddiscussed the necessity of thepreventative inhaler.

The patient remembered theadvice given and had used it onseveral occasions. He found theservice very useful and remarkedthat it was “10 out of 10”. Hecommented that it had made himthink more about the importanceof taking his medication.

participate if they were starting a new chronic medication and were either 75 yearsor older or had one of the following chronic conditions: stroke, coronary heart disease,asthma, diabetes, or rheumatoid arthritis. Patients were followed up by a semi-structured telephone interview and postal questionnaire at 10 days and four weeks.4

The results showed that problems with the new medicine emerged rapidly. At10 days, almost a third of patients reported non-adherence to their new medicineand two-thirds had a medicine-related problem, concern or need for furtherinformation. Common issues raised by patients were the experience of side-effects,deciding to stop taking the new medicine, forgetting to take doses and needingmore information on what the medicine was for and how it worked.4

It was clear that the period of starting a new medicine was problematic and that itwas an important time to intervene to provide better support to patients.4

A randomised controlled trial was then undertaken which involved developing andevaluating an intervention for community pharmacists to support patientsreceiving a new medicine for a long-term condition. In the intervention,pharmacists used a patient-centred approach to identify and understand theproblems or concerns each patient had with their new medicine. The pharmacistthen gave advice or information to support the patients’ individual needs. Thecontrol group received normal care. When patients were followed up four weekslater, self-reported non-adherence and medicine-related problems or concernswere significantly lower in the intervention group, compared to the control grouppatients. The pharmacists involved enjoyed delivering the service and theintervention was found to be more cost-effective than normal care.5

Here are two examples which show the nature of the problem identified, the advicefrom the pharmacist, and the results at follow-up.

Example 1

Patient-reported issue Advice from pharmacist Outcome at four weeks

Example 2

Patient-reported issue Advice from pharmacist Outcome at four weeks

A U G U S T 2 0 1 1

S E C T I O N 1

The findings from this research have helped to inform the list of questions used inthe new medicines service. The questions use plain language, and are structured toflow as a conversation. The order of the questions is provided for guidance only;points can be covered in any order, depending on how the patient responds.Pharmacists may find it more useful, for example, to ask about adherence quitelate on in the interview schedule allowing time to build rapport with the patient.Then, if the patient mentions that they are non-adherent at the beginning of theinterview, a conversation about that should take place, and the other questionspicked up later.

Patient adherence – the Numark service

In 2010, Numark worked in partnership with Pfizer to support patients bydelivering a patient adherence programme in the pharmacy environment. Theservice involved interventions by community pharmacists for patients who hadbeen newly prescribed Champix to help with smoking cessation. Although this isnot one of the medicines included in the new medicine service, and it does notrelate to a long-term condition, the Numark service was based on the sameconcept in that it offered support and follow-up for patients on a newly prescribedmedicine.

The service involved the pharmacist providing face-to-face counselling on themedicine at the point when the patient first presents to the pharmacy with aprescription. Then, over the course of the treatment period, the pharmacistprovides regular face-to-face and telephone support. They encourage the patientto share their expectations of the treatment, discuss progress, and report anybehavioural changes in terms of smoking cessation, in order to increase theprobability of a successful quit attempt.

Information collected from the pharmacist-patient interventions was captureddirectly onto the patient medication record (PMR) system as part of thecounselling process.

An internal evaluation of the pilot (unpublished) showed that the interventions bycommunity pharmacy increased adherence to Champix by 20 percent over thefirst four weeks, and showed over 50 percent increase in the number ofprescriptions dispensed. In addition, patients valued access to this service within apharmacy environment:

� 84 percent of patients rated the support programme as valuable or very valuable

� 100 percent of patients rated the pharmacist’s knowledge as excellent

� 83 percent would recommend the patient support programme to a friend.

Mimi Lau, director of pharmacy services for Numark says: ‘The support programmeis designed not just to measure adherence to medication, but also how this impacts on thehealth outcome for the patient, reasons for a patient discontinuing treatment and theassociated NHS spend.

‘The active involvement and passion of the pharmacy team and Numark central office inrecruiting patients and keeping them on treatment was fundamental in ensuring that thepilot was as successful as it was.The pilot will inform the development of similarprogrammes with the aim of forging greater links between the pharmacist and thepatient.’

8

A U G U S T 2 0 1 1

WATCHTHIS SPACE!

B A C K G R O U N D T O T H E N E W M E D I C I N E S E R V I C E

1.5 New medicine service and medicines use reviews

From the patient’s point of view, the new medicine service should be part of aseamless package of medicines support that you offer from your pharmacy.However, from both a legal and contractual point of view, you need to be clearabout the relationship between the new medicine service and MURs (whethertargeted or untargeted).

While each of these services help support patients with their medicines, there aredistinct differences.

The new medicine service aims to help patients who have been prescribed a newmedicine for a long-term condition. It involves a follow-up consultation within ashort time period to support adherence in the first two months of the medicinebeing prescribed.

The MUR service is an adherence review for patients on multiple medicines,particularly those for long-term conditions and is usually carried out every12 months.

As both services may target similar patient groups this mayraise a few questions in your mind. NHS Employers andPSNC have issued guidance around the relationship betweenthe two services, which can be found along with the servicespecification on the PSNC website:http://www.psnc.org.uk/pages/nms.html

9

A U G U S T 2 0 1 1

CPPE have developed a guide

to targeted MURs. To access the

guide go to http://www.cppe.

ac.uk/guides

http://www.cppe.ac.uk/guides

S E C T I O N 110

1.6 Outcomes of the service

As this service is based on ‘proof of concept’ research, a range of outcomes can bepredicted or expected. Being aware of and understanding these outcomes will helpyou as you liaise with local healthcare providers and commissioners.

Exercise 2

Looking at the list of stakeholders, partners or organisations in the table

below, jot down a list of the outcomes you expect or predict will occur due to

the new medicine service; bear in mind that there may be some overlap.

Stakeholders, partners Your predicted or expected outcomes of the newor organisations medicine service

Patients

GPs, other medicalprescribers, andnon-medical prescribers

The wider NHS

Community pharmacy

Pharmacy as a profession

Others

Turn to the end of the section for suggested answers.

A U G U S T 2 0 1 1

Proof of concept research

provides evidence that a

product, technology or an

information system is viable

and capable of solving an

organisation's particular

problem.6


Summary

The new medicine service provides a key opportunity for pharmacy to make asignificant difference to patient care. By providing this service – which has beendeveloped in line with research evidence – pharmacists can offer additionalsupport and advice to patients who have been prescribed a new medicine for along-term condition, thereby playing a vital role in the QIPP agenda for medicinesoptimisation. Providing an effective and consistent service will help patients,pharmacy, and the wider NHS.

11

Intended outcomes

By the end of this sectionyou should be able to: Can you?

list the key drivers for the new medicineservice and its importance for thepharmacy profession

describe the evidence that supports thenew medicine service

describe the key outcomes of theservice for patients, the NHS and thepharmacy profession

outline the link between the newmedicine service and the quality,innovation, productivity and prevention(QIPP) agenda for medicinesoptimisation

compare the new medicine service tothe MUR service.

A U G U S T 2 0 1 1

12 S E C T I O N 1

Suggested answers

Exercise 2 (page 10)


Patients � Provide an opportunity to give patients enoughknowledge to make informed decisions about their care.

� Improve patient adherence which will generally lead tobetter health outcomes.

� Increase patient engagement with their condition andmedicine, supporting patients in making decisions abouttheir treatment and self-management.

� Help patients and carers manage newly-prescribedmedicines for a long-term condition so that they canmake shared decisions.

GPs, other medical � Supplement and reinforce information provided by theprescribers and prescriber and practice staff to help patients makenon-medical informed choices about their care.prescribers

� Promote multidisciplinary working with the patient’s GPpractice.

The wider NHS � Reduce medicines wastage.

� Reduce hospital admissions due to adverse events frommedicines.

� Lead to increased Yellow Card reporting of adversereactions to medicines by pharmacists and patients,thereby supporting improved pharmacovigilance.

� Support the development of outcome and/or qualitymeasures for community pharmacy.

� Increase patient adherence to treatment andconsequently reduce medicines wastage and contributeto the quality, innovation, productivity and prevention(QIPP) agenda.

� Promote better local working between pharmacies.

Community pharmacy � Training for the new medicine service will result in animproved approach to providing the MUR service.

� Provide an evidence base for continuing pharmacyservices (to secure extended funding of the new medicineservice post 2013).

� Pharmacists need to demonstrate that they care about thepatient, ie, providing an ‘after sales service’ for the newmedicine.

� If patients have a positive experience of the service it willimprove loyalty to the pharmacy.

� Provide support and integration with services for long-term conditions from other providers and offerappropriate signposting and referral to these services.

A U G U S T 2 0 1 1

B A C K G R O U N D TO T H E N E W M E D I C I N E S E R V I C E 13


� Link the use of newly prescribed medicines to lifestylechanges or other non-drug interventions to promotewell-being and promote health in people with long-termconditions.

� Promote and support self-management of long-termconditions and increase access to advice to improvemedicines adherence and knowledge of potential side-effects.

Pharmacy as a � Provide an opportunity for pharmacists to take the leadprofession role in reducing medicines non-adherence.

� Produce measurable outcomes – how do you know youperform well?

� Improve the evidence base on the effectiveness of theservice.

� Recognise the important and expanding role ofpharmacists in optimising the use of medicine.

A U G U S T 2 0 1 1

Section 2Supporting medicines adherence

Objectives


appreciate the patient experience when receiving a new medicine

describe the potential problems faced by patients receiving a newmedicine and how the new medicine service can address these, inpartnership with the patient

define the term, adherence, according to the National Institute forHealth and Clinical Excellence (NICE)

understand unintentional and intentional non-adherence and some ofthe reasons behind it

outline the pharmacist’s role in supporting patients to make decisionsabout their medicines.

In Section 1 we considered the research which provides the evidence base for thedevelopment of the new medicine service. In this section we will look at the theorybehind the service, reflecting on the concept of medicines adherence and lookingat some of the reasons why patients are non-adherent. Research shows that thepharmacist can support the patient in making decisions about their medicines byaddressing and discussing their problems and concerns.

2.1 A new medicine – the patient journey

A GP usually works within a ten-minute timescale to conduct the consultation withthe patient, reach a diagnosis and prescribe a medicine. It is not surprising to learntherefore that sometimes patients come away from the GP practice feeling asthough they have not got as much from the consultation as they would have liked.Research has shown that patients may have issues which they want to raise thatthey feel they cannot raise, for example, relating to side-effects, or lack ofunderstanding about the prescribing decisions. This can result in patients feelingworried, misguided and non-adherent.7, 8

The style of communication used by the GP is an important factor in theconsultation and may contribute to patients finding it difficult to raise theirconcerns. Studies have shown that involving the patient in decision-making abouttheir medicines, and using everyday language as much as possible, can help.9, 10

Research has also shown that only 10 days after getting a new medicine for achronic condition around two-thirds of patients say they have a problem of onekind or another, and around a third are non-adherent. This situation does notimprove much over the next three months.8

It is not only communication that contributes to this problem. Prescribing is an actmade under great uncertainty. Not only is the diagnosis sometimes unclear, no-oneknows whether the patient will have any side-effects, and if so, which ones and how

14

A U G U S T 2 0 1 1

S U P P O R T I N G M E D I C I N E S A D H E R E N C E

it will affect them. Finally, we do not know whether the drug will work in thepatient (most drugs have a number needed to treat (NNT) of more than two, sowould be expected to give the desired clinical outcome in less than half the patientstreated).

Given that there is so much uncertainty around prescribing it makes sense that weshould check what happens after prescribing, and resolve any problems that thepatient has. That way we are giving information just when it is needed. Even if theprescriber offers completely comprehensive information to the patient at the timeof prescribing, most of it would be irrelevant as it would not happen to everypatient, even assuming the patient could remember it all.

As an illustration, imagine that you buy a new piece of technology, such as asmartphone or advanced camera, and someone reads the manual to you in theshop. It is highly unlikely that you would then be able to take it home and startusing it perfectly. It is more likely that you would only know the problems you hadonce you started trying to use it. Even then, while you might try to gain support orguidance from the internet, what you would really like is an expert to come along,show you how to do the things you could not do, and perhaps show you some ofthe things it could do, but which you had not realised.You can listen to ProfessorNick Barber talk about this illustration in the CPPE e-learning programme for thenew medicine service (http://www.cppe.ac.uk/e-learning).

Well, medicines are a technology too and with the new medicines service you arethe expert who can find out what the patient's problems are, and help them solvethem.

2.2 The problems patients face

An excellent book on the consultation process, entitled, Meetings between experts,portrays a useful way of thinking about the situation from the perspective of bothparties involved. The pharmacist is an expert in providing information and adviceabout medicines, but the patient is also an expert in terms of their own feelings andexperience.

15

A U G U S T 2 0 1 1

16 S E C T I O N 2

Exercise 3

Imagine you are the patient; think about what you might bring to a

consultation. We have provided some examples to get you started.

The patient knows:

...how they are feeling

...their past experiences of medicines


While both the pharmacist and the patient have their own areas of expertise therewill also be things which neither is certain about; for example, whether the patientis feeling different as a result of a side-effect, or whether it is reasonable for thepatient to take the medicine in a different dosing schedule.

A Johari window is a tool which was developed by Joseph Luft and Harry Ingham11

which can help to summarise this sort of uncertainty.We have adapted the toolbelow to show how this could help.

The patient knows The patient does not know

The pharmacist knows Common knowledge, some of which Our expertise can help the patientwill need to be established. learn this.

The pharmacist Discover some of this by asking. Unknown; by problem-solvingdoes not know together, and getting feedback, this

area will reduce through shareddiscovery.

A U G U S T 2 0 1 1


2.3 Adherence

In January 2009 NICE published a clinical guideline on medicines adherence:Medicines adherence: involving patients in decisions about prescribed medicines andsupporting adherence.12

NICE define adherence as:

‘the extent to which the patient’s behaviour matches agreed recommendations from theprescriber’.12

If a patient is non-adherent then they are unlikely to get the best from theirmedicines. Some suggest being within 80 percent of the intended dose is sufficient(although with some medicines this would lead to therapeutic failure). However,any deviation from the recommended treatment regime can be relevant as it mayindicate something which can be improved.

Other terms which are sometimes used and are related to ‘adherence’ are:

� compliance – defined as the extent to which the patient’s behaviour matches theprescriber’s recommendations. This term is no longer in common use as it isseen as implying a subservient role for the patient as there is no element ofshared decision-making.

� concordance – relates to the nature of the prescribing relationship andsubsequent medicine-taking behaviour

� persistence – which relates to the length of time a patient continues to take theirmedicine.

The NICE guideline provides guidance on the three key ways that healthcareprofessionals should support patients in adhering to their medicines:

a) involving patients in decisions about their treatment

b) supporting adherence and

c) reviewing medicines12

The introduction to the NICE guideline emphasised that:

‘Addressing non-adherence is not about getting patients to take more medicines per se.Rather, it starts with an exploration of patients’ perspectives of medicines and the reasonswhy they may not want or are unable to use them. Healthcare professionals have a dutyto help patients make informed decisions about treatment and use appropriatelyprescribed medicines to best effect.’ 12

17

A U G U S T 2 0 1 1

Look out for the CPPE guide to

reducing the wastage of

medicines; available in

October 2011.

18 S E C T I O N 2

Exercise 4

If you are not familiar with the NICE guidance on adherence, access the quick

reference guide using the link below, and make a note of your key learning

points.

http://www.nice.org.uk/nicemedia/live/11766/42891/42891.PDF

Reflectivequestions

Think about the MURs you have conducted. What are some of the main

reasons that you have come across which lead patients to be non-adherent

with their medicines?

A study commissioned by the Department of Health found that the annual cost ofprescription medicines wastage in England is around £300 million and thataround £150 million of this is avoidable.13 Improving adherence is likely tocontribute to the reduction of medicines wastage, as well as to improved patientoutcomes and reduced costs for the NHS.

A U G U S T 2 0 1 1

S U P P O R T I N G M E D I C I N E S A D H E R E N C E 19

Practice point

Go online and find the Department of Health commissioned study on

medicines wastage: Evaluation of the scale, causes and costs of waste medicines.13

http://www.pharmacy.ac.uk/fileadmin/documents/News/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf

Section 5 of the study looks at ‘The economic impact of poor compliance’ and

shows the potential cost saving to the NHS from improved adherence. How

much does the study estimate that improving adherence to asthma medicines

could save the NHS? How does this compare to the potential savings for

improving adherence to medicines for diabetes?

2.4 Non-adherence: how common it is and what it means forthe patient

Adherence is a particularly difficult thing to measure; there is no foolproofmethod. However, for the new medicine service we need a method which willidentify a lot of the cases, rather than capturing every single case. For this reasonwe use a recommended method, known as self-reporting, which is widely used andstraightforward in its approach.When you understand why patients are non-adherent (see below) the effectiveness of this method becomes less surprising.

Researchers from a range of disciplines have explored the reasons why patients donot take their medicines as prescribed. Demographic factors (eg, age, gender) arenot consistently associated with adherence so there is no easy way to identify apatient who may have adherence problems. Identifying which other factors dopredict non-adherence has been an elusive aspiration for researchers in this fieldfor several decades. Taken together, it is clear there are many wide-ranging reasonsfor non-adherence. It may be as simple as forgetting the odd dose or it could bemore complex and related to a combination of factors, such as not having anysupport at home or having strong beliefs against taking prescribed medicines.

A recent systematic review of 50 years of adherence research found that theaverage rate of non-adherence to medical recommendations is 24.8 percent.14 Interms of medicines for long-term conditions, researchers suggest that between30-50 percent of patients do not take their medication as prescribed.15TheWorldHealth Organization stated ‘poor adherence to treatment of chronic diseases is aworldwide problem of striking magnitude’.16

A U G U S T 2 0 1 1


S E C T I O N 2

Non-adherence to medicines has consequences for both the patient and thehealthcare system. For patients, the costs are a missed opportunity for treatmentgain and potentially impaired health outcome. Findings from a meta-analysissuggested that the difference in health outcomes between high and low adherers is26 percent.17 Examples include: low levels of adherence have been associated withpoor control of hypertension; reduced efficiency of highly active antiretroviraltherapy (HAART) treatment; poor management of asthma and a greater risk ofdiabetes complications. Studies vary depending on the regimes, measurements anddiseases under investigation.

Non-adherence may also result in costly health complications that requirepotentially preventable medical appointments or hospitalisations.

One of the most useful conceptual distinctions in understanding why patients arenon-adherent, is to think about whether the reasons are intentional orunintentional. Patients who are unintentionally non-adherent want to be able totake their medicines in the right way and are quite happy to discuss any problemsor barriers they are facing. Many of the intentionally non-adherent patients havetheir own reasons and beliefs for non-adhering and are usually happy to talk aboutthem.

2.5 Unintentional and intentional non-adherence

Unintentionally non-adherent patients wish to take the medicine as prescribed,however, there is some barrier or problem which stops them doing so. Examplesinclude forgetfulness, inability to open containers, tablets being too big to swallow,dosing regimes that do not match their lifestyle, devices they cannot operate (forexample, a patient with rheumatoid arthritis trying to open a foiled pack oftablets), and there may be external reasons why the person cannot adhere, such asa child being unable to take a lunchtime dose of a medicine because the school willnot allow it.

Intentionally non-adherent patients have made a decision not to take the medicineas prescribed. There may be many reasons for a patient deciding not to adhere,which could include:

� a general concern about taking a medicine and the associated risks

� their health beliefs

� feeling that the doctor has not really listened to them or understood theirproblem

� taking the medicine and suffering unacceptable side-effects

� being unconvinced of the necessity of the medicine.

In reality, there is some overlap between these intentional and unintentionalreasons for non-adherence; for example, if you are not particularly convinced thatthe medicine is useful, you may not put any effort into overcoming barriers totaking it.

20

A U G U S T 2 0 1 1

21S U P P O R T I N G M E D I C I N E S A D H E R E N C E

To learn more about a

patient-centred approach to

adherence, take a look at the

CPPE open learning

programme Patient-centred

care available for download at:

http://www.cppe.ac.uk/

openlearning

Reflectivequestions

Think back to the previous Reflective question (see page 18) where you

identified some of the reasons why the patients you see are non-adherent.

Can you group these reasons under the headings below?

Intentional non-adherence Unintentional non-adherence

Internal and external causes of non-adherence

An alternative approach is to think of the causes of non-adherence as internal andexternal. Internal causes are, crudely speaking, the ones within the patient’s head.These could include the conscious decisions we make about medicines, but couldalso include forgetfulness, misunderstandings about how the medicine works andtherefore should be used, and the odd errors that our brains make, such as slipsand lapses when we know what we should do but unintentionally do the wrongthing. Mood and anxiety can also affect adherence.

External causes may involve the medicines themselves, such as ease-of-use, theease of the dose regime which has been prescribed, the family and close friendshipgroups around the patient (for example, if the patient is a carer of someone else, orhas a carer themselves), social factors, such as deprivation, the cost ofprescriptions, and so on.

2.6 What we are trying to achieve with the new medicineservice

The new medicine service approach is consistent with the philosophy of NICE,(ie, ‘involving patients in decisions about prescribed medicines and supportingadherence’), providing community pharmacists with the opportunity to supportpatients with appropriate use of their newly-prescribed medicines.The overallapproach recommended by NICE is one in which healthcare professionals arenon-judgmental about discussing non-adherence with patients and the concernsthey may have about their medicines; then being patient-centred in dealing withrelevant issues and encouraging informed adherence.12

A U G U S T 2 0 1 1

http://www.cppe.ac.uk/openlearning

S E C T I O N 2

Strategies to support adherence are recommended in the NICE guideline andshould be used, where applicable, in delivering the new medicine service. There isno ‘one size fits all’ intervention, so the strategies used to support adherenceshould be considered on a case-by-case basis to meet patients’ unique needs, andthe concerns or specific difficulties they are experiencing. Key strategies from theNICE guideline that are relevant to the new medicine service setting are shown inTable 1.12

TABLE 1 Key strategies to support adherence

1. Determine whether patients are having problems with adherence for intentional or unintentionalreasons. Intentional reasons usually involve patients’ beliefs, concerns or problems such as side-effects. Unintentional reasons are mostly related to lack of understanding, poor memory or practicalissues, eg, difficulty opening the medicine container.

2. Consider the options for supporting patients with their adherence and ask the patient what form ofsupport they would prefer.

3. Address any beliefs and concerns that patients have that may have resulted in reduced adherence.

4. Practical problems should be tackled if patients raise a specific need. Strategies may include:suggesting patients monitor their condition and/or medicine-taking; simplifying the dosing regimen;using a multi-compartment medicines system.

5. If side-effects are a problem then discuss with the patient how they would like to deal with them.Practical solutions can be suggested (eg, timing of medicines) or it may be necessary to refer back tothe prescriber in order to consider adjusting the dosage or switching to another appropriatemedicine.

Adapted from NICE, 200912

NICE acknowledges that evidence for adherence-enhancing interventions is notconclusive; however, this reflects a lack of well-designed interventions and studiesin this area. There is strong and consistent evidence that patients’ concerns are afrequent cause of non-adherence, so the patient-centred approach advocated in thenew medicine service will allow pharmacists to understand each patient’s uniqueconcerns and needs, and tailor their advice and support accordingly.

22

A U G U S T 2 0 1 1


Summary

In this section we have started to understand some of the reasons why patients donot always take their medicines in the right way and how the new medicine servicecan help patients make informed choices about the way they use their medicines.

With this new service we are trying to solve the patient’s medicine-relatedproblems, in partnership with the patient. This is not the same as making themadherent – helping them to decide not to take the medicine, or agreeing with theirdecision not to take it, can be equally valid outcomes.

23

A U G U S T 2 0 1 1

Intended outcomes


appreciate the patient experience whenreceiving a new medicine

describe the potential problems facedby patients receiving a new medicineand how the new medicine service canaddress these, in partnership with thepatient

define the term, adherence, accordingto the National Institute for Health andClinical Excellence (NICE)

understand unintentional andintentional non-adherence and someof the reasons behind it

outline the pharmacist’s role insupporting patients to make decisionsabout their medicines.

24 S E C T I O N 2

Suggested answers


The patient can be considered an expert in:

� what they are thinking and feeling

� their own beliefs about their medicines

� the knowledge they already have about their medicines

� what they are able to do or not do when taking medicines

� their work and domestic circumstances.

Reflective questions (page 21)

We have provided some examples of intentional and unintentional non-adherence in the

table below. Remember, while we have separated these into two categories, in many

cases there is overlap.

Intentional Unintentional

Fear of side-effects Lack of understanding of instructions

Fear of dependence Difficulty of obtaining repeats

Thinking medicine is not helping Poor memory

Cultural beliefs Carer does not understand how to givemedicines

Not taking the medicine because it Misunderstanding around needing toreinforces the fact that they are continue medicine for long-termchronically ill conditions

Feel better so don’t feel the need for Difficulty opening packagesfurther medicine

Experiencing adverse effects Unsuitable formulation

Disagree with doctor’s diagnosis Cognitive factors – confusion

Side-effects interfere with the patient’s Poor instructions/information fromability to work or undertake usual daily healthcare professionalactivities

A U G U S T 2 0 1 1

Section 3Planning and preparing for the newmedicine service

Objectives


consider how you can optimise teamwork and leadership whenimplementing the new medicine service in your pharmacy

start to plan how you will involve the whole pharmacy team in theservice, delegating appropriately to manage time and organisation

plan a strategy to communicate with local healthcare professionals andpharmacy colleagues

start to address some of the organisational and information governanceissues relating to the service

discuss how to overcome potential barriers to implementing anddelivering a consistent service.

This section will look at the steps and actions you need to take before you start todeliver the new medicine service. In this section we reflect on what you need to doto prepare your pharmacy team to deliver a quality service and to ensure youcomplete the required number of interventions each month to achieve payment.We also highlight the importance of communicating with local GPs and theirteams, other healthcare providers and local community pharmacy colleagues.Finally, you will consider some of the information governance issues relating to thisservice, as well as some of the barriers you could face and how best to overcomethem.

Reflectivequestions

Before starting this section, take a moment to reflect on what you have learned

so far from reading the new medicine service specification (see page 3) and the

service flowchart (see final page of this programme). What do you need to

consider and what processes do you need to put in place to make sure you,

your pharmacy and your team are ready to deliver the service when it starts?

25

A U G U S T 2 0 1 1

S E C T I O N 326

3.1 Self-assessment of readiness for community pharmacists

Most pharmacists will have the majority of the skill sets required to deliver the newmedicine service effectively and safely. Although there is no certificated assessmentassociated with the service you will need to complete a self-assessment form. Thisself-assessment will provide you with a framework to assure yourself, youremployer (where appropriate) and the NHS that you have reflected upon and candemonstrate those skills; for example, by confirming that you have MURaccreditation and that you understand the purpose and intended outcomes of thenew medicine service. (See Appendix 1 for the self-assessment form.)

Contractors will be required to ensure that the pharmacy premises meet therequired standard and that all the pharmacists providing the service havecompleted the self-assessment form and can demonstrate the skills required.

3.2 Delivering the service within the NHS communitypharmacy contract

The new medicine service is the fourth advanced service within the NHScommunity pharmacy contractual framework. The other advanced services are:

� medicines use review and prescription intervention (MUR)

� appliance use review (AUR)

� stoma appliance customisation (SAC).

Like the other advanced services, you do not have to be commissioned to providenew medicine services; providing you meet the necessary requirements, you canstart providing it when you are ready.

The payment mechanism for the service will include target payments. The level ofthe target payments will depend on achieving a threshold number of interventionswhich will be related to the individual pharmacy’s prescription volume. There willalso be a one-off implementation payment to cover set-up costs, such as publicityand data collection. Payments will be based on self-declared information and willbe made by the NHS Business Services Authority. Further information about thepayment mechanism is available at:http://www.psnc.org.uk/pages/nms.html

A U G U S T 2 0 1 1

P L A N N I N G A N D P R E PA R I N G F O R T H E N E W M E D I C I N E S E R V I C E

Practice point

The payment for the new medicine service is linked to the number of patients

you provide the service to in relation to the pharmacy’s prescription volume.

How will you ensure you understand the payment mechanism for the service

and make sure you know the level of service you will need to deliver to meet

this?

Patients will be able to access the service in two ways; they can be referred by aprescriber when a new medicine is prescribed, or they can be offered the servicewhen they present a prescription in the pharmacy. So, two of the critical factors inembedding the service and making it a success will be effective communicationwith GP practices and teamwork in the pharmacy.

27

A U G U S T 2 0 1 1

S E C T I O N 328

3.3 Preparing your pharmacy

Before you start to provide the service you need to make sure your premises meetthe standards required. The new medicine service involves you seeing a number ofpatients every month, so your consultation room is going to be used more often. Ifit is currently used for storing stock or for counting prescriptions, you may need totake another look at it to ensure it portrays a professional image.

Practice point

Ask someone from your staff team to take a photograph of the consultation

room as it is currently. Gather your team together and look at the photo,

critically through your patients’ eyes. Does it look professional? Do you think a

patient would consider it to be welcoming? What steps could you take to

improve it?

Preparing your resources

As part of the new medicine service, it is highly likely you will need to supportpatients who have encountered problems with their medicines.You will identifyany problems as you run through the interviews with your patients (see Section 4 fordetails about the interview process). We assume you will be familiar with themedicines that are included in the service and confident about any necessaryproblem-solving. Clearly an up-to-date version of the British National Formulary(BNF) will be an essential resource to support you, but to make sure you are wellprepared, take a look at the questions below to help you identify any learning needsyou may have about the medicines covered by the new medicine service.

A U G U S T 2 0 1 1


Practice point

Consider each of the groups of medicines included in the new medicine

service and try to answer the questions set out below.

� Are you familiar with the different indications for the medicinesincluded in the service?

� How are the effects of the medicine monitored?

� How will the patient know the medicine is working? Will anythinghappen?

� What are the short-term and long-term side-effects of the medicinesincluded in the service?

� Are the side-effects transient or intractable? How will they appearand can they be managed or resolved?

29

A U G U S T 2 0 1 1

S E C T I O N 330

� How can dosage regimes be altered to improve adherence?

� Are you confident that you are familiar with the MHRA Yellow Cardreporting system for adverse drug reactions? Would you know whichreactions to report and how?

What other resources do you have in your pharmacy to help you solve patient andclinical problems? Consider online resources, as well as books and leaflets; we havelisted a few below which you may find helpful.

Online resources

� NHS Evidence – provides access to evidence-based health information.http://www.evidence.nhs.uk/

� The National Prescribing Centre – provides up-to-date clinical information anduseful information on supporting patients and their medicines.http://www.npc.nhs.uk/

� Medicines.org.uk – contains UK approved information sheets for prescribedmedicines, as well as information relating to adverse effects.http://www.medicines.org.uk

� CPPE are currently developing an e-learning programme, entitled Adverse drugreactions, which will be available later in 2011. Keep an eye on the CPPEwebsite for further details.

Leaflets and factsheets

Patients sometimes find it useful to have information that they can refer to after aface-to-face consultation.You may consider advising the patient to read the patientinformation leaflet (PIL) for their medicine, or signpost them to patient-friendlywebsites, such as:Medicines guides, available at:http://www.medicines.org.uk/guides

A U G U S T 2 0 1 1


The National Pharmacy Association are producing a resource pack which willinclude factsheets for each of the long-term conditions covered by the newmedicine service (see http://www.npa.co.uk for more details), and the RoyalPharmaceutical Society is producing a series of quick reference guides for eachcondition (see http://www.rpharms.com/your-day-to-day-practice/nhs-community-pharmacy-contract-england.asp for more details).You may find ithelpful to have access to these during your consultations with patients.

Practice point

Consider what resources you might need to help you give advice on healthy

lifestyles. Look at the leaflets and other resources you currently use to support

your work under the essential service for public health. What else do you need

to fill any gaps?

3.4 Optimising team work and leadership in your pharmacy

Many of those who have been successful in delivering pharmacy services havefound that engaging the whole pharmacy team is vital. Pharmacy support staff,such as medicine counter assistants, are ideally placed to actively sell the benefits ofthe new medicine service and can have their own role to play in recruiting patients.

It is critical to the success of the service that all staff members understand how thisnew service will benefit the pharmacy and use their skills to engage potential patients.

31

CPPE has developed a range of

soft skills guides to support

your personal development

and leadership and

management skills. Soft skills

are also known as

interpersonal skills and include

personal attributes such as

assertiveness, time

management and delegation.

Take a look at the website to

find out more


guides

A U G U S T 2 0 1 1


S E C T I O N 332

Practice point

Get your team together and discuss how you plan to communicate with

patients about the service.

What benefits could the service bring to your pharmacy?

What benefits could the service have for patients?

How does the team plan to recruit patients to the service?

A U G U S T 2 0 1 1

P L A N N I N G A N D P R E PA R I N G F O R T H E N E W M E D I C I N E S E R V I C E 33

It is common for medicines use reviews to be put on hold during busy dispensingperiods or when the usual pharmacist is on holiday. This has led to inconsistenciesin service provision and to peaks and troughs; for example, fewer MURs areundertaken in December compared with other months. With the new medicineservice, it will be vital to ensure that patients are recruited continually and that theservice continues to operate irrespective of the time of year or the responsiblepharmacist on duty. Payment for the service will be based on undertaking athreshold number of interventions each and every month and so you will need toplan ahead and use your team to make sure you achieve this.

You also need to have a standard operating procedure (SOP) in place for theservice and again, this is something that could benefit from input from the wholeteam. The National Pharmacy Association has developed a template SOP for itsmembers which can be accessed at: http://www.npa.co.uk/

Practice point

Get your team together and discuss the practical issues involved in

implementing and delivering a consistent and continuous service.

What concerns do they have about the service and how can these beaddressed?

How will the team ensure that patients continue to be recruited to theservice during busy periods?

How will you ensure that your locums engage with and provide theservice?

A U G U S T 2 0 1 1

You can learn more about

effective delegation in the CPPE

guide, Delegating, which is part

of the soft skills series on

management and leadership,

available at:


guides


S E C T I O N 3

In the Practice point above, one of your team’s concerns may have been how theservice will fit into an already busy schedule and how this will impact ondispensary workflow and the rest of the pharmacy service.

Effective delegation can enable you to manage your time better and can improveteamwork by developing the skills and capability of team members; for example,support staff can help with the logistics of running a smooth service, such asmaking appointments.

Practice point

Complete the table below as you identify the key players within your team.

34

A U G U S T 2 0 1 1

Key task Who could perform this? How will it fit with their current role?

Marketing the service to

potential and suitable

patients

Identifying suitable

patients from the patient

medication record (PMR)

Recruiting patients onto

the service

Arranging and recording

appointments

Reminders for patients to

attend

Following up patients

who do not attend


Reflectivequestions

When MURs were first introduced, many pharmacists found that appointing an

MUR champion helped to embed the service and increase the number of reviews.

Who could fulfil the role of new medicine service champion to help drivethe service in your pharmacy? What would you include in the jobdescription?

Good team work is important and can help overcome some of the challenges ofdelivering the service. Make sure you feedback positive comments from patientsand keep the team up to date with the figures and progress you are making. Bygiving them the recognition they deserve in delivering a successful service the teamwill know you appreciate their involvement and that they are getting it right.

35

A U G U S T 2 0 1 1

Key task Who could perform this? How will it fit with their current role?

Recording service data,

ie, number of consultations

Submitting service data

for payment

36 S E C T I O N 3

The NPA resource pack

developed to support the new

medicine service includes hints

and tips on how to engage

with GPs.

3.5 Communication with GPs, their practices, other prescribers,healthcare professionals and local pharmacy colleagues

Much of the initial lack of GP engagement with the MUR service was due to poorcommunication with local pharmacists. In some cases, the first GPs knew of theservice was when they started to receive MUR forms to action. It is clear thateffective partnership working between GP practices, other medical and non-medical prescribers and pharmacists is needed to make sure the new medicineservice delivers better outcomes for patients. Pharmacists from other sectors, andother healthcare professionals, need to work together to ensure patients areappropriately referred and managed within the service.

The key messages you need to communicate are:

� the extent of non-adherence by patients and the consequences

� what the new medicine service is and how it will work

� why the service is being introduced

� how you will feedback information to the GP and other prescribers

� how the service helps to reinforce the messages prescribers already give to thepatient

� the benefits the service will bring to patients and the NHS.

Practice point

Why do you think it is important that local GP practices support theservice?

What concerns do you think GP practices may have about the service?

How could you reassure them about those concerns?

What overall strategy do you plan to use to get your local GP practiceson board?

A U G U S T 2 0 1 1


Many pharmacy-prescriber relationships have been based around the prescribing-dispensing interface, with only limited personal contact. If the service is to gain thesupport of local prescribers, it is important to meet face-to-face with members ofthe practice team to discuss how it will work locally.

Also, although only prescribers can make patient referrals into the service, they arenot the only members of the practice team who need to know and understand theservice. It is important that you liaise with the wider practice team to ensure thatpractice managers, reception staff, practice nurses and primary care pharmacistsall appreciate the benefits of the service for their patients. If you cannot attend apractice meeting, could you invite practice members to your pharmacy teammeeting?

If you send a leaflet or letter to the GP practice, inviting them to a meeting aboutthe new medicine service, follow it up with a telephone call where you emphasisethe importance of the meeting. If you secure a meeting date, ensure you arrive ontime and are well prepared.

You also need to consider how you will communicate the benefits of the newmedicine service to members of the wider primary healthcare team, such ashospital pharmacist colleagues, and community matrons. Any prescriber whomanages patients with one of the specified long-term conditions can refer into theservice, not just GPs.

Practice point

Make a list of other local prescribers who may refer patients into theservice.

How do you plan to contact these prescribers to explain the benefits ofthe service?

Apart from your local GP practices, which other local healthcareprofessionals need to be aware of the service?

37

A U G U S T 2 0 1 1

Community pharmacy practice

can be isolating, with little

opportunity for peer support.

A CPPE learning community

could provide an ideal solution

to this problem! Turn to

page 64 to find out more.

S E C T I O N 338

Although communication with your local GP practice is vital, you may be in anarea where there are several community pharmacies near one GP surgery. In thissituation, it is important to work collaboratively with your community pharmacycolleagues. Pharmacists often feel as though they work in isolation, even whenthere is another pharmacy just around the corner from them. The new medicineservice gives you the opportunity to find common ground with colleagues so thatyou can support each other, sharing good practice, and ultimately working towardsthe success of the service for everyone in pharmacy.

Making a joint approach to GPs can also help to share the workload regardingcommunication. When was the last time you picked up the phone to your localpharmaceutical committee (LPC)?Why not give them a call to find out what ishappening in your area relating to the new medicine service; they may have a roleto play in helping to communicate with local GPs and the local medical committee(LMC).

Practice point

Think about ways you can liaise with your colleagues and other healthcare

professionals.

How will you work with your local community pharmacy colleagues toco-ordinate communication to GP practices? Who will do what? Whatplans does your LPC have to communicate with the LMC about theservice?

How will you share relevant information with hospital pharmacycolleagues?

A U G U S T 2 0 1 1


3.6 Further considerations when preparing for the service

Organising patient appointments

It is likely that you will see more patients as a result of the new medicine servicethan you currently see in your MUR service. Also, as you will see in Section 4,each patient taking part in the service will need an appointment for both theintervention and follow-up stages of the service.

It is important therefore that you have a comprehensive appointment system inplace to make sure you know which stage of the service each patient has reachedand when each person is due back for their follow-up appointment.

Here are some tips to point you in the right direction:

� use a diary system (paper or computer-based) to book in appointments

� make sure the diary system allows you to highlight whether the appointment isfor the intervention or follow-up stage of the service

� provide patients with appointment cards

� put a note in the diary the day before each appointment to phone or text thepatient with a reminder (see the Practice point below)

� plan your time carefully; ideally try to book appointments when the pharmacy ismore likely to be quiet or when the pharmacist has extra dispensary supportsuch as an accredited checking technician (ACT).

Practice point

Effective organisation will be critical to helping the service run smoothly and

efficiently. Spend some time thinking about each member of your pharmacy

team. Who could offer support with planning appointments, keeping the diary

and arranging reminders for patients?

39

A U G U S T 2 0 1 1



medicine service includes

stickers, appointment cards,

reminder cards and an audit

book to help with your record-

keeping.

WATCHTHIS SPACE!

S E C T I O N 3

Patients who do not attend (DNA)

If you have previously made appointments for patients to come to the pharmacyfor an MUR then you will be well aware that there will be some patients who donot attend (DNA). It will be your responsibility to make at least one attempt atboth the initial intervention and follow-up stages of the process to contact a patientwho does not attend and encourage them to make a further appointment.Arranging a telephone consultation at either the intervention, or the follow-upstage is an option for patients who seem reluctant to visit the pharmacy(see Section 4 for more details) but there may be some patients who you cannotcontact at all.

If the patient does not complete the intervention stage (either in person or via atelephone interview), you cannot count them when providing your data for theservice.

Information governance

Providing the new medicine service will involve you in keeping certain records,some of which you will need to pass on to your commissioning organisation(see Section 4 for more details).

Look through the points relating to information governance set out below toremind yourself of some of the elements you need to consider:

� data – always make sure that the data you collect electronically is password-protected; paper-based data should be stored securely in a lockable cupboardwhich is inaccessible to patients

� the consultation – ensure that any consultation area in the pharmacy at leastmeets the minimum requirements for the MUR service

� a patient always needs to grant permission for another person to be present atthe consultation

� telephone consultations – you need to be completely confident that you arespeaking with the patient. If you phone and need to leave a message then leaveyour name and contact details and a message for the patient to call you back.However, you need to be careful not to state the reason for your call.

Some patients may need or prefer another person to bepresent during the consultation (for example, a carer). TheNHS Employers and PSNC will be issuing guidance relatingto this, which can be found along with the service specificationon the PSNC website:http://www.psnc.org.uk/pages/nms.html

40

A U G U S T 2 0 1 1



medicine service includes

guidance relating to the new

information governance

requirements.


3.7 Challenges

There may be a number of areas within the service which could present barriers toyou when implementing this service. Work through the Practice point below whichconsiders these issues.

Practice point

For each of the challenges listed below consider whether you feel it is a barrier

for you, what action you or your team could take to address this and what the

risks are of deciding not to do so.

41

A U G U S T 2 0 1 1

Challenge relating to Is this an issue in our What action could other What is the risk of notimplementing the new pharmacy? members of the pharmacy doing this?medicine service team take?

Getting in touch with local GPpractices to tell them about theservice

Letting local pharmacycolleagues know what you aredoing about the service

Hosting a local launch event

‘I’m too busy dispensingprescriptions to get involved inanother service.’

‘My pharmacy is already busy,we don’t need more customers.’

‘My pharmacy team don’t wantto offer another service.’

S E C T I O N 342

Practice point

Before you move onto the next section, complete the following checklist to

help you prepare and plan for service delivery.

Target date to Place a tick in thisachieve this by column when you

are confident thatthis element is inplace

Keep up-to-date with plans that arebeing developed centrally

Put plans in place to involve thepharmacy team in the variouselements of the new medicineservice

Communicate with local GPpractices and other healthcarecolleagues

Communicate with the LPC

Ensure information governanceprocedures are in place

Organise an efficient system forpatient appointments

Prepare the consultation roomor area

Ensure appropriate resources areavailable

Update knowledge on therapeutic areas coveredby the service

A U G U S T 2 0 1 1


Summary

It is vital that you think through all the elements involved in preparing for this newservice so that you can foresee any potential challenges and plan to overcomethem. Communicating with local prescribers and other healthcare professionalsand having the support and interest from the rest of your pharmacy team are likelyto be two critical success factors in establishing the new service and running iteffectively.

43

A U G U S T 2 0 1 1

Intended outcomes


consider how you can optimiseteamwork and leadership whenimplementing the new medicine servicein your pharmacy

start to plan how you will involve thewhole pharmacy team in the service,delegating appropriately to managetime and organisation

plan a strategy to communicate withlocal healthcare professionals andpharmacy colleagues

start to address some of theorganisational and informationgovernance issues relating to theservice

discuss how to overcome potentialbarriers to implementing and deliveringa consistent service.

44 Section 4How to deliver a quality new medicineservice

Objectives


think about the key communication and soft skills you will need tocommunicate the new medicine service message to patients and otherhealthcare professionals and deliver a quality service in practice

describe the three stages of the service and the key steps within eachstage

consider how you will tell customers about the service so that they canunderstand what it offers them

outline the questions you will ask during the consultation and thinkabout your style of delivery to ensure your approach is patient-centredand supportive

be aware of the pitfalls of telephone consultations and identify the stepsyou can take to ensure your telephone consultations are professionaland effective

complete the self-assessment form to determine your readiness toprovide the new medicine service.

So far in this programme we have looked at why the new medicine service is beingcommissioned and how you can start to plan to implement the service in yourpharmacy. In this section we will move forward and consider what the service willlook like in practice and how you and the pharmacy team can focus on makingsure your service runs smoothly and delivers quality. However, first let us considerthe communication skills you will need and how you can ensure you take a patient-centred approach.

4.1 Communication skills – a patient-centred approach

Effective communication skills are vital throughout each stage of the new medicineservice process, from engaging patients, conducting consultations, planning with thepharmacy team, sharing your experiences with pharmacy colleagues and passingrelevant information back to prescribers and other healthcare professionals.

Let us start by focusing on communicating with patients about their medicines andconsider the skills you can use to get the most from the discussion.

Since the introduction of the MUR service, conducting patient consultations isnow part of everyday practice for many pharmacists.You may feel confident thatyou display effective consultation skills, but can you be certain that you are gettingit right and putting the patient at the centre of the consultation?

A U G U S T 2 0 1 1

H OW TO D E L I V E R A Q U A L I T Y N E W M E D I C I N E S E R V I C E

Reflectivequestions

Think about your consultations and ask yourself these questions.

Do you:

� give the patient an opportunity to tell you their beliefs and concerns?

� let the patient tell you what they already know about their medicines?

� involve them in decision-making and problem-solving discussions?

� make sure they go away with a clear plan they have agreed with you?

If the answer is ‘no’ to any of these questions, don’t worry, you are not alone.

Take this opportunity to reflect on your own consultation skills and identify

any gaps in your own skill set.

It is important that patients feel they are valued; patient-centred care simply meansputting the patient at the centre of all decisions about their healthcare. By usingeffective communication skills you can ensure the patient has been giveninformation and advice to help them make informed choices about theirmedicines. They should be given an opportunity to talk about their feelings andconcerns and contribute to and agree plans for problem-solving.

As part of the new medicine service you will be working through a series ofquestions at both the intervention and follow-up stage. The questions have beendeveloped in order to get as much information as possible from the patient,without them feeling as though they are being quizzed or interrogated about howthey are taking their medicines. They should be delivered in a relaxed and non-judgmental way. It is important that you are familiar with the questions; this willhelp you to be flexible in your style of delivery, as an answer to the first questionmay direct you to another question further down the list. Try to ensure that thepatient does not feel as though the interview is simply a checklist of questions thatyou are working through in front of them.

Here is a list of points to think about when conducting your consultation.

� Initiating the consultation – welcome the patient and introduce yourself. Buildrapport. Remind them of the purpose of the consultation and be open tolistening to any initial concerns they may want to offload.

� Use open body language, such as reflecting the patient’s eye contact and usingappropriate facial expressions to acknowledge their concerns.

� Questioning – effective questioning is a key skill; asking the right questions atthe right time can help you get the correct information and allows the patient totell their story.

� Listening skills – the patient may know more about their medicines than youthink; give them a chance to tell you what they already know before you decidehow much information they need. Repeat back the key messages the patient hastold you.

45

A U G U S T 2 0 1 1

S E C T I O N 446

� Use language the patient can understand. Make sure you avoid medical jargon.Patients may have their own ways of describing their condition, or how theirmedicines work; using the same words that they use will keep them involved inthe conversation. Using medical terms can make them feel disconnected fromthe conversation.

� Use empathy to acknowledge and show understanding of their concerns.

� Involve the patient in problem-solving and decision-making.

� Be non-judgmental – as pharmacists we supply medicines and we take it forgranted that the patient will go home and take the medicine. However, somepatients may make an informed decision to stop taking their medicine andalthough this may be difficult to understand, it is important that youacknowledge that this may be an outcome of the service and accept the patient’sdecision.

Closing the consultation in the right way helps you establish that the patient hastaken on board the information you have given them and has agreed to thedecisions about the action they are going to take. They should also be clear aboutwhat to do if they have any further problems.

Here are some tips for closing the consultation:

� summarise the key points

� list the three most important things you would like the patient to remember

� ask the patient to tell you what the next steps are to ensure they have a clearpicture of the plan

� give the patient the option of getting back in touch if there is anything they feelconfused about or feel they may have forgotten.

Practice point

Think about how you will close a consultation effectively to make sure the

patient has understood the information you have given them and is happy

with the plan. Write a few sentences here using the actual words you would

use.

A U G U S T 2 0 1 1


The CPPE open learning programme, Patient-centred care, provides usefulguidance on communication and consultation skills (available from:http://www.cppe.ac.uk/openlearning).

The NPA have also produced a resource to support pharmacists with theircommunication skills.

You may find it helpful to work through these and other suitable resources to helpdevelop your consultation skills before starting to provide the new medicineservice.

4.2 The new medicine service – the three key stages

There are three stages to the service:

� patient engagement

� intervention

� follow-up.

You will see that some of the steps involved are repeated at each stage. As youwork through this section look again at the flowchart (see final page of thisprogramme) to help you get a clear picture of each stage of the process.

Patient engagement

This first stage of the service links to part of the essential service for dispensingmedicines. As part of everyday practice you are familiar with talking to patientsand providing advice and information when handing over a new medicine. As apharmacist you have a professional responsibility to do this as part of your termsof service.

Identifying and recruiting patients

For patients to be eligible to join the service they need to be prescribed a newmedicine to manage one of the following long-term conditions:

� asthma/COPD

� type 2 diabetes

� antiplatelet/anticoagulant therapy

� hypertension.

There is a specified list of medicines which are covered by the service which willfall under the specified BNF category for the long-term condition. This list isavailable on the PSNC website at: http://www.psnc.org.uk/pages/nms.html

You will be aware that some of the listed medicines may have more than oneindication and you will need to check with the patient the reason why the medicinehas been prescribed. (Note: Changes to patients’ doses are not covered by theservice specification.)

Unlike the MUR service, if this is the first time a patient has visited your pharmacythen they are still eligible to join the service providing they fulfil the criteria above.

47

A U G U S T 2 0 1 1

S E C T I O N 448

The prescription for the new medicine can be generated in either primary orsecondary care. The pharmacy must dispense the first prescription in order to beable to provide the new medicine service to the patient, except in thecircumstances that the new medicine has been dispensed by a hospital and thepatient has been referred by the prescriber to the community pharmacy forprovision of the new medicine service.

If a patient is eligible, then you can recruit them on to the service by one of tworoutes:

� prescriber referral

� opportunistically by the community pharmacy.

Practice point

a) Take a look at your dispensing SOP. At what point of the procedure could

you identify appropriate patients to be recruited to the service? You may

already identify patients for MUR in a similar way and so this step can be

built into your SOP at the same point. Make a note of the step here and the

plans you will make to amend your dispensing SOP.

b) How will patients be highlighted to the pharmacist?

A U G U S T 2 0 1 1

49H O W TO D E L I V E R A Q U A L I T Y N E W M E D I C I N E S E R V I C E

Building rapport with patients

is the key to engagement.

The PSNC and NHSE are

developing a national template

for a patient information leaflet

which you may find useful.

Visit:

http://www.psnc.org.uk/

pages/nms.html

for more details.

Practice point

There is a fixed list of medicines which are applicable to the new medicine

service. How will you make sure the dispensary team are familiar with these?

Engaging the patient into the service

When you hand over the new medicine to an eligible patient, you have an idealopportunity to encourage them to engage with the service. At this point you willshare useful information and advice about the medicine so they will see thebenefits of coming back to talk with you again.

You need to let people know about the service – offering an overview and makingit clear that you will need to share some of the data that you collect with otherindividuals and organisations.You can use a leaflet to support this, but talking withpatients is crucial. It will help you to build rapport and show that you’re willing toanswer any questions that they may have. It will also start to make the patient thinkabout the importance of the new medicine and the part they can play in managingtheir condition.

We have provided some tips below, developed from the pharmacies who have beenpiloting the service, ie, the ‘early implementer’ pharmacies.They focus on how toengage a patient in conversation, based on things that have worked with the MURservice.We have suggested some phrases you could use (in italics) but everyone hastheir own style of conversation and it is up to you to develop your own script.

Starting a conversation� Choose the right place – respect the patient’s privacy whenever you giveadvice about medicines. Don’t be afraid to use the consultation area.

� Show that you’re interested in them – use appropriate body language to buildrapport. Focus on the patient, keep eye contact with them as much as possible,and try not to be distracted by other things going on around you. Remember– a simple smile can go a long way to engaging someone in conversation.

� Sound like you want to engage with them – be welcoming and introduceyourself by name. Use a relaxed tone of voice and think about the words youuse; make them patient-friendly.

� Use a standard opening line ‘I see you’ve been prescribed some metformin tablets,if you don’t mind me asking, is this the first time you’ve taken this medicine?’

A U G U S T 2 011

http://www.psnc.org.uk/pages/nms.html

S E C T I O N 450

� Sell the service with enthusiasm – ‘I’m not sure if your doctor mentioned this butwe are providing a new NHS service to help patients who’ve been given a newmedicine’.

� Point out the benefits and personalise your conversation – ‘We know thatsometimes people get a few niggly worries or problems when they start a newmedicine. Often there’s a simple explanation or solution for this. I’d really like tomake sure that you are getting the most from your medicine.Would you like to booka time to come back to the pharmacy in a week or so then we can sit down togetherand have a chat to see how you’re getting along with it?That way if you had anyquestions we could discuss them then.’

Reflectivequestions

Think about your own experiences of engaging patients with the MUR service.

What words could you use to engage a patient into the new medicine service

when you are handing over the new medicine? Write down a few sentences

here, using the actual words you might use to start your conversation.

Consent

You may already be familiar with obtaining consent during the MUR process.When a patient takes part in the new medicine service they need to consent to yousharing relevant information with the prescriber as necessary, and with thecommissioning organisation as part of clinical audit. They also need to provideconsent for you to share information with the commissioning organisation and theNHS Business Services Authority to verify that the service has been delivered bythe pharmacy, as part of the post-payment verification process. Once a patient hasa clear understanding of the service and why it is important that the prescriber isaware of the outcomes, then obtaining consent should be straightforward.

You need to gain consent when you first approach the patient, ie, at theengagement stage. This will ensure that any patient who requests a telephoneconsultation has already completed a consent form.You should ensure that anyinformation leaflet or letter you give to the patient to explain the new medicineservice clearly sets out the requirement for consent.

A U G U S T 2 0 1 1

Remember – even if a patient

says ‘no’ to the new medicine

service, you still need to

provide them with advice and

information about their new

medicine as part of your

standard terms of service.

WATCHTHIS SPACE!


Here are some suggestions to help the consent process run smoothly:

� take a soft approach

� build rapport with your patient

� give a clear but concise explanation why this step is necessary.

A consent form has been developed for the service and thismust be completed before the consultation can take place.It is available to download from the PSNC website:http://www.psnc.org.uk/pages/nms.html

Remember – no consent means no intervention!

Reflectivequestions

What would you do if a patient refused to give consent to sharing information?

Pharmacies need to record the number of patients who are offered the service, butwho do not consent to receive it. This information will help inform thedevelopment of the service.

Once the patient has agreed to join the service you will need to arrange anappointment in one to two weeks’ time for the intervention stage and agree howthe conversation will take place. This will normally be face-to-face in the pharmacyconsultation area, but could take place as a telephone conversation if the patientprefers this (see page 56).

51

A U G U S T 2 0 1 1

S E C T I O N 452

Intervention stage

This is the stage of the service where the patient returns for their first appointmentand you will find out how the patient has been getting along with their newmedicine. There are a few things to cover when talking with the patient at theintervention stage.

Clarify the purpose of the service

Before you start to work through the interview questions it is important that thepatient understands the nature of the service and why they have come along to thepharmacy today. It is equally as important to check the patient’s understandingand confidence in use of their medicine. The consultation itself will cover some ofthese points.

The consultation

Once you have been through the steps above you will carry out an interview withthe patient which aims to:

� establish the degree of adherence to the new medicine

� identify any problems the patient may be experiencing and explore solutions

� assess the patient’s needs for further information

� provide opportunistic healthy living advice.

What questions will you ask and how will this be done?

A list of questions have been developed as part of the national specification for thenew medicine service, and you should use this to guide your interview. Thequestions have been developed to make sure you get open and honest informationfrom the patient; information which will give you a true picture of their adherenceto the medicine while still allowing them to express any concerns or beliefs theymay have about their medicine.

Although the questions are presented in a structured format, the style of delivery iscritical; you want to ensure the patient feels comfortable and reassured that youwill listen to their responses in a non-judgmental way. As far as possible try tomake the patient feel that it is a relaxed discussion, rather than a structuredinterview.

The patient needs to feel happy to answer openly and honestly. Explain that thereason for the consultation is to provide help and support. Before you start theconsultation think about your own frame of mind and be conscious of your tone ofvoice.Your aim is to encourage the patient to give their own story, rather thanmerely answering a list of questions.

Figure 1 overleaf provides an outline of the intervention stage questions, togetherwith prompts to make you think about the question and how you can address thepatient’s responses.

A note about terminology

The two sets of questions which have been developed to use at the interventionstage and at the follow-up stage of the consultation process for the new medicineservice are being referred to as the ‘interview schedule’.

A U G U S T 2 0 1 1

H OW TO D E L I V E R A Q U A L I T Y N E W M E D I C I N E S E R V I C E 53

A U G U S T 2 0 1 1

FIGURE 1 Interview schedule for the new medicine serviceIntervention stage

Questions Prompts and notes

1. Have you had the chance to If the patient has not started taking the medicine then explorestart taking your new the reasons for this by moving to the non-adherence issues belowmedicine yet? (see Question 6). The pharmacist can then go back and address

other reasons or concerns, or raise the need for information at theend of the interview.

2. How are you getting on This is an open question to get the patient talking and to bring outwith it? any issues which are important to them. These issues can be dealt

with here rather than waiting until the appropriate question below.

3. Are you having anyproblems with your newmedicine, or concernsabout taking it?

4. Do you think it is working? This gives a chance to explore the fact that some patients will not(Prompt: is this different feel any different, even if the drugs are working.from what you were Do they know what it is for?expecting?)

It would be useful to say a little about how the drug works. Somepatients may feel happier and more content to take the medicine ifthey have a rational explanation of how the drug helps theircondition.

5. Do you think you are If the patient feels different it may lead them to change theirgetting any side-effects or behaviour, even though it is not a side-effect of the drug. This mayunexpected effects? also be an opportunity to fill in a Yellow Card.

This is an opportunity to discuss whether side-effects are likely to betransitory and what can be done to minimise them. If severe, thepharmacist could suggest a return to the prescriber and possiblycessation of the drug.This could also alert you to serious side-effects that may occur andwhich require you to take immediate action.

6. People often miss taking This question may be challenging for the patient so is further downdoses of the medicines, for the interview schedule. However, you may not need to ask it as anya wide range of reasons. relevant issues may already have emerged. It is necessary to exploreHave you missed any doses the reason(s) why this has happened. Was it intentional or not?of your new medicine, or Was it appropriate (eg, missing a morning dose of a diuretic becausechanged when you take it? they had a long bus journey).(Prompt: when did you last Does the patient understand why the medicine is necessary?miss a dose?)

The pharmacist will work to resolve the issue if there is one to besolved.

7. Do you have anything elseyou would like to knowabout your new medicine oris there anything you wouldlike me to go over again?

S E C T I O N 454

Using the interview schedule

We have already looked at the key consultation skills you can use when havingdiscussions with a patient; now we will move on to consider the practicalities ofhow the discussion will take place.

Most of you will already have experience of documenting information during aconsultation when conducting an MUR. It can sometimes be challenging to keep anote of things the patient has said while at the same time trying to give them yourfull attention. It is important that the patient feels involved throughout theconsultation; here are some tips on how to make this part of the process runsmoothly.

� Make sure the patient knows why you are writing things down and what willhappen to the information.

� Be flexible – although it is important that all the questions are addressed, do notfeel that you need to follow the order too rigidly. It is fine to change the order ofquestions if the patient’s answer to one question leads automatically to anotherquestion further down the list. The questions have not been designed to beasked in a sequential way.

� Be familiar with the questions – this will help you ask them in a natural andrelaxed way and will help the flow of the consultation.

� Listen to the patient – give them a chance to talk and if they have given youinformation which needs documenting, then do this after they have finishedspeaking.

� Use phrases to acknowledge you have heard their story, such as: ‘that’s a reallyimportant point, I’m just going to make a note of it here’; ‘don’t worry lots of peoplefeel like this when they first start this medicine’.

The list of questions is there to provide a structure, but it should not dictate theconsultation.Your focus should always be on the patient and their concerns andnot about the piece of paper in front of you. Look at the CPPE e-learningprogramme on the new medicine service to see a discussion about the interviewschedule, to help you understand how to get the best out of it for your patients.

Practice point

Think about how you are going to carry out this part of the process. Practise

working through the list of questions in the consultation room with one of

your pharmacy team acting as the patient. Ask them for feedback on how they

felt during the consultation and look back at the pointers mentioned earlier

about communication skills.

This is a great way to get the pharmacy team involved. It will help them to

understand the service and promote it to patients, for example, they can say

‘I’ve been through it with the pharmacist and it’s really good!’.

A U G U S T 2 0 1 1

Remember - this is not purely a

paper filling exercise – it’s all

about the patient!

Make sure the patient feels

they are at the centre of the

consultation and focus on their

questions and concerns.


Embedding healthy lifestyle advice into the consultation

You are already delivering public health messages to patients as an essentialservice, and as a part of delivering MURs. The new medicine service offers youadditional opportunities to provide healthy lifestyle advice as part of theconsultation process. Section 3 focused on preparing for the service andhighlighted that as part of those preparations you need to ensure you haveappropriate resources available to support people in healthy lifestyle choices(see page 31).

Remember that even one or two key points of advice can make a difference to apatient. We know from the process of change that people will not commit tochange until they are ready. Look for the signals from your patients and if youconsider that they may be ready to change, encourage them by providing relevantinformation, or by making a referral to an appropriate service.

Exercise 5

Which two key healthy lifestyle points of advice could you give to a patient

who has received a new medicine for hypertension? If the patient wanted

more information are there any suitable websites you could refer them to?


A U G U S T 2 0 1 1

S E C T I O N 456

Undertaking the consultation on the telephone

The focus of the new medicine service is for face-to-face consultations, and thespecification for the service clearly states that. However, there may be occasions, asa result of patient preference, where a face-to-face consultation is impractical andthe only way to conduct the consultation is via the telephone.

Exercise 6

Before reading on, spend a moment considering the advantages and

disadvantages of telephone consultations, when compared with face-to-face

consultations.

Advantages Disadvantages

Phone

Face-to-face


Telephone conversations can never be equivalent to face-to-face consultations.Although the patient may feel they are convenient, you are restricted to verbalcommunication. Building rapport with the patient can be more difficult withoutthe use of body language and giving advice can be limited without the opportunityto pass on information in the form of leaflets, or visual guidance (eg, inhalertechnique).

However, there may be situations when it is preferable for the patient to have aconsultation on the telephone and provided the following points are consideredthen an effective consultation can still take place.

Confidentiality is critical whenever you speak with a patient, but during atelephone consultation you should be even more aware of confidentiality issues.

A U G U S T 2 0 1 1


You need to be confident that you are talking with the right person and that youconduct your conversation in a quiet and private area which cannot be overheard.

Here are some tips to help you make sure your telephone consultations areconfidential, professional and effective.

� Environment – if your pharmacy phone does not have a mobile facility then youwill need to relocate it to a quiet area where you can have a confidentialdiscussion with minimal interruption and without being overheard by otherpatients.

� Patient identity – make sure you are talking to the right person.You can askadditional questions, such as address and date of birth to establish identity.

� Introduce yourself clearly – many patients get frustrated with sales calls so rightfrom the start it is important to ensure they know who you are and where youare from.

� Explain the reason for the call and make sure the patient is happy to continuewith the discussion. Set a timeframe with them. If you have caught them at abusy time it may be more productive to arrange another time for the call.

� Verbal communication

� Yourself – you can only communicate verbally, so be aware of your tone ofvoice. Remember the patient cannot see you smile so use a relaxed and calmtone of voice, be polite, speak more slowly to build rapport. If a patient ishard of hearing and you need to raise your voice slightly then be careful notto alter the tone. Intonation in your speech can be used to show empathy andunderstanding, but avoid using it to express judgmental feelings.You willhave no visual cues from the patient, so ask open questions to gatherinformation.

� The patient – be aware of the patient’s tone of voice and listen for signswhich might show the patient does not understand or is not totally happywith a suggested plan. Listen to the patient and reflect back the main issuesso they are reassured you are listening. Allow a pause after you have givenadvice or are establishing a solution to a problem, to give the patient a chanceto air their feelings.

� Information – check that the patient understands any key points of advice orinformation by asking them to repeat them back. Explain that you are happy ifthe patient wants to make notes if they would find that helpful.

� Throughout the call check repeatedly that both you and the patient are happythe telephone consultation is working well and is appropriate.

� Ending the call – let the patient disconnect first, so you know you have giventhem the opportunity to clarify any last minute issues.

� Document your calls – record both the date and time of calls (even the oneswhich are unanswered), the details of the consultation and any extra advice orinformation you have given to the patient.

� If the patient is out and another member of the house answers the phone do notbe tempted to tell them the nature of your call.

A U G U S T 2 0 1 1

WATCHTHIS SPACE!

S E C T I O N 458

Some patients may need another person to assist them with atelephone consultation (for example, a carer). The NHSEmployers and PSNC will be issuing guidance relating to this,which can be found along with the service specification on thePSNC website: http://www.psnc.org.uk/pages/nms.html

Practice point

If the patient is out and you are prompted to leave a message – what will you

say? Prepare a script which you can use in these situations.

Hint: Look through your script to ensure it does not contravene anyconfidentiality issues.

Practice point

Think back to the earlier Practice point (page 54) where you went through the

consultation with a member of your pharmacy team. Repeat the exercise, but

this time do it sitting back to back. How does it feel when you have no eye

contact and you cannot interpret body language? Think about the missed

signals.

Think about your telephone discussions with patients. What will you do if one

of the pharmacy team asks for a prescription check while you are talking to a

patient?

A U G U S T 2 0 1 1

The patient is adhering to the newmedicine and not experiencingany problems. In this case you cantell the patient they are doing welland encourage them to continuewith the new medicine.

The patient is not taking the newmedicine as it was prescribed, butyou have discussed the reasonsfor this and have both agreed asolution to the problem.

It is at this point that you will agree a final appointmentin two to three weeks’ time for the follow-up stage ofthe service.

It is at this point that you refer thepatient back to the prescriber andthey leave the service.

The patient is not taking the newmedicine as it was prescribed.Although you have done your bestto try and support a patient theremay be times when you areunable to find or agree a solutionto a medicines problem.


Outcomes from the intervention consultation

Once you have conducted the intervention consultation there could be one of threeoutcomes, which are set out below. (Turn to the last page of this programme for acomplete flowchart of the new medicine service.)

There may be occasions when a patient has been prescribed two new medicines.They may have problems with one of the medicines which requires early referralback to the prescriber, while they are able to continue to the follow-up stage for theother new medicine. In this situation, once the patient has completed the follow-upappointment the pharmacy will be able to claim for one completed new medicineservice.

Referral/providing feedback to the prescriber

A standard feedback form has been developed for you to use to refer the patientback to the original prescriber; this will be available for download from the PSNCwebsite (http://www.psnc.org.uk/pages/nms.html). If you feel a referral isurgent then you should phone the prescriber straight away and back up yourconversation with a copy of the feedback form.

For non-urgent referrals explain to the patient that you will be sending a feedbackform to the original prescriber so that they can decide how to deal with the issuethat has been identified. A copy of the feedback form can be given to the patient,with an explanation that the prescriber will contact them to deal with the issue.The patient should not normally contact the GP surgery or other prescriberthemselves to make an appointment, as some practices may choose to deal withissues that arise from the new medicine service in a different way.You couldsuggest that the patient contacts the prescriber if they have not heard from themwithin an appropriate timeframe.

The approach to making referrals/providing feedback may be a topic that youcould discuss with your local GP practices before you start to provide the service.

A U G U S T 2 0 1 1

S E C T I O N 460

Follow-up stage

When patients attend or are contacted on the telephone for the follow-upconsultation you need to follow a process which is similar to the intervention stage.You will have a further structured discussion with the patient based on a differentset of questions (see Figure 2 below). At the follow-up consultation you will also beable to progress any actions you agreed with the patient at the intervention stage,as well as checking whether they have any further questions or concerns which youcan address.

FIGURE 2 Interview schedule for the new medicine serviceFollow-up stage

Questions Prompts and notes

1. How have you been getting on This is a general question to open up a natural dialogue and towith your new medicine since see whether patients are still taking the new medicine.we last spoke?(Prompt: are you still taking it?)

2. Last time we spoke, you Use the pharmacy records to refer to each of the issues thatmentioned a few issues you’d arose from the initial contact with the patient at thebeen having with your new intervention stage. Issues may have arisen from any of themedicine. Shall we go through questions at the initial contact (eg, problems/concerns,each of these and see how you information needs, side-effects, adherence issues).are getting on?

3. A) The first issue you mentioned Use the pharmacy records to refer back to the advice or solutionwas [refer to specific issue] – is recommended to the patient. This question should be phrasedthat correct? according to the specific advice, information or solution offeredB) Did you try [the advice/ to the patient at the intervention stage.solution recommended at theprevious contact] to help withthis issue?

4. Did you try anything else? This allows you to check whether patients received help oradvice from elsewhere.

5. Did this help? Document the outcome from the issue.(Prompt: how did it help?)

6. Is this still a problem or concern? The question above may give you the answer to this already, butif not, it allows you to clearly establish whether or not theproblem/concern is still an issue.If the problem/concern is still there then the patient will need tobe referred appropriately before exiting the service.

REPEAT QUESTIONS 3-6 FOR EACH ISSUE THAT THE PATIENT DISCUSSEDAT THE INITIAL CONTACT

7. Have there been any other If new problems exist then the patient will need to be referredproblems/concerns with your appropriately, as mentioned above.new medicine since we lastspoke?

8. People often miss taking dosesof their medicines, for a widerange of reasons. Since we lastspoke, have you missed anydoses of your new medicine, orchanged when you take it?(Prompt: when did you lastmiss a dose?)

A U G U S T 2 0 1 1


At the end of this follow-up consultation you need to think about closure for thepatient. This should involve summarising the discussions you have had and thepoint you have reached. Although this is the final stage of the service it isimportant that the patient knows they can come back for further advice at any time.

Any patients who are experiencing problems with adherence at this stage should beadvised of the risks of not taking their new medicine in the right way and if theproblem they have cannot be dealt with by providing more information orguidance, they should be referred back to the prescriber.

4.3 Data recording and record-keeping

There are several steps within the new medicine service process which will requireyou to record certain data and information.

The data set, ie, the information which you will be required to record and report,has been defined nationally and is available for download from the PSNC websiteat: http://www.psnc.org.uk/pages/nms.html

You will need to keep accurate records of the numbers of new medicine serviceconsultations that you complete, at both the intervention and follow-up stage. Thisis to ensure you are meeting the requirements of the service and conducting theminimum number of consultations each month.

Data can be collected and recorded using a paper-based system or by using yourcomputer system.You can choose whichever system is preferable to you and yourpharmacy team.

Make sure you consider the relevant information governance issues whicheverroute of data collection you choose. If you use a paper-based data collectionsystem you will need to think about where and how you file your data. This shouldbe organised in such a way so that it is easily retrievable when needed (see page 40for further details about information governance).

Some companies provide web-based solutions to help you document specific datasets and help you run your services more efficiently.You will be required to send inspecific data to your commissioning organisation upon request and so using thissystem will help this part of the service run more smoothly.

61

A U G U S T 2 0 1 1

Your computer system supplier

may choose to support you

with this element of the service.

This may include a case finding

functionality to help you

identify eligible patients.

Regular communication with

your supplier will keep you

informed of their progress and

make you aware of the areas in

which they will support you.

Intended outcomes


think about the key communication andsoft skills you will need to communicatethe new medicine service message topatients and other healthcareprofessionals and deliver a qualityservice in practice

describe the three stages of the serviceand the key steps within each stage

consider how you will tell customersabout the service so that they canunderstand what it offers them

outline the questions you will askduring the consultation and think aboutyour style of delivery to ensure yourapproach is patient-focused andsupportive

be aware of the pitfalls of telephoneconsultations and identify the stepsyou can take to ensure your telephoneconsultations are professional andeffective

complete the self-assessment form todetermine your readiness to provide thenew medicine service.

Summary

In this section we have looked at the approaches you can take to deliver a qualityservice which puts the patient’s medicines concerns and beliefs at the heart ofeverything you do. Having worked through this section and the other threesections within this programme you will be familiar with the evidence base tosupport the development of this service and the importance of the service to theprofession of pharmacy. Having had the opportunity to reflect on theimplementation of the service in your pharmacy you should be confident inplanning the next steps to delivering a quality service.

62 S E C T I O N 4

A U G U S T 2 0 1 1

63HOW TO D E L I V E R A QUA L I T Y N EW M ED I C I N E S E R V I C E

Advantages Disadvantages

Phone Deal with greater workload It is more difficult to establish rapport

Easier if all the patient requires is reassurance More difficult to gather information

More convenient for patient You may not be talking to the patient

Easier if the patient has few or no issues May be less opportunity for patient toask questions and air concerns

Can’t back up with written advice/information

Unable to demonstrate visual information, such asinhaler technique

Patient may have hearing problems, making themunable to hear the questions and informationaccurately

If English is not the patient’s first language, theymay find it more difficult to converse over thetelephone

Face-to-face Build rapport More time-consuming

Easier to read non-verbal cues from patient

Easier to communicate

Easier to show empathy

Opportunities to give written and visual adviceand information

Suggested answers


Key healthy lifestyle points of advice for patients with hypertension include any of the

following:

� eat less salt

� eat more fruit and vegetables

� keep a healthy weight

� drink less alcohol

� be more active.

A useful website to signpost patients to for information and advice is:

http://www.bpassoc.org.uk


Before reading on, spend a moment considering the advantages and disadvantages of

telephone consultations, when compared with face-to-face consultations.

A UGU S T 2 011

64 Your personal action plan

Now that you have finished working through this open learning programme, takesome time to think about your learning to date and prepare an action plan.

Look back at the Reflective questions on page x to see if you have developed yourknowledge and skills in the key areas required for the new medicine service.

Reflectivequestions

Have you met all the learning needs you identified at the start of this learning

programme?

Are there particular areas which are relevant to this new service where you

would like to increase your knowledge and skills further?

Here is a reminder of some of the further learning that is available:

� For the new medicine service CPPE local solutions workshop materials, visit:http://www.cppe.ac.uk/localsolutions

� To access the complementary video-based e-learning programme, visit:http://www.cppe.ac.uk/e-learning

Why not start or join a CPPE learning community?

A CPPE learning community could provide an ideal opportunity to discuss someof the learning experiences from this programme. This is a group of up to20 pharmacy professionals who get together to learn, share ideas and gatherinformation. More information about how to set up learning communities can befound on the CPPE website at: http://www.cppe.ac.uk/learningcommunities

Once you are happy that you have completed your learning and youhave your MUR accreditation and a consultation room which is fit forpurpose, you can sign the self-assessment form to declare that youhave the necessary skills and knowledge to deliver the new medicineservice.You are ready to go!

A U G U S T 2 0 1 1

65References

1. Pharmaceutical Services Negotiating Committee/NHS Employers. NHSCommunity pharmacy contractual framework – summary of service developments in2011/12. 11 May 2011.http://www.psnc.org.uk/data/files/PharmacyContract/Contract_changes_2011/summary_of_cpcf_changes_may_2011.pdf

2. HM Government.White Paper. Equity and excellence: liberating the NHS. July2010.

3. Pharmaceutical Services Negotiating Committee (PSNC) web page.Generalnews: New medicines servicehttp://www.psnc.org.uk/news.php/899/new_medicines_service

4. Barber N, Parsons J, Clifford S, Darracott R, Horne R. Patients’ problems withnew medication for chronic conditions.Quality and Safety in Health Care, 2004;13 (3): 172-175.

5. Elliot R, Barber N, Clifford S, Horne R and Hartley E.The cost-effectivenessof a telephone-based pharmacy advisory service to improve adherence to newlyprescribed medicines. PharmacyWorld and Science, 2008; 30 (1): 17-23.

6. The free dictionary online resource.http://encyclopedia2.thefreedictionary.com/Proof-of-concept

7. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoicedagendas in general practice consultations: qualitative study. British MedicalJournal, 2000; 320 : 1246 doi: 10.1136/bmj.320.7244.1246.

8. Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. Misunderstandingsin prescribing decisions in general practice: qualitative study. British MedicalJournal, 2000; 320 : 484 doi: 10.1136/bmj.320.7233.484.

9. Stevenson FA, Barry CA, Britten N, Barber N, Bradley CP. Doctor-patientcommunication about drugs: the evidence for shared decision-making.Social Science & Medicine, 2000; 50 (6): 829-840.

10.Barry CA, Stevenson FA, Britten N, Barber N, Bradley CP. Giving voice to thelifeworld. More humane, more effective medical care? A qualitative study ofdoctor-patient communication in general practice. Social Science & Medicine,2001; 53 (4): 487-505.

11.Luft J, Ingham H.The Johari window, a graphic model of interpersonalawareness. Proceedings of the western training laboratory in group development.Los Angeles: UCLA, 1955.

12.National Institute for Health and Clinical Excellence. Clinical guidelines CG76:Medicines adherence: involving patients in decisions about prescribed medicinesand supporting adherence. London: NICE, January 2009.

13.York Health Economics Consortium and School of Pharmacy, University ofLondon. Evaluation of the scale, causes and costs of waste medicines. London:Department of Health, 2010.http://www.pharmacy.ac.uk/fileadmin/documents/News/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf

A U G U S T 2 0 1 1

http://www.psnc.org.uk/data/files/PharmacyContract/Contract_changes_2011/summary_of_cpcf_changes_may_2011.pdf


R E F E R E N C E S

14.DiMatteo, MR. Variations in patients’ adherence to medical recommendations:a quantitative review of 50 years of research. Medical Care, 2004; 42 (3): 200-209.

15.Haynes RB, Ackloo E, Sahota N, McDonald HP,Yao X. Interventions forenhancing medication adherence. Cochrane Database of Systematic Reviews,2008; Issue 2. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub3.

16.World Health Organization. Adherence to long-term therapies: evidence for action.2003. Available from:http://apps.who.int/medicinedocs/en/d/Js4883e/5.html

17.DiMatteo MR, Giordani PJ, Lepper HS et al. Patient adherence and medicaloutcomes: a meta-analysis. Medical Care, 2002; 40: 794-811.

66

A U G U S T 2 0 1 1

Appendix 1Self-assessment of readiness for communitypharmacistsThis self-assessment is to provide you (the pharmacist) with a framework to assure yourself, your employer(where appropriate) and the NHS that you have reflected upon the skills and knowledge necessary todeliver the New Medicine Service (NMS) and can demonstrate them.

Pharmacy contractors are separately required to ensure that their premises meet the required standard andthat all the pharmacists providing the service have completed this self-assessment.

1) Are you eligible to provide the service?

Are you accredited to provide Medicines Use Reviews (MURs)?

Yes No

2) Do you understand the purpose and background of the service?

Do you know why this service is being commissioned and the evidence behind it?

Yes, because I have undertaken the following:

This requires you to reflect on your knowledge about the service, including its role in supporting appropriatemedicines adherence and where it fits in the NHS QIPP (Quality, Innovation, Productivity and Prevention) workprogramme and Government policies to increase patients’ involvement in their own care.

3) Do you understand the aims and intended outcomes of the service?

Do you understand the aim of the service to support patients taking a new medicine?


Do you understand what outcomes are required when providing this service?


This requires you to reflect on your knowledge about adherence, the eligible conditions/therapies and the medicinesused in the eligible conditions/therapies. This includes the theory and practical application of supportiveinterventions, together with how this will work in the pharmacy/pharmacies where you work and in your dailyprofessional practice.

67

A U G U S T 2 0 1 1

A P P E N D I X 168

A U G U S T 2 0 1 1

4) Do you understand the service specification and how to deliver it effectively?

Do you understand the service and how to provide it?

Yes, I understand the patient engagement, intervention and follow-up steps because I have undertaken thefollowing:

This requires you to examine the service specification, remembering that there are both requirements andprohibitions.

You should be particularly mindful of the following aspects to ensure you have a full understanding:

Recruitment/referral from another healthcare professional

Eligible clinical conditions/medicines

Where opportunities to offer relevant healthy lifestyle advice can be taken

Obtaining and recording consent

Method of undertaking the intervention – face-to-face/telephone appointment

Intervention process – interview schedule and next steps

Arranging the follow-up appointment

Follow-up – advice and support, next steps and action to be taken if you cannot contact the patient

Appropriate referral to the GP at the intervention and follow-up stages

Record-keeping for the pharmacy and reporting to the PCT (or successor organisation)

You may also wish to review the clinical areas covered by the service to ensure that you are competent in thoseparticular areas, in the mechanism of action and initiation protocol of the medicines and especially any side-effects,to help you address patients’ questions or concerns.

5) Have you considered the necessary communications that are required with pharmacy staff, patientsand other local healthcare providers in order to provide the service?

Have you reflected on your communication skills?

Yes, I have reviewed the interview schedule and considered how I will communicate with patients and otherhealthcare professionals and have undertaken the following:

Are you aware that the pharmacy contractor or their representative is required to communicate with local GPpractices about the service?

Yes

Are you aware that colleagues in the pharmacy are required to have an appropriate understanding of the service?

Yes

S E L F - A S S E S S M E N T F O R M

If you have NOT answered ‘Yes’ to all of the above questions you are not yet ready or eligible to deliverthe NMS.

The Centre for Pharmacy Postgraduate Education (CPPE) has facilitated the development of learning materials for theNMS. The learning materials support pharmacists with gaps in their skills and knowledge in order to help themdemonstrate they are able to deliver the NMS. For more information visit http://www.cppe.ac.uk.

Pharmacist’s declaration

I have answered ‘Yes’ to all the above questions and therefore declare that I have the necessary skills and knowledgeto deliver the New Medicine Service and can demonstrate these.

Signed: Date:

Name: GPhC registration number:

A completed copy of this form should be given to the pharmacy contractor at any pharmacies where you provide theNMS.

You may want to record the activities you have undertaken to prepare yourself for providing the NMS in your GPhCContinuing Professional Development Record.

69

A U G U S T 2 0 1 1

70

A U G U S T 2 0 1 1

Patient hands in prescription for a new medicine

Is the patient eligible for recruitment?The new medicine must be to manage one of the following LTCs:� asthma/COPD� type 2 diabetes� anticoagulant/antiplatelet therapy� or hypertension.

Patient engagement� Dispense medicine and provide advice� Provide patient with information relating to service, eg, leaflet� Provide opportunistic lifestyle advice� Does the patient agree to be recruited to the service?� Get patient to sign consent form

Patient and pharmacy agree a methodand time for intervention in one to two weeks’ time

Talk with patient next time they bring theirprescription to the pharmacy

InterventionTalk with the patient:� Do they understand why they have come to the pharmacy today?� Do they know and are they happy that information will be shared?

Remember: no consent means no intervention� Use the interview schedule list of questions to support your consultation� Provide opportunistic lifestyle advice

Is the patient adhering to their medicine?

Tell the patient they are doing well– encourage and motivate them to

continue with adherence.

Make next appointment forfollow-up in two to three weeks.

Check the patient understands the solution.

Make next appointment for follow-up in two to three weeks.

Encourage and motivate the patient to work with the solution.

Explain potential clinical risk ofnon-adherence. Refer patient to

general practice.

End of service

Follow-upTalk with the patient� Use the interview schedule list of questions to support your consultation� Provide opportunistic lifestyle advice

Is the patient adhering to their medicine?

Explain potential clinical risk of non-adherence.Refer patient to GP practice

End of service

Solution is identified and agreed Solution not identified or agreed

New medicine service flowchart

YES NO

NO

NO

NOYES

YES

For information on your orders or bookings,or any general enquiries, please contact usby email, telephone, fax or post. A memberof our customer services team will be happyto help you with your enquiry.

Email: [email protected]

Telephone: 0161 778 4000

Fax: 0161 778 4030

Do you have any comments on your learningexperience?

Email: [email protected]

© Copyright Controller HMSO 2011

Centre for Pharmacy Postgraduate Education, School of Pharmacy and Pharmaceutical Sciences,University of Manchester, Oxford Road, Manchester M13 9PT

http://www.cppe.ac.uk

newmedicinese rvice - cppe · newmedicinese rvice deliveringquality andmakingadifference developed...

Documents