Supporting care homes in England Print E-mail
Written by Claire Jones   
When the new pharmacy contract was introduced in April 2005 the previous arrangements for community pharmacists providing Advice to Care Homes ceased. Primary care trusts now have the choice of commissioning enhanced community pharmacy services to care homes (particularly under enhanced service EN5 – see below).

Medication standards


Care homes are required to meet National Minimum Care Standards (NMCS), which are set by the Department of Health (DH)[1]. Standard 9 deals with medication and includes requirements for care home policies around medicines use and the training of care staff in basic medicines knowledge. For example, it states that the training for care staff must be accredited and must include:

  • Basic knowledge of how medicines are used and how to recognise and deal with problems in use;
  • The principles behind all aspects of the home’s policy on medicines handling and records.

The Commission for Social Care Inspection (CSCI), which is responsible for regulating social care services, monitors the attainment of these NMCS.

Evidence of poor management


In February 2006, a CSCI report showed that nearly half of care homes are failing these medication standards. The report found that people are given the wrong medication, someone else’s medication, medication in the wrong doses or no medication at all. The report also found that staff are poorly trained and records are not properly kept[2].

In addition, there are numerous other studies demonstrating poor medicines management in care homes. For example, almost a quarter of elderly residents in a sample of UK nursing homes were prescribed benzodiazepines, but in two-thirds of these cases no appropriate medical reason could be found[3]. Another study reported an association between potentially inappropriate medication prescribing and subsequent hospitalisation and death in nursing homes[4].

Evidence that pharmacy can help


Nursing home residents in the UK take an average of six to seven drugs[5]. A major study of pharmacist-conducted medication review in homes showed that treatment modifications were needed for half the medicines prescribed. The most frequent recommendation (47 per cent) was to stop medication. In two-thirds of all cases there was no stated indication for the medicine being prescribed[6,7]. Longer-term follow up showed the number of medicines prescribed for older people can be reduced with no adverse impact on morbidity or mortality[8].
 
Additional studies have shown that clinical medication review by a pharmacist does have a positive impact[9], and that community pharmacists reviewing repeat prescriptions of care home residents can improve the quality and cost-effectiveness of prescribing[10].

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Table 1. Key elemets of template service specifications, with reference to EN5.

 

So where can pharmacy help?


Community pharmacists should consider targeting care home patients for repeat dispensing services and medicines use reviews (MURs). Remember that the PCT first needs to consent to the pharmacist conducting MURs at alternative premises.

The PSNC website (www.psnc.org.uk) contains the template service specifications for the enhanced pharmacy services. The following template service specifications would apply to care homes:

  • EN5 – Care home (support and advice on storage, supply and administration of drugs and appliances);
  • EN6 – Medicines assessment and compliance support;
  • EN7 – Medication review (full clinical review);
  • EN10 – Supplementary prescribing by pharmacists.


Table 1 describes the key elements of each template service specification with particular reference to EN5. Therefore if PCTs wish community pharmacists to provide a more clinical service to a care home in addition to EN5, they would either create a local enhanced service of their own to take this element into account, or would also need to commission from EN6, EN7 or EN10.

And, of course, with the advent of independent pharmacist prescribing and the development of ‘pharmacists with special interests in primary care’ in 2006, the scope for providing pharmacy services to care homes further increases.

It is also important to link in any medication support or review service in care homes to the existing targets in the NSF for Older People, and the Quality and Outcomes Framework (QOF) in the GP contract. These are described in Table 2.

In addition, practice-based commissioners will be interested in improving services to care homes as managing medicines in care homes takes up a significant amount of GP practice time. GPs often find that one of the most useful services available to them is an overhaul of all prescribing for their care home patients[11].

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Table 2. Targets in NSF for older people and the Quality and Outcomes Framework (QOF).
 

 

Resources to help


The Royal Pharmaceutical Society’s practice guidance Administration and Control of Medicines in Care Homes and Children’s Services is designed to assist owners and managers of care homes to handle medicines safely and to meet the medication requirements in the NMCS12. This document is therefore essential reading for any pharmacist providing an advisory service to a care home.

In Wales, enhanced services fall into three categories (further details are available at www.wales.nhs.uk/sites3/page.cfm?orgid=498&pid=7552 ). For national enhanced services, of which care home support is one, there is a template service level agreement (SLA) in addition to a template service specification. For the care home support service there are also further templates available including:
  • A care home agreement form;
  • A visit report form;
  • An action plan.

The NPA offers numerous practical tools to support care home services. For example, the Education and Training Department can provide an accredited resource for community pharmacists who wish to provide training on medicines to care home staff, and numerous template standard operating procedures (SOPs) are available from the NPA Information Department.

Conclusion


There continues to be significant scope for community pharmacists to provide enhanced services to care homes, over and above the day-to-day essential and advanced services. A significant number of care homes continue to fail to meet required medication standards and enhanced services can be commissioned from community pharmacy to support care homes in meeting these standards. These services range from providing advice and support to ensure the proper and effective management of drugs through to medication review services to reduce unnecessary polypharmacy.

References
1.     Care homes for older people: National Minimum Care Standards. Department of Health 2002.
2.     Care homes fail to meet medication standards.     CSCI press release February 2006.
3.     Osborne CA et al. Explicit, evidence-based criteria to assess the quality of prescribing to elderly nursing home residents. Age Ageing 2003; 32: 102–108.
4.     Lau DT et al. Hospitalisation and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 2005; 165: 68–74.
5.     Prescribing for the older person. MeReC 2000; 11(10): 37–40.
6.     Furniss L et al. Medication reviews in nursing homes: documenting and classifying the activities of a pharmacist. Pharm J 1998; 261: 320–323.
7.     Furniss L et al. Medication use in nursing homes for elderly people. Int J Geriatric Psychiatry 1998; 13: 433–439.
8.     Furniss L et al. Effects of a pharmacist’s medication review in nursing homes: Randomised controlled trial. Br J Psychiatry 2000; 176: 563–567.
9.     Alldred et al. Clinical medication review by a pharmacist for older people in care homes: preliminary report. IJPP, September 2003 (abstract), R90.
10.     Corbett J et al. Provision of prescribing advice for     nursing and residential home patients. PJ 1997; 259: 422–424.
11.     GP prescribing support: a resource document and guide for the new NHS. NPC, 1998.
12.     Administration and control of medicines in care homes and children’s services. RPSGB Practice Guidance, June 2003.
 
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