Managing Patients Medicines After Discharge From Hospital

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National study

Managing patientsmedicines after dischargefrom hospital

October 2009


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About the Care Quality Commission

The Care Quality Commission is the independent regulator of health andadult social care services in England. We also protect the interests of peoplewhose rights are restricted under the Mental Health Act.

Whether services are provided by the NHS, local authorities, or privateor voluntary organisations, we make sure that people get better care.We do this by:

Driving improvement across health and adult social care.

Putting people first and championing their rights.

Acting swiftly to remedy bad practice.

Gathering and using knowledge and expertise, and working with others.


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Contents

Summary 2

Why did we carry out this study? 2

Our approach 2

Key findings 2

Recommendations 6

Introduction 9

1. Providing information on medicines to acute trusts 12

2. Providing information when a patient is discharged

from hospital 16

3. Medicine reconciliation after discharge 20

4. Repeat prescribing 23

5. Medication review 26

6. Supporting patients with their medication 30

7. Reporting medication incidents and errors from across the care pathway 35

Conclusion 39

Appendix A: Methodology 43

Appendix B: Assessment framework 46

Appendix C: Acknowledgements 50

References 51

Care Quality Commission national report: Managing patients medicines after discharge from hospital 1


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Summary

Why did we carry out this study? Key findings

A large proportion of the UK population is taking amedicine, and the number of medications prescribedis increasing. Managing medicines when a patientis transferred from one setting to another is centralto safe, high-quality care. It is also an area whereconsiderable efficiencies could be made, by reducingavoidable hospital admissions.

Our approach

This study looked at what organisations were doing toensure the safety of patients who had been dischargedfrom hospital with a change of medication, along thekey steps of the pathway in this process (see figure 1).This report sets out our findings from visits to 12

primary care trusts (PCTs) including a survey oftheir GP practices, analysis of national datasets,and research exploring the experience of patients.

In general, there were good systems in place toensure the safety of repeat prescribing, and to ensurethat reviews of medication for high-risk patients tookplace after their discharge from hospital.

However, our study raises concerns about a number ofareas in the medicines management process that occurbetween general practices and hospitals. In particular:

Acute trusts need to improve the quality ofinf


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PCTs need to ensure that there are safe processesin place for critically reviewing medication changesand updating patients records after they aredischarged.

Acute trusts and GPs need to ensure that theycommunicate more effectively with patientsabout their medicines, both at and after discharge.

GPs need to report to their PCTs and the NationalPatient Safety Agency when things go wrong. PCTs


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Two of the PCTs we visited were encouraging acutetrusts to provide timely and accurate dischargeinformation by including financial penalties orincentives within their local discharge protocol,which is good practice.

Updating patients medication records afterdischarge from hospital (reconciliation)Once a discharge summary is received by the GPpractice, the information on changes to medication

needs to be critically reviewed and incorporated intothe GPs patient record, so that appropriate changesmade to medicines during a patients stay in hospitalare continued as intended by the hospital prescriber.This process is central to reducing the risk ofmedication error; if not carried out, in more extreme

cases, this could result in patients taking duplicatemedicines or taking medicines that are incompatible,which increases the risk of complications.

A large number of practices were not operatingto an agreed protocol for reconciliation: only halfof the PCTs we visited provided GPs with anyspecific guidance on reconciliation, and in thesePCTs the majority of GP practices were not awareof the guidance. In the six PCTs where no guidance

on reconciliation had been issued, only 25% ofGP practices had set out their own guidance.Furthermore, eight of the 12 PCTs visited hadno systems to monitor reconciliation and nonewere able to provide evidence to confirm whether

reconciliation was timely or accurate.

GPs and other clinical staff took responsibilityfor reconciliation in the majority of practices, buta small number of practices (17%) delegated the

responsibility for medicines reconciliation to managerialor clerical staff. These practices must ensure thatclinical staff carry out proper cross-checking.

Repeat prescribingThe repeat prescribing arrangements that a patienthas with their GP before hospital admission presenta risk to their safety if medication is altered duringa hospital stay and repeat prescriptions are notquickly changed. Appropriate authorisation needsto be granted for any new repeat prescriptions, anda time limit set beyond which no more repeats may be

issued. Repeat prescriptions can introduce risk becausethey reduce the need for GPs to interact with theirpatients, and because they could be inadvertently

continued after changes to intended medicationare made. Any repeat prescribing arrangements,therefore, need to be monitored closely.

All 12 PCTs had either produced guidance onrepeat prescribing or had encouraged GP practicesto develop their own guidance based on the PCTs

guidelines. The majority of GP practices (87%)had a protocol for repeat prescribing. However, keyrequirements such as the competencies required

to authorise repeat prescriptions, drugs not suitablefor repeat prescribing and recommended treatmentperiod, were absent in 32% to 45% of practices.

Nine of the PCTs we visited provided evidenceof having audited repeat prescribing, and eight PCTsreported that they or their practices had completed an

audit of Clopidogrel a drug used in the treatmentof patients who have recently had a heart attack orstroke. However, there was little available evidenceof changes having been made as a result.

Care Quality Commission national report: Managing patients medicines after discharge from hospital4


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Medication reviewOnce someone has returned home on their newmedication regimen, a healthcare professionalshould review their medication to check that it ishaving the best possible therapeutic effect, discussside effects and also spot potential problems.

Nationally, over 95% of GP practices are meeting

the Quality and Outcomes Framework (QOF) targetsthat require a medication review to take place every15 months for at least 80% of patients who are

prescribed repeat medicines. In fact, our surveyshowed that performance seems considerably betterthan that set out by QOF, with an average of 57%to 63% of GP practices conducting a medicationreview within the first month of discharge fromhospital. Over 70% of the GP practices surveyed said

that they discuss patients experience, side effects,drug monitoring, test results and length of treatmentduring medication reviews most of the time.

The majority (10 out of 12) of the PCTs we visitedprovided GP practices with some form of writtenguidance for medication review and in nine out ofthese 10 PCTs, GPs were prioritising patients forreview, on the basis of population group, medicalcondition, or type of medicine. However, only one

PCT monitored both the timeliness and quality ofmedication reviews.

Supporting patients to adhere to theirmedication regimen

It is important that patients are given clearinformation about their medicine and possible sideeffects, and then have an opportunity to discusshow the regimen is working out.

At a national level, however, between 11% and

34% of people say they were not given enoughinformation on leaving hospital, and patients wereprovided with copies of discharge letters (asstipulated by the NHS contract and constitution)in only seven of the 12 PCTs we visited.

Medication reviews provide a forum for patientsto discuss any concerns they might have with theirGP and identify changes needed, but only 55%of practices said that patients are present duringmedication review most of the time; and 5% saidpatients were hardly ever present.

All the PCTs we visited had some other mechanismsin place to pick up on whether particular groups of

patients were following their medication regimen, andall either employed or commissioned pharmacists,

nurses and matrons to support patients. However,there was a great variation in the way pharmacistswere used, which reflected the fact that thepharmacist resource available to practices varied by afactor of 10 across PCTs. In the best PCT, pharmacistsreviewed patients with complex medication needs,undertook home visits and identified potential

changes in treatment. Community (high street)pharmacies can also talk through medications withpatients in medicine use reviews, but the take-up of

these has been slow, as not all community pharmaciesare accredited to provide this service, and the numberof accredited pharmacies varies greatly by PCT.

Learning from incidents and errorsDespite the fact that 90% of the contact thatpatients have with the NHS is within primary care,

only 2,165 incidents involving errors in medicationwere reported from general practice last year and 657(7.8%) of GP surgeries do not meet the relativelylow QOF requirement to carry out a minimum of 12

significant event audits (SEAs) within three years.All of the PCTs we visited had developed initiatives toencourage GPs to report incidents and share learning,which is good. However, only eight had systematicallycollated, analysed and benchmarked their number of

incidents; five had evidence of analysing SEAs fortrends; and only one PCT could show us evidencethat it had taken action to improve its medicinesmanagement as a result of learning from its ownincidents, which is a wasted opportunity.



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There are a number of areas where PCTs need toimprove how they govern, monitor and managecontracts with acute providers, and how they targetresources. It is essential that PCTs hold GP contractorsand acute trusts more effectively to account on howthey share information when a patient is admittedand discharged from hospital. The PCTs we visited

were monitoring aspects of how GPs deliver care,but they needed to set expectations for, and gathermore comprehensive information on, the quality (asopposed to just the timing) of medication reviews.

And, given its fundamental importance to safety, theyneeded to develop expectations for reconciliationprocesses within GP practices, and monitor these.

The learning from monitoring had only resulted inimprovements in care to a limited extent. PCTs were

not making effective use of information alreadylocally available: for example, a number of PCTswere not analysing the audit data or information onsignificant events that was available to them. PCTs

need to focus on setting action plans and drivingimprovement in medicines management, based onlocal learning.

Our study highlights the potential of national systemssuch as the QOF and the electronic patient record.

The QOF requirements that relate to the medicinescare pathway appear to set the bar quite low, andthey should be tightened to cover quality as well astiming issues and reflect what is already being donein the better GP practices.

IT systems have the potential to significantly improvecommunication between acute trusts and GPs. Themovement towards standardised electronic dischargesummaries should be encouraged. By granting alllocal partners immediate access to individual patientrecords, the proposed electronic patient recordwill considerably improve the communication ofmedicines-related information across organisationsfor all patients and types of admission. Aspects ofthe national programme for IT (NPfIT) that enable

electronic communication between different care

settings and professionals, such as the summary carerecord (SCR), should be given high priority.

This study highlights the errors that can be madewhen patients move from one care setting to another,and the importance of a good transfer of informationand good checking systems, to minimise risks. Allorganisations involved in providing, commissioning,regulating, and setting standards for care need to

pay particular attention to these interface issues,

to ensure that care becomes safer for patients.

Recommendations

Primary care trusts should:

Work with GPs to agree the use of standardreferral forms, including a specification forthe information that GPs will provide tolocal acute trusts when a patient is admitted,

taking account of the guidance from theNational Prescribing Centre. This shouldcover elective and emergency admissions,and set out timeframes for the provision of

this information. They should then audit theuse of this form, and whether timeframesare met, holding practices to account.

Work with GPs to clarify their expectationsof GP practices, in relation to reconciliation,medication review and repeat prescribing.These should be in line with national



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guidance and cover the quality of processes(for example, the elements of medication reviewthat are completed) as well as their timeliness.

Make far better use of the information they


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Share learning, by recording instances when themedicines pathway goes wrong, and reportingthem to their PCTs and the National PatientSafety Agency. This should include any issues

relating to discharge summaries and incidentsrelating to the care they provide themselves.

Community pharmacies should:

Report instances of prescribing error to PCTsso that lessons are learned and the safety andquality of patient care is improved.

Ensure that the categories of patients identifiedby their local PCTs are offered a MUR serviceconsultation.

Acute trusts should:

Ensure that all their clinicians are aware oftheir obligations with regard to admissionsand discharge arrangements. In particular,communicating with patients about their

medicines, providing discharge letters topatients, and completing discharge summariesfor GPs on time and to include full informationon medication changes.

Provide objective information to PCTs regardingthe extent to which information from GPs isincomplete or late, for both emergency andnon-emergency referrals, to drive improvement.

Review their medicines managementarrangements in readiness for the introduction

of registration with the Care Quality Commission this applies to all organisations providinghealthcare, in both the NHS and independentsector. They should pay particular attention tothe requirements of regulation 11 (outcome 8)as described in our consultation document

Guidance about compliance with the Healthand Social Care Act 2008 (RegistrationRequirements) Regulations 2009.

National bodies

Aspects of the National Programme for IT(NPfIT) will bring about considerableimprovement in the communication ofmedicines-related information acrossorganisational boundaries for all patients and

types of admission. The Department of Healthshould ensure that practitioners use aspects ofthe NPfIT that enable electronic communication

between primary and secondary care, inparticular, the summary care record (SCR)and where possible accelerate its use acrossdifferent care settings.

NHS Connecting for Health should ensure thatall healthcare practitioners involved in patientcare are able to record necessary informationon SCR, so that other practitioners may haveaccess to reliable information when needed.

The Department of Health should modifythe Pharmaceutical Services (Advanced andEnhanced Services) Directions 2005, to ensurethat pharmacies are required to follow a PCTsnotification regarding categories of patientswho benefit from MUR services, rather thansimply having regard to them. The related

proposals in the recent pharmacy White Paper,

Pharmacy in England, Building on strengths delivering the future in this respect are helpfuland should be introduced as soon as possible.

The great majority of GP practices are meeting

and exceeding the QOF target for some medicinesindicators. NHS employers and the GeneralPractitioners Committee should review the targetsand indicators that relate to this care pathway, toset more stretching objectives that allow betterdiscrimination and benchmarking, and that takeaccount of national guidance and best practice,when QOF is reviewed in 2011/12. They shouldalso set out more stretching expectations

of a medication review, to include patientinvolvement, and set new measures of quality

(rather than measures of timeliness).



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Introduction

Just over two-thirds of the UKs population will betaking a medicine at any one time,1 with the numberof medicines prescribed per individual increasing byaround 3.5% a year.2 This increase is particularlynotable for older people, for whom it is notuncommon to be taking four or more medicines atany one time.3 Managing the way that medicines areprescribed, dispensed, administered and monitored is

central to the provision of a safe, high-quality service.

Adverse events involving medication are the fourthmost commonly reported type of incident to theNational Patient Safety Agency (80,150) during 2008

in England.4

Studies suggest that almost half of allpatients may experience an error with their medicationafter they have been discharged from hospital.5, 6

It is difficult to assess the level of harm to peoplearising from these incidents, principally due to alack of data. However, one study estimated that

approximately 4% of all hospital admissions maybe due to preventable medicine-related issues.7, 8

The same study estimates that adverse drugreactions (both preventable and non-preventable)

are likely to account for over 10,000 deaths inEngland a year, taking account of those reactionsthat also occur during a hospital stay.8

Since there are so many preventable hospitaladmissions, aside from improving safety considerably,there is the potential to make considerable efficiencysavings by managing patients medicine better.Studies estimate that the annual cost of preventablemedicines-related admissions in England is 466

million.8

There are many reasons why errors occur withpatients medication, but research into this area hashelped identify particular themes. These include poorcommunication between teams or organisations atkey transition points, when the responsibility for a

patients care is transferred from one place to another;a lack of suitable monitoring and review of treatment;or patients not taking their medicines as agreed.9, 10

Therefore, when a patient is admitted to anddischarged from hospital and their medication ischanged, good communication between the hospitaland general practitioner (GP), and good monitoring

and review by GPs, are extremely important.



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Figure 2: The ideal patient pathway

Admission Discharge

Criticallyreviewing and

updatingpatients

medicationrecords

(reconciliation)

Medicationreview and

repeatprescribing

Support foradhering tomedication

Patient admitted Treatment received GP critically reviews GP invites patient Patients do not

to hospital with in hospital. Changes changes and updates to a consultation. always take their

list of up-to-date to medication may the patient record Patients medication medicines as

medicines, obtained be made. Patient with the details in is discussed and intended. Furtherfrom the GP and discharged with a the discharge potential medication monitoring ispatient. Hospital copy of discharge summary. This errors and adverse required to identifypharmacists then letter. Discharge ensures that any reactions are spotted patients who maycarry out medicines summary sent to appropriate changes and dealt with. not be taking theirreconciliation to GP and community made in hospital Where necessary, a medicines asestablish what the pharmacist with are documented on repeat prescription intended so thatpatient is currently details of changes the patient record, is issued and review support can betaking. to medication. and prescriptions date set. provided as

changed. appropriate.

The ideal patient pathway

Figure 2 outlines the ideal patient pathway formedicine management from the point that thepatient is admitted to hospital through to dischargeand further support after discharge. As the aboveevidence shows, the pathway is not always followed

by professionals and healthcare providers, and thiscan lead to harm.

10 Care Quality Commission national report: Managing patients medicines after discharge from hospital


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This review

Given the potential harm to patients, and theconsiderable efficiencies to be made, the Care QualityCommissions predecessor, the Healthcare Commission,decided to carry out a review of performance inmanaging medicine after discharge. This has beencompleted by the Care Quality Commission.

We looked at how well primary care trusts (PCTs),as contractors and commissioners of both primary

care and hospital care, were promoting goodcommunication, monitoring and review ber18(o car)-(act)18(o. Sp(deeffally)54((e, (e look)12(ed :n. )]TJEMC LILa
http://www.cqc.org.uk/


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1 Providing information on medicines to acute trusts

If accurate, timely information on medicines is tobe passed back to a patient and their GP when theyare discharged, it is essential that good quality dataaccompanies the patient on admission.12

If a hospital does not have complete information onthe medication a patient was taking before admission,

this can cause harm. A patients current medicationscould be incompatible with their treatment or anynew prescriptions (see case study 1). Studies suggestthat discrepancies between what medicines a patientis taking and what the hospital has actually recordedmight affect 19-54% of admissions13, 6 with

approximately 40% of these considered to bepotentially harmful to the patient.6 An underlyingissue is that information provided to acute hospitalsremains patchy and inconsistent.13, 14

The guidance issued by the National Institutefor Health and Clinical Excellence (NICE) and the

National Patient Safety Agency (NPSA) requires allhealthcare organisations that admit adult inpatientsto have a policy in place for medicines reconciliationon admission.15 The policy should set out systems

for collecting and documenting information aboutcurrent medicines and that pharmacists are involvedin medicines reconciliation as soon as possible afteradmission.

Case study 1: Hospital not being awareof all the medication a patient is taking

Two of the 18 patients we interviewedreported that the hospital was not aware of allthe medication that they were taking. In onecase, the patient was prescribed incompatiblemedicines. He continued taking steroidmedication for his arthritis after recovering froma knee operation. The medication prolonged thehealing of a wound caused by the operation. Thismeant that he was in hospital for several months.

Overall, we found that GPs provided many aspectsof relevant information to acute trusts when theyrefer patients in non-emergency cases (see figure 3).Ninety-eight per cent of GP practices reported thatthey provide a list of all medicines currently prescribed

for the patient, 90% provide the dosage of all listeddrugs and 85% provide the frequency of all listeddrugs. However, far fewer provided information on:

Medicines that should be stopped only 14%.

Formulation and route of administration 59%.

http:///reader/full/admission.12http:///reader/full/admission.12http:///reader/full/inconsistent.13http:///reader/full/inconsistent.13http:///reader/full/admission.15http:///reader/full/admission.15http:///reader/full/admission.12http:///reader/full/inconsistent.13http:///reader/full/admission.15


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Figure 3: Information provided by GPs when patients are referred to hospital for elective admissions

100

80

60

40

20

0

Patientdetails

Presenting

condition

Co-morbidities

Prescribed

medicines

Over-the

counter

medicines

Dosage

Frequency

Formulation

Routeof

administration

Medicinestobe

discontinued

Knownallergies

Previousdrug

reactions/

sensitivities

Type of information

Furthermore, although the majority of GPs reportedthat they provide information on co-morbidities,

known allergies and previous drug reactions, thereare a considerable minority (14%, 11% and 24%respectively) of GPs who did not systematicallyprovide this information. This is concerning, sincethis type of information is particularly importantto ensure safe care.

Emergency admissions present particular challengesfor the transfer of information about medicinesthat patients are taking. They account for 40%of all admissions into acute hospitals,16 and willdisproportionately affect high-risk groups beingtreated on multiple medications in the community.We found the approach for providing information onmedicines to acute trusts for emergency admissionstended to be too slow, and informal. Acute trustsusually requested clinical information from GPs the

following day, but there were no clear requirementsto avoid a delay in obtaining information over a

weekend.



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Figure 4: The number of PCTs providing guidance or monitoring information that GPs includein referrals

12

11

10

9

8

7

6

54

3

2

1

0

Numberof

PCTs(outof12)

PCTs setting out what information PCTs monitoring whether GPs areshould be shared by GPs sharing adequate information on time

Guidance for GPs Ad-hoc incident reporting or one-off auditsStandardised referral forms Regular independent monitoring of referrals

The role of primary care trusts inproviding guidance, monitoringand leading change

The flow of information between GPs/out-of-hoursservices and acute trusts should be governed byclear guidelines to ensure consistency and promotepatients safety, for both elective and emergencyadmissions. Only two primary care trusts (PCTs)

provided GPs with guidance, but a further five ofthe PCTs we visited used standardised referral forms,which helped to capture all the necessary information(see figure 4). However, in some cases forms didnot cover all acute services, or only applied to apercentage of practices.

It is essential that PCTs hold their contractors toaccount for the care they provide, particularly whenit can impact on safety. However, only one of the PCTs

that we visited had reliable, systematic knowledge ofwhether GPs were sending the correct informationat the right time (see figure 4).

Case study 2: Peer review of referrals

NHS Plymouth PCT has a contract with a not-for-profit company that ensures that completeinformation is provided to the acute care trust forall elective admissions. GPs use the companyspro-forma for almost all elective referrals; it isa practice-based commissioning requirement.

The pro-forma requires standardised patient

information, including information on currentmedication and known drug allergies or sideeffects and body mass index, blood pressureand smoking status. All pro-formas are peerreviewed through the company, and any whichhave incomplete information are returned tothe practice for correction before the admissioncan proceed. Only 3% of referrals were

returned at the last check.



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Developing extra ways ofcommunicating drugs regimens

As mentioned above, there are different ways ofgetting information to the acute hospital one isvia the GP, and the other is via patients themselves.A number of PCTs have introduced ways of helpingpatients to communicate what medication they are

taking. A few of the PCTs we visited, in conjunctionwith their acute and ambulance trusts, operated

patients own drugs (POD) or green bag schemes.


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2 Providing information when a patient isdischarged from hospital

During a patients stay in hospital, their medicationmay be changed.17 To ensure that ongoing care isconsistent with any new regimen that is introducedin the hospital, good information on medicationchanges should be sent to GPs when a patient isdischarged.

Problems may arise when discharge informationis either late or incomplete. A survey by the NHSAlliance reported that 70% of GP practices weresent discharge summaries late either very often orfairly often; 39% of practices reported instanceswhere this failing had directly compromised patient

safety.18

Another study found that when changes weremade to patients medication during emergencyadmission to hospital, almost a third of patients werereadmitted within two weeks of discharge theyhad reverted to pre-admission medication becauserepeat prescriptions were not amended. This was

partially attributed to a failure to provide timelydischarge information to the patients GPs.17 In

a separate study, a third of all discrepancies indischarge information had the potential to causepossible or probable patient discomfort and/or

clinical deterioration.19 Common discrepancieswith discharge information include the omissionof medications,19 failing to provide a rationale forwhy a patients medication had been changed20

and the absence of follow-up plans.6

In line with previous studies, our review raisesconcerns around the timeliness of dischargesummaries. Only 53% of practices in the primarycare trusts (PCTs) we visited reported that dischargesummaries were received in enough time to beuseful either all of the time or most of the time

(see table 1).

However, GP practices reported particular concernswith the quality of discharge summaries: only 27%reported that discharge summaries are hardly everor never inaccurate or incomplete (see table 2). Oneof the main inaccuracies that GPs reported related to

medicines that had been prescribed when the patientwas discharged. Eighty-one per cent of practicesreported that details of prescribed medicines were

incomplete or inaccurate on discharge summariesall of the time or most of the time. Eighty-eightper cent of practices also reported that the summaryof diagnosis was incomplete or inaccurate all of thetime or most of the time(figure 5).

http:///reader/full/changed.17http:///reader/full/changed.17http:///reader/full/safety.18http:///reader/full/safety.18http:///reader/full/deterioration.19http:///reader/full/deterioration.19http:///reader/full/changed.17http:///reader/full/safety.18http:///reader/full/deterioration.19


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Table 1: Within your practice, over thepast 12 months, how often weredischarge summaries received(from the discharging provider)in enough time to be useful?

Response from 280 GP practices

All of the time 4%

Most of the time 49%

Some of the time 34%

Not very often/hardly ever 13%

None of the time 0%

Table 2: Within your practice, over thepast 12 months, how often weredischarge summaries inaccurateor incomplete?

Response from 280 GP practices

All of the time 0%

Most of the time 16%

Some of the time 56%

Not very often/hardly ever 25%

None of the time 2%

Figure 5: Within your practice, over the past 12 months, how often were the following aspectsof discharge summaries inaccurate or incomplete?

70

60

50

40

30

20

10

0

Dont know/Other

All of the time

Most of the time

Some of the timeNot very often/Hardly ever

Summary of Details of Allergies or Name of the Immediate Any planned Contactdiagnosis on prescribed adverse patients post-discharge follow up details for

admission medicines on reactions to responsible requirement arrangements queries afterdischarge medicines consultant discharge

Items in discharge summary



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The absence of accurate and complete informationon prescribed medicines increases the risk that GPswill prescribe incompatible medication. This can havea severe adverse impact on patients, which may notalways relate to their health (see case study 5).

The increased use of standard, electronic dischargeforms can help, and the majority of PCTs we visited

(eight out of 12) are using, or plan to use them.One PCT that had introduced them fully reportedimprovement in the timeliness and legibility of the

summaries.

Case study 5: Patients GP does notreceive complete discharge summary

The GP is the pig in the middle the GPdoesnt know any of my problems until I tellhim. His notes were out of date, he thoughtthey cured me of arthritis, and then when I

went to see him he told me that I dont havenotes so I gave him the discharge summary.

It has got better though now and his notesare up to date. Because my GP didnt knowthat I was still taking medicine for arthritis mydisability benefit was affected, they took awaymy wifes wages as a carer and they reducedmy benefits by half because my GP had toldthem that I had been cured of arthritis. Sincethen, everything that happens to me I tellto the GP. I never used to check with my GP

about letters until I had the problem with mydisability benefits, so now I check that theresalways communication between the doctors.

(Patient with mental health problems)

Sharing discharge informationwith patients and pharmacists

Sharing discharge information with others can providean additional check that subsequent prescribing is safe.

Patients themselves were receiving copies of theirdischarge letter in only seven of the PCTs we visited,

in spite of this being a requirement of the NHSconstitution and NHS standard contract for acute

care. This echoes the earlier findings of the mostrecent NHS inpatient survey, which reported greatvariation in the proportion of people that said theyhad received copies of all letters sent between thespecialist and their GP. At the highest scoring trust,78% of people said that they had received copiesof all letters. At the lowest scoring trust, this figurewas just 8%.

In the PCTs we visited, discharge summaries werenot regularly shared with community pharmacies.

In half of the PCTs we visited, information on apatients medication would only be copied to thecommunity pharmacist if the patient was using acompliance aid or was prescribed a high-risk drug.

Research has demonstrated that providing informationto a community (high street) pharmacist preventspotential adverse events.21 In one study, for every19 patients discharged, a community pharmacistidentified at least one discrepancy, which if goneunnoticed, could have resulted in an adverse outcomefor the patient.22There are a number of barriersto sharing information in this way for example,

identifying a patients community pharmacist.However, those patients with a long-term conditionare likely to have an established relationship with aparticular community pharmacist. Confidentialitywas raised as a barrier to information-sharing, butthe NHS Confidentiality Code of Practice sets outthat information can be shared between all thoseworking within and under contract to the NHS,

for the purposes of delivering healthcare.

http:///reader/full/events.21http:///reader/full/events.21http:///reader/full/patient.22http:///reader/full/patient.22http:///reader/full/events.21http:///reader/full/patient.22


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The primary care trusts role inmonitoring and driving improvement

A new standard contract for NHS-funded hospital carecame into force in April 2008 although a minorityof PCTs are still tied into old contracts. The newcontract for the first time sets out specific mandatoryobligations relating to discharge arrangements. This

includes the requirements for discharge summariesto be shared with patients and issued to the patients

GP within 72 hours of discharge. It also stipulatesthat the discharge summary should include:


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3 Medicine reconciliation after discharge

Once the discharge summary is received by the GPpractice, the information on medication changes needsto be critically reviewed and incorporated into theGPs patient record. This means that any appropriatechanges made to medicines during a patients stayin hospital are continued as intended by the hospital

prescriber. This process is often referred to asmedicines reconciliation, and should include thecollation of information on medicine history,checking that medicines and doses currentlyprescribed are correct, and making changes to thepatients prescriptions. National Institute for Healthand Clinical Excellence (NICE) guidelines state that

medicines reconciliation should occur wheneverpatients move from one care setting to another.

This process is central to reducing the risk ofmedication error;9 if not carried out, in more extremecases this could result in patients taking duplicatemedicines or taking medicines that are incompatible,which increases the risk of complications.21

The National Prescribing Centre (NPC) recommendsthat practices should carry out reconciliation according

to agreed local processes and guidelines. However,a large number of practices are not aware of, oroperating to, an agreed protocol for reconciliation.

Figure 6: Does your PCT provide written guidance for medicines reconciliation at discharge?(Practice survey: n = 280)

60

50

40

30

20

10

0

PCTs withno guidance (n=6)

PCTs withguidance (n=6)

Yes No Dont know

http:///reader/full/complications.21http:///reader/full/complications.21http:///reader/full/complications.21


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Figure 7: Does your practice have its own written policy or protocol for reconciliation?(Practice survey: n = 280)

60

50

40

30

20

10

0

Practices where PCTsprovided no guidance

Only half of the primary care trusts (PCTs) wevisited provided GPs with any specific guidanceon reconciliation, and in all PCTs the majority

of GP practices were not aware of guidance (seefigure 6). In the six PCTs where no guidance onreconciliation had been issued, only 25% ofpractices had set out their own (see figure 7).

Who is responsible for medicines

reconciliation?

On average, a GP practice would receive approximately1,645 discharge summaries per year, which wouldequate to around six per day*. To manage thisworkload, responsibility for medicines reconciliationand subsequently updating the electronic patientrecord may sometimes be delegated to an individualwithout clinical training.

Practices where PCTsprovided guidance

NPC guidance recommends specific skills requiredfor anyone undertaking medicines reconciliation

(see box A). Medicines reconciliation requiresclinical judgement and should only be undertakenby competent healthcare staff. Non-clinical staffshould only undertake the administrative aspects ofreconciliation9 and good checking processes by thosewith clinical knowledge should always be in place.

Box A: Skills required for medicinesreconciliation

Effective communication skills.

Technical knowledge of relevant medicinesmanagement processes.

Therapeutic knowledge.

Medicines Reconciliation: A guide toimplementation, NPC, 2007

* Assuming a five-day working week and without taking

public holidays into account.



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Figure 8: Within your practice, who is normally responsible for undertaking medicinesreconciliation on a day-to-day basis? (Please tick one option) (n = 280)

Proportion of staff undertaking reconciliation

Our GP Practice Survey revealed that GPs wereresponsible for undertaking reconciliation in 76%of practices (see figure 8). A small number ofpractices reported that nurse prescribers and practicepharmacists also undertake this process. However, in17% (47 out of 280) of practices surveyed, medicinesreconciliation is undertaken by managerial or clericalstaff, rather than someone with a clinical background.Unless training has been provided, receptionists andsenior clerks will not commonly have the required

skills or competencies for medicines reconciliation.Although clinicians provided additional scrutiny ineach of these cases, we have not been able toassess the extent or quality of this oversight.

GP 76

Practice manager 2

Receptionist/Senior clerk 15

Pharmacist 1

Pharmacist technician 0

Nurse prescriber 1

Dont know 1

Other 3

The primary care trusts role inmonitoring and driving improvement

In eight of the 12 PCTs visited, there were nosystems for monitoring whether reconciliation istaking place safely or effectively. Others carried outinformal and random checks, but none of the PCTswe visited were able to provide evidence to confirmwhether reconciliation was timely or accurate.

Medicines reconciliation, if systematically implementedand monitored, will help reduce medication error andprevent adverse drug events. GPs and other clinicalstaff took responsibility for reconciliation in the greatmajority of practices, but a number of them delegatedit to receptionists and clerks which could increase therisk of errors if not properly checked. A number ofPCTs had produced guidance for GPs on reconciliation,but there were a number that still needed to do so,ensuring that reference is made to the best practicearrangements set out by the NPC. PCTs also need

to improve monitoring of reconciliation.



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4 Repeat prescribing
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%oGpacethsad

Figure 9: Does the protocol/policy (either the PCT policy or the practice policy) containinformation on the following items?

100

90

80

70

60

50

40

30

20

10

0Who can Competencies for Drugs not suitable Recommended Setting future dates

re-authorise authorising repeat for repeat treatment period for reviewrepeat prescribing prescribing prescribing for key drugs

Items in protocol

Case study 6: Patients were sometimesunsure whether they should be on repeatprescriptions or not

I took them [the tablets] for six to eight weeksafter coming out of hospital but then they ranout. I havent been taking them since I dontreally know how long I was supposed to betaking them for but I assumed that if I was

meant to get another prescription they wouldhave made me an appointment. Ill just sit andwait, theres nothing you can do about it.

(Patient with heart failure)



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Monitoring and audit

Nine of the PCTs we visited had audited aspects ofrepeat prescribing. Some of these audits were relatedto the Quality and Outcomes Framework for generalpractice (QOF).

We asked whether PCTs had completed any auditsof repeat prescribing of certain high-risk drugs.11

Many PCTs (eight out of 12) reported that they hadcompleted an audit of Clopidogrel, a drug used forpatients who have recently had a heart attack or

stroke or who are at risk of one. It is often prescribedbeyond recommended timescales. Only three PCTscould provide information on the outcome of theiraudits, which had been carried out at practice levelby pharmacists. Unless practices had been givenincentives, results of the audit remained at practicelevel and were not aggregated to give a PCT-widepicture. Clopidogrel continued to be prescribedbeyond recommended timescales in two of the three

cases. Despite this, there was no evidence of anyaction taken in response to the lapses identifiedthrough the audits.

In summary, all PCTs had either produced guidanceon repeat prescribing or had encouraged GPpractices to develop their own, and the great majority

of practices were aware of a protocol for repeatprescribing. However, key information like lengthof treatment for certain high risk drugs, and drugssuitable for repeat prescribing was not always includedin practices repeat prescribing protocols. The majorityof PCTs had audited repeat prescribing, but therewas patchy evidence of change being implementedas a result of any monitoring that did take place.

Case study 7: Repeat prescribing monthlyaudit

One PCT had employed practice medicinescoordinators, funded through practice basedcommissioning, for the sole purpose of reviewing

repeat prescribing and submitting monthly auditdata to the PCTs medicines management team.

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5 Medication review

Once someone has returned home on their newmedication regimen, a healthcare professional shouldreview their medication to check that it is having thebest possible therapeutic effect, discuss side effects andalso spot potential problems. A medication review iscrucial in helping patients gain a better understanding

of their medication particularly immediately afterleaving hospital and key to the safety of care.Studies have suggested that a breakdown in

monitoring arrangements accounts for approximatelya fifth of preventable drug-related admissions11 and

just over a quarter of all adverse drug events.25

Two patients we interviewed recounted instanceswhere the lack of a review had caused them harm;other patients that had had a review reported that

it had helped avoid potential problems as well asproviding reassurance.

Case study 8:Missed reviews

Nobody realised that one patient was on a low

dosage of Warfarin.

When I was in hospital the first time, I was keptin for two to three days and was discharged with

just that Warfarin. Six weeks later in March thesame thing happened, I was rushed back intohospital, and it was almost like dj vu I haventhad any reviews If there was something likethat going around, then [my problem] probably

would have been picked up. They could haveseen my medication list and seen glaringly that I

wasnt on the right amount. The period betweenfirst and second time in hospital, I never felt reallywell but I thought that this was usual. I shouldhave rung the hospital, but I didnt know betterI was a little surprised that the GP didnt flaganything up there was a bit of finger wavingbetween GP and hospital when I went intohospital the second time everyone wasblaming each other for not picking it up.

(Patient with an irregular heartbeat)

Another patient was told when he was at hospitalto take the medication for six months, but then he

carried on taking it for longer as he had assumedthat a healthcare professional would contact himto tell him to stop or have a check-up.

I was told that I would be taking the Warfarinfor six months, but after six months had passedthey didnt tell me to stop it so I carried on with

it for another three weeks. In the end I startedgetting nosebleeds and I kept bleeding if Iscratched myself. So I went to the GP and toldhim that I wasnt sure whether I should be on it

still couldnt understand why they hadnt toldme, why did I have to go down there myself? Iassumed that the hospital would be checking that.

(Patient with high blood pressure)

A successful review

After the treatment my GP explained to me that

my blood pressure was too low because of all thedrugs, so he reduced my dosage because theyrealised I was being overmedicated.


http:///reader/full/events.25http:///reader/full/events.25http:///reader/full/events.25


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Figure 10: GPs responses to the question How frequently are the following issues discussedat the medication review?

%ofG

Ppractices

90

80

70

60

50

40

30

20

10

0 7.3507Tm(9Ptiontl)TjE-.875 -.899 d(0experontcs dTjEMC /TE/igur)e/MCID 11 BDC /q0 0 11 5.5723007 5921.5330048 c

8hardy aever8Don220 t know/ohe r


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Timeliness of medication reviews

There are two indicators relating to medicationreview in the Quality and Outcomes Framework forgeneral practice (QOF), which relate to timeliness.The target is that these should be achieved for80% of patients. These are:

1. A medication review is recorded in the notes inthe preceding 15 months for patients prescribedfour or more repeat medicines. Across all primary

care trusts (PCTs) in England, 95% of practiceson average are meeting the target level for thisindicator (see figure 11).

2. A medication review is recorded in the notesin the preceding 15 months for patients beingprescribed repeat medicines. Across all PCTs inEngland, 97% of GP practices are meeting thetarget level for this indicator.

Although the great majority of practices are meetingthe level required in the QOF, it has generoustimescales and thresholds. Furthermore, the QOFdefinition of a medication review is closely related to

the more limited prescription review often takingplace without the patient and focusing on adjustingprescriptions.

Our survey showed that performance seemsconsiderably better than that set out by the QOF,with 57-63% of GP practices, on average, conducting

a medication review within the first month ofdischarge from hospital for those patients aged 65or more on high risk drugs (see figure 12). The

survey shows that about 75% of practices reviewthe medication for these patients within six monthsof discharge.

Figure 11: Percentage of GP practices where medication review is recorded in the notes in thepreceding 15 months for all patients prescribed four or more repeat medicines

100

90

80

70

60

50

40

30

20

10

0

%ofGPpractices

All PCTs

Source: QOF in 2007/08



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Figure 12: If a patient aged 65 or older has been discharged from hospital with one or moreof the following drug groups, how soon is their medication typically reviewed?

70

60

50

40

30

20

10

0

%ofGPpractices

1 month

NSAIDS

Anti-platelets

Diuretics

1-3 months 3-6 months 6-12 months Dont know

Policies, protocols, and monitoring

The NPC recommends that a medication reviewstrategy should prioritise patients for review, and

sets out a number of triggers for identifying whena review should be undertaken.

The majority (10 out of 12) of the PCTs we visitedprovided GP practices with some form of writtenguidance for medication review. In nine out of these

10 PCTs, we found evidence of prioritising patientsfor review, on the basis of either population group,condition or type of medicine. In five PCTs, cleartimescales were additionally provided for when a

review should be undertaken for priority groups for example, patients over 75 who are taking fouror more medicines should be reviewed at least everysix months.

Most of the PCTs (eight out of 12) we visitedwere monitoring medication review, however

six of these relied on the QOF process to do so.

The data provided by the QOF process is limitedand does not cover whether reviews are meetingagreed quality standards, nor will it address whetherprioritised patients are receiving reviews at therequired frequency. Only one PCT monitored boththe timeliness and quality of medication reviews.

In summary, the majority of practices were carryingout the essential elements of medication review, anda number were exceeding the QOF requirements interms of frequency of reviews. PCTs had establishedpolicies and prioritised patient groups for reviews,and a number were monitoring the frequency ofmedication review, at least in terms of the QOFrequirements. PCTs should also set expectations for,and monitor the quality (content and outcome) of

reviews. The QOF requirements should be tightenedto drive improvement, consider other nationalguidance and reflect what is already being donein the better GP practices.



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6 Supporting patients with their medication

After returning home, some patients do not alwaystake their medicines in the way they should. Thisnon-compliance remains a considerable cause ofmedication error.26 Approximately half of older peopledo not take their medicine as agreed.27This coststhe NHS between 100 million to 200 million peryear in wasted medicine.28, 29 However, this cost maybe far higher when you take into account the knock-

on costs from increased demands for healthcare ifand when someones health deteriorates as a result.26

Patients may fail to follow their recommendedmedication regimen due to difficulties in

understanding instructions, forgetfulness, or theirbeliefs and preferences particularly if medicineshave side effects.26, 30 People that we interviewedwere able to identify some barriers to compliancewith prescribed medication (see box C).

Box C: Barriers to complying withmedicine regimens reported by patients

Lifestyle issues: for example, one patient

with high blood pressure who was addictedto alcohol.

Confusion on possible side effects.

Uncertainty about how long to take themedication for.

Failure of systems to help patientsremember to take their medicine.

Difficulties collecting prescriptions.

It is particularly important that patients are givenclear information about the purpose of their medicineand possible side effects. Despite this, nationalsurvey results show that between 1134% of peopledischarged from hospital said that they were not

given enough information about the purpose of theirmedicine (see figure 13). Five of the 18 patients weinterviewed told us that they were not being givenadequate information by the healthcare professionalsat the hospital, and six sought additional informationfrom other sources. This was because they felt theyhad not received adequate information about theirmedication or professionals used language that they

did not understand.

As discussed in the last chapter, medication reviewsprovide a forum for patients to discuss any concernsthey might have and to reach an agreement overtheir current and future treatment. However, theNational Prescribing Centre recently reported thatlittle progress had been made in adopting a morepatient-centred approach to medication review.31

When we surveyed GP practices in the primary caretrusts (PCTs) we visited, it became apparent that

patients are often not present during reviews. Only55% of practices said that patients are presentduring medication review most of the time, afurther 36% said they were present some of thetime, and 5% hardly ever.

http:///reader/full/error.26http:///reader/full/error.26http:///reader/full/agreed.27http:///reader/full/agreed.27http:///reader/full/medicine.28http:///reader/full/medicine.28http:///reader/full/result.26http:///reader/full/result.26http:///reader/full/effects.26http:///reader/full/effects.26http:///reader/full/review.31http:///reader/full/review.31http:///reader/full/error.26http:///reader/full/agreed.27http:///reader/full/medicine.28http:///reader/full/result.26http:///reader/full/effects.26http:///reader/full/review.31


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Figure 13: The percentage of patients in all PCTs that said they were not given enough

%ofG

Psachifai2(c)6sgh


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Box D: Patients experiences of being giveninformation on medication

You had to ask questions because all they told

you was the bare minimum, like you have to takethis one and then you ask, well why, what doesit do? (Patient with kidney failure)

The nurses might mumble something to youabout what theyre giving you, but theyre sobusy you feel you cannot ask them. So they justsay that you had a stroke or something and thatyou need to take medicine and thats it. It canbe a little nerve-wracking.

(Patient who had a stroke)

Knowing that the heart is the most importantorgan, it should have been explained what themedicine is for, unless youre one of these peoplewho actually likes reading about the medicines.

(Patient with an irregular heartbeat)

As well as the doctor sitting down with me andgoing through each of the medicines, he alsogave me a chart to take home with me which

had each of the medicines on it and said whatdosage I should have been taking, when to takeit, and what potential side effects might be.


The pharmacist technician explained all about themedication and why they did the ECG and bloodtests. They told me what I had to avoid when I wastaking the Warfarin, like I mustnt drink cranberry

juice. I thought the way they explained it to mewas very good.


Sometimes the GPs are so busy that they tellyou to go on the internet for more information.

Its good for the things that you dont necessarilythink to ask the GP for example, when to takeit. My GP told me to read the information sheetin the pack but that information is not always soclear and I dont understand all of it. Google tellsyou everything in a laymans language.


I was telling a friend that I was taking Warfarinand he tells me thats what they give to rats tokill them. So I wanted to check that out andGoogled it. It reassured me somewhat.


Im an inquisitive person so had several chatswith my GP [about the anti-depressant] and havegone on the internet. I go to the manufacturerswebsite, I look at case studies of people that are

taking it, and any news items about it thesekinds of drugs are always in the news.

(Patient with mental health problems)

Community (high street) pharmacies

If they apply and are subsequently accredited,community pharmacies may carry out medicines usereviews (MURs). These are designed to check how wella patient is following their medication regimen, assistthe patient to take their medicine, and identify issues

such as side effects that might limit adherence.

32

Someof the patients we interviewed have experiencedMUR and spoke highly of the service (see box E).

However, take-up of this approach has been slow:33, 7

not all community pharmacies are accredited toprovide this service, and the number of accreditedpharmacies varies greatly by PCT (see figure 14).

And as it is a national scheme, PCTs do notcommission pharmacies to provide the service.However, PCTs do have a role to play in identifyingsuitable patients for review, based on an assessment

of local need.8

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Although the majority of PCTs we visited (10 out of12) had prioritised groups for a MUR (see table 3),only two out of 10 were able to provide evidencethat they had carried out any needs assessment tounderpin this. Furthermore, community pharmaciesare not currently required to follow PCT priorities,but have regard to them.

Box E: A patients experience of medicines

use review[The chemist] took me into a little room; it

was the first time that it happened and theymake sure you know what tablets youre takingand why. I didnt really need it but its niceto think that theyre thinking like that nowI can go to two people if I need any help my GP and the chemist.


Case study 9: Concordance services fromthird sector

Calderdale PCT commissions a home fromhospital service from Age Concern. The charityprovides practical support for the patientdischarged from hospital and works closelywith ward staff and community matrons inthe discharge process. Staff of the agencyescalate medication issues to the communitynurses. The service is part of a multi-agencyprogramme for healthy ageing and the PCTscommissioning strategy.

Figure 14: Percentage of community pharmacies accredited to provide medicines use reviewswithin PCTs in England

%ofcommunitypharmacies

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10

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All PCTs

Source: General Pharmaceutical Services in 2007/08



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Table 3: PCTs identification of priority groups for a medicines use review

Priority group PCT PCT PCT PCT PCT PCT PCT PCT PCT PCT PCT PCT1 2 3 4 5 6 7 8 9 10 11 12

Did not prioritise Prioritised but did notspecify patient groups

Long-term conditions Patients taking 4+ medicines Care home residents Complex medication regime Patients discharged withinthe last 3 months

Patients aged 65+

Monitoring patients adherence to

medicines regimen at a PCT level

The National Institute for Health and ClinicalExcellence recommends that healthcare professionalsshould assess levels of adherence to identify whichpatients require further support. One way in whichthis can be achieved is through reviewing the recordsof prescription re-ordering, pharmacy patient

medication records and the return of unusedmedicines.26

All of the PCTs assessed had mechanisms in placeto pick up compliance issues for particular groupsof patients. However, some mechanisms weremore robust than others. Two PCTs relied solelyon individual medication reviews to detect over-or under-usage of medication. Other mechanismsincluded audit, including monitoring of repeatprescribing, and reviews of concordance with specificmedicines; reviewing the quantity of medicines taken

and quantity ordered; reviewing prescribing data

through ePact and retrospective case note review; and

reviewing community pharmacy patient medicationrecords. In a number of cases, it was not alwaysclear whether and how this information was collatedfor analysing particular trends among populationgroups at PCT level. PCTs monitoring of MURs carriedout by community pharmacies was limited to the

number that are completed: community pharmaciesare not obliged to report the outcomes of MURsto PCTs unless an enhanced service has beencommissioned from them.

Far more effective communication with patients

is needed to ensure that they understand theirmedicines. Acute trusts and GPs need to ensure theyprovide better information to people about theirprescriptions, and spend more time talking to patients

about adherence to medication regimens. There arevarious professionals involved in the patient pathwaywho can provide this information and support patientsto take their medicines, and PCTs should evaluate thepharmacist and nursing resources available acrosstheir practices and the community, and target themon the practices and the patients most in need.

e t
http:///reader/full/medicines.26http:///reader/full/medicines.26http:///reader/full/medicines.26


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Between January and December 2008, 863,691incidents were reported to the National Patient SafetyAgency (NPSA) from across all aspects of NHS-fundedcare 9% of which related to medicine management.4

A study of 18,000 patients admitted to two largehospitals showed that 6.5% of admissions were theresult of harm from medicines, with approximately

two-thirds of these thought to be preventable.8

Based on this study, adverse drug reactions are


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Figure 16: Proportion of practices that have undertaken a minimum of 12 significant eventreviews in the past three years

%ofGPpractices

100

90

80

70

60

50

40

30

20

10

0

Source: QOF in 2007/08

In a similar vein, as part of the Quality and OutcomesFramework, GPs are required to complete a minimum

of 12 significant event audits (SEAs), relating to carethey have provided, in three years. SEAs are carriedout when there has been a significant occurrence which is analysed to ascertain what can be learntabout the overall quality of care and to indicatechanges that might lead to future improvements.37

The number of SEAs required is low, but a numberof GP surgeries in some PCTs still do not meet the

requirement (see figure 16). Across England, 657(7.8%) of practices do not meet this requirement.Furthermore, a recent study found that the quality

of completed SEAs was variable.38

All PCTs

All of the PCTs we visited had developed initiativesto encourage GPs to report incidents and share

learning. However, only four of the 12 PCTs wevisited provided evidence that they were usingNPSA quarterly feedback reports to benchmarktheir reporting rates against others. It is concerningthat four of the PCTs we visited did not provideany evidence to suggest that figures for medicationerrors were systematically collated, analysed andbenchmarked against neighbouring trusts.

http:///reader/full/improvements%E4%AE%B37http:///reader/full/improvements%E4%AE%B37http:///reader/full/variable.38http:///reader/full/variable.38http:///reader/full/improvements%E4%AE%B37http:///reader/full/variable.38


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Analysing and reporting trends,and putting in place improvements

Across the PCTs we visited, despite discussion ofmedication incidents having taken place, there waspatchy evidence that these had been analysed fortrends, or that changes to practice had been madeas a result of learning (see figure 17). For example,

seven of the 12 PCTs we assessed did not provide anyevidence of analysing the SEAs for trends and themes.

The NPSA recommends that a medicines managementreport should be produced and presented to a trustsboard on an annual basis. At a minimum, this shouldcontain levels of incident reporting and a summaryof resulting learning points. Five out of the 12 PCTshad produced annual (or more frequent) medicinesmanagement reports. However, of these five, only two

contained information on the number of medicationincidents reported over the preceding year.

Only one PCT could present evidence that it hadtaken action to improve medicines management as aresult of learning from its own incidents. In this case,GPs were reporting a number of dispensing errors froma particular pharmacy, which led to an investigationand local improvements. Four additional PCTs wereable to demonstrate that action had been taken in

response to either an NPSA alert or some other formof monitoring activity.

Case study 10

One PCT disseminates learning from medicinesincidents through protected learning time

for GPs. It also undertook a comprehensivereview of the organisations incident reportingarrangements, intending to raise awareness ofreporting and to identify good practice. Thereview referred to, and built upon, the bestpractice guidanceSeven steps to patient safety

for primary care, produced by the NPSA.

A second PCT had implemented a greencard scheme a process designed to gather

feedback from healthcare professionals on theirexperiences of care across the interface betweenprimary and secondary care. Among other things,this allowed for additional data to be collectedon incidents involving late and inaccuratedischarge summaries.

In another PCT, we were informed that themain acute trust provider fed back learningpoints arising from incidents, through its own

reporting system, to the PCT, including GPsand community pharmacists.



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Figure 17: PCTs reporting and response to medication incidents

NumberofPCTs

12

10

8

6

4

2

0

Promote reporting Analysis Dissemination Areas for improvement

Incident

reporting

policy

Newsletter

Training

Monitoring

committee

SEA

monitoring

NPSA

alerts

NPSA

feedback

reports

Learning

pointsvia

newsletter

From

incident

From

alert/audit

Learning

point

identified

The safety of medicines management cannot be

improved if incidents and errors are not reported.The culture of reporting incidents and errors by GPsto PCTs needs to improve, and the PCTs we visitedwere attempting to improve reporting and sharingof learning. However, a number of PCTs were notanalysing the incident or significant event audit dataavailable to them, few were reporting incidents tothe board, and only one had implemented learningfrom its incidents, which is a wasted opportunity.

Such actions will not lead practices to believe thatreporting incidents is worthwhile.



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Conclusion

The management of medicines when a patient isdischarged is fundamental to pro-ent 2l5s5 2l5s5 2l2-i549.7248Hh


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It is very important that GPs capture and report moreinformation about when care goes wrong: the levelsof incident reporting from practices is low, and anumber of GP surgeries across PCTs still do not meetthe requirement to carry out significant event audits.

There is considerable variation in the resourcesavailable to PCTs to ensure the safety of patientsacross the discharge pathway, and current provisionhas not generally arisen or been targeted as a plannedresponse to need. For example, pharmacists can have

a key role in driving improvement, but there is greatvariation in the level of support from pharmacists indifferent PCTs, and also in how pharmacists are used.Some PCTs focus their pharmacists more on directpatient care; some focus pharmacists on value-formoney issues (such as prescription of generic drugs)rather than safety issues. PCTs need to benchmarkthe level of their pharmacist resource against others,and target pharmacist time on the patients at greatestrisk. They should also compare the type of worktheir pharmacists and their medicines management

teams carry out.

Monitoring care and drivingimprovement

The review looked at PCTs roles in monitoring careand driving improvement across this care pathway.There are a number areas where PCT monitoring andcontract management, governance and targeting of

resources need to improve.

It is essential that PCTs hold GP contractors and acutetrusts more effectively to account on how they shareinformation when a patient is admitted and dischargedfrom hospital: they must set clear expectations ofboth acute trusts and GPs, setting out requirementsby varying acute trust contracts, and taking theopportunity to set requirements for primary carewhen commissioning new services. They need toestablish systematic monitoring and strengthen

contract management in order to ensure that theinformation shared regularly includes the key factsthat are needed to ensure care is safe, and that

patients receive discharge letters as set out in theNHS constitution.

The extent to which learning from monitoring hadtranslated into evidenced improvements in care waspoor, with monitoring (particularly for QOF purposes)often an end in itself. PCTs were not making effectiveuse of information already locally available, to improvecare. PCT structures need to prioritise medicinesmanagement more highly, given its potentiallysignificant impact on patients and on efficiency.

They need a stronger focus on setting action plansand driving improvement based on local learning.

This study highlights the potential of national systemssuch as the QOF and the electronic patient record.QOF is clearly a useful tool that enables PCTs togather information on performance from practices a number of PCTs in our study relied heavily on thatmonitoring information. However, there is potential forQOF to more effectively help PCTs drive improvement.The QOF requirements that relate to this medicines

care pathway appear to set the bar quite low,with the majority of practices across PCTs meetingrequirements. QOF indicators should be tightenedto take other national guidance on medicinesmanagement into account, cover quality as well astiming issues and reflect what is already being donein the better GP practices. This will enable moreeffective benchmarking between practices andincentivise further improvement.

IT systems have the potential to significantly improve

communication between acute trusts and GPs. Themovement towards standardised electronic dischargesummaries and the summary care record, for useacross different settings, is to be encouraged.

This study highlights the potential for error whenpatients move from one care setting to another,and the importance of good information transferand good checking systems, to minimise risks. Allorganisations involved in providing, commissioning,regulating, and setting standards for care, need to

pay particular attention to these interface issues,to ensure that care is safe.



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RecommendationsPrimary care trusts should:

Work with GPs to agree the use of standardreferral forms, including a specification for theinformation that GPs will provide to local acutetrusts when a patient is admitted, taking accountof the guidance from the National PrescribingCentre. This should cover elective and emergencyadmissions, and set out timeframes for theprovision of this information. They should then

audit the use of this form, and whether timeframesare met, holding practices to account.

Work with GPs to clarify their expectations of GP

practices, in relation to reconciliation, medicationreview and repeat prescribing. These should bein line with national guidance and cover thequality of processes (for example, the elementsof medication review that are completed) as wellas their timeliness.

Make far better use of the information they alreadyhave on the performance of their GPs in relation tomedicines management. This includes informationon the quality of referrals (information on electivereferrals should be readily available in electronicformat from practices), information from National

Reporting and Learning System (NRLS) feedbackreports, local audits and QOF. All this informationcan be used to focus local improvement activity,through benchmarking activity, discussion inpractice visits and in discussions about contracts.

SEAs and incident reports should be used topromote learning across the PCT.

Ensure that contracts with acute trusts set out therequirements and quality markers for both the

timeliness and content of discharge summaries.Information on diagnosis, changes to medicationand the reason for them must be included. Theyshould put in place contract variations to set thisin place at the earliest opportunity, includingincentives through the commissioning for higher

quality and innovation (CQUIN) system andpenalties for poor contract performance.

Review and set up better monitoring systemsto ensure that acute trusts are meeting theircontractual obligations regarding the content andtimeliness of discharge summaries and letters. Theyshould do this by collecting feedback from practices,through snapshot or continuous monitoring.

Evaluate the level of pharmacist support availableto them, and how this resource is currently beingused, where possible benchmarking against otherPCTs. They should ensure that their employed

pharmacists and medicines management teamfocus on medicines management after discharge,to improve patient safety and efficiency. Such anevaluation should include:

- Understanding how pharmacists and techniciansemployed by PCTs and GP practices are currentlydeployed, in terms of their location and type ofwork (for example, focus on increasing genericprescribing as compared to focus on medicinesmanagement after discharge).

- A pharmaceutical needs assessment of theirlocality, to identify practices with the greatestdemand for medication review, and support forelderly patients to comply with their medication.

- Shifting and, where possible, increasing theirpharmacist resource to provide more direct careto high-risk patients (for example medicinereviews), and to work with practices to improvetheir performance in this area and providefeedback to PCTs.

- The level of medicine use reviews (MURs)

carried out by community (high street)pharmacies, how these are targeted, andgetting better feedback on outcomes whenreviews are carried out.

To ensure that information is shared moreeffectively, PCTs should develop patient-heldsystems (for example, green bag schemes), andshould press for the early introduction of localintegrated electronic referral and discharge systems.

Ensure that acute trusts, GPs and communitypharmacies share information within theframework set out in the NHS Confidentiality



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Code of Practice. This sets out that informationcan be shared between all those working withinand under contract to the NHS, for the purposesof delivering healthcare.

GPs should:

Ensure that they carry out a higher proportionof medication reviews with the patient present,so that they can discuss the patients experienceof taking the medicines.

Share learning, by recording instances when themedicines pathway goes wrong, and reportingthem to their PCTs and the National PatientSafety Agency. This should include any issuesrelating to discharge summaries and incidents

relating to the care they provide themselves.

Community pharmacies should:

Report instances of prescribing error to PCTs sothat lessons are learned and the safety and qualityof patient care is improved.

Ensure that the categories of patients identifiedby their local PCTs are offered a MUR serviceconsultation.

Acute trusts should:

Ensure that all their clinicians are aware of theirobligations with regard to admissions and discharge

arrangements. In particular, communicating withpatients about their medicines, providing dischargeletters to patients, and completing discharge

summaries for GPs on time and to include fullinformation on medication changes.

Provide objective information to PCTs regardingthe extent to which information from GPs isincomplete or late, for both emergency andnon-emergency referrals, to drive improvement.

Review their medicines management arrangements

in readiness for the introduction of registrationwith the Care Quality Commission this appliesto all organisations providing healthcare, in both

the NHS and independent sector. They shouldpay particular attention to the requirements ofregulation 11 (outcome 8) as described in our

consultation document Guidance about compliancewith the Health and Social Care Act 2008(Registration Requirements) Regulations 2009.

National bodies

Aspects of the National Programme for IT (NPfIT)will bring about considerable improvement in thecommunication of medicines-related informationacross organisational boundaries for all patientsand types of admission. The Department of Health

should ensure that practitioners use aspects ofthe NPfIT that enable electronic communicationbetween primary and secondary care, in particular,the summary care record (SCR) and where possibleaccelerate its use across different care settings.

NHS Connecting for Health should ensure that all

healthcare practitioners involved in patient careare able to record necessary information on SCR,so that other practitioners may have access toreliable information when needed.

The Department of Health should modifythe Pharmaceutical Services (Advanced andEnhanced Services) Directions 2005, to ensurethat pharmacies are required to follow a PCTsnotification regarding categories of patients whobenefit from MUR services, rather than simplyhaving regard to them. The related proposals inthe recent pharmacy White Paper, Pharmacy inEngland, Building on strengths delivering thefuture in this respect are helpful and should beintroduced as soon as possible.

The great majority of GP practices are meetingand exceeding the QOF target for some medicinesindicators. NHS employers and the GeneralPractitioners Committee should review the

targets and indicators that relate to this carepathway, to set more stretching objectives thatallow better discrimination and benchmarking,and that take account of national guidance andbest practice, when QOF is reviewed in 2011/12.They should also set out more stretchingexpectations of a medication review, to includepatient involvement, and set new measures ofquality (rather than measures of timeliness).



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Appendix A: Methodology

Background


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Characteristics of the PCTs visited

We visited a variety of PCTs with different social-economic description and varied level of performancein the quality of care category of the annual healthcheck 2007/08.

PCTs visited Region Population Annual health ONS area

served check 2008 classification

quality rating

Calderdale PCT North 200,421 Good Centres with industry

Central Lancashire PCT North 438,711 Fair Prospering small town

Coventry PCT Central 322,770 Fair Centres with industry

Kirklees PCT North 391,969 Fair Centres with industry

Lewisham PCTLondon and

257,420 Fair London cosmopolitanSouth East

Middlesbrough PCT North 144,105 Excellent Industrial hinterlands

North East LincolnshireNorth 163,551 Fair Manufacturing town

Care Trust Plus

Plymouth PCT South West 250,298 Fair Regional centres

South East Essex PCT Cen

Documents

Managing Patients Medicines After Discharge From Hospital