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Innovation 'Elevator Pitch':
This project aims to improve patient knowledge and confidence in the correct use of injectable therapies via pharmacy intervention with New Medicines Service (NMS) and Medicines Use Review (MUR).
Overview of Innovation:
It is intended that this work will develop:
  • A framework for both the NMS and MUR consultation for community pharmacists on injectable therapies in diabetes. To include safe administration, safety, including appropriate quantities of insulin adn adherence. 
  • Pharma outcomes will be used to support framework and implementation of project. This will also enable commissioners to understand the quality of the interactions from pharmacy. 
  • Develop an education framework for pharmacists to deliver injectable therapy NMS and MUR.
  • Upskill community pharmacists around the pilot site to deliver patient support for injectable therapies via NMS and MUR.
  • Process map current and future state for MUR service.
  • Measure outcomes to show the value of interventions.
Stage of Development:
Evaluation stage - Representative model or prototype system developed and can be effectively evaluated
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Overview summary:
The project used existing pharmacy interventions, New Medicine Service (NMS) and Medicines Use Reviews (MURs) to improve knowledge and confidence in using the correct injectable therapies for both community pharmacy and patients. Pharmacists attended 2 training events focused on improving knowledge and consultation skills with patients with diabetes who were using injectable therapies. Pharmacists were also introduced to a consultation framework, the Five Star Diabetes Consultation, which became the framework for future patient consultations.  
Challenge identified and actions taken :
It was intended that the project would:
  • Develop an education framework for a community pharmacy consultation on injectable therapies in diabetes  
  • Develop a community pharmacy consultation framework for injectable diabetes therapies
  • Enable community pharmacists in the pilot to deliver patient support for injectable therapies for diabetes via a consultation
  • Measure outcomes to show the value of interventions  
  • Increase confidence of pharmacists in conducting consultations and improve the competence of patients using injectable therapies
  • Foster closer relationships between community pharmacy and general practice
27 community pharmacies and eight general practice surgeries in the Coventry and Rugby CCG participated in the project around the following areas: 

Pharmacy education: An initial engagement meeting was held ito communicate the project. This also provided an insight into the training needs for community pharmacy. Two pharmacy training events were delivered. 

Framework for pharmacy consultation: The project team developed a pharmacy consultation framework, the Five Star Consultation, which provides a guide to pharmacy on how to deliver a patient consultation.

Development of an education framework: A declaration of competence was produced in order to provide a framework for pharmacists to develop and maintain skills.
Impacts / outcomes: 
Project outcomes include: 
  • A pharmacy consultation and education framework was written
  • Pharmacists who attended the training reported an increase in confidence pre- to post-training as a consequence of the training, with 77% likely to complete and NMS/MUR consultation as a result of the training.  
  • During May and June 2017, 50 consultations on injectable therapy were completed as a result of the training.
  • An improvement in pharmacists’ ability to deliver consultations for diabetes injectable medication.  
  • Pharmacist reported a significant increase in their confidence to deliver consultation for patients taking injectable diabetes therapies. Figure 1: illustrates the impact which the project has had on improving the ability of community pharmacy to deliver NMS/MUR.
  • Pharmacists felt the face to face training was excellent, ‘the best’ one the pharmacist had ever attended. 
Videos of the 2 start and 5 star consultation along with an engagement video are available upon request. 
Which local or national clinical or policy priorities does this innovation address:
Five Year Forward View and providing support to long term conditions
Supporting quote for the innovation from key stakeholders:
“As barriers are broken down across the NHS and boundaries become blurred, patient pathways for injecting become all the more important and this needs to begin with better support for Advanced people to manage their own health. 

“Much greater pharmacist support to people with long-term conditions should be the ultimate aim, but only as one element of a patient’s care and alongside measures to improve public health. It needs to be delivered in a way that is integrated both in terms of NHS and public health systems.”

Community Pharmacy Clinical Review The Kings Fund 

"Diabetes is a fast growing health threat facing our nation.  Over 3 million people are living with diabetes in England.  If their condition is managed they can live longer and fuller lives. The cost of diabetes to the NHS will continue to rise.  In order to ontrol these costs, the Department and the NHS must take significant action to improve prevention and treatment for diabetes in the next couple of years"

Diabetes United Kingdom - State of the Nation 2016
 
Plans for the future:
This programme highlighted the benefits of involving Community Pharmacists in supporting people with long term conditions and the future could involve a much wider cohort of conditions to support.  The Health Living Pharmacies start to underpin this approach and are evolving across the region at pace and scale. 
Tips for adoption:
Conclusions and lessons learned:
  • The project identified a lack of integration between general practice and community pharmacy, with little or no incentive to integrate community pharmacy into general practice. Figure 2 within the case study attached illustrates the current interface between general practice and community pharmacy and an envisioned process.
  • The project team had not anticipated the lack of awareness from primary care of pharmacy NMS and MUR
  • When engaging with general practice it is essential to secure a CCG sponsor who will facilitate engagement from general practice
  • Education and consultation frameworks were developed and can be used for future projects
  • Completing the data recording paperwork by pharmacists was a barrier to data collection owing to other data collection work happening at the same time. This resulted in a lower than expected data return. 
Contact for further information:
NHS England’s (NHSE) West Midlands Pharmacy Local Professional Network, the West Midlands Academic Health Science Network, Coventry and Rugby Clinical Commissioning Group (CCG) and Coventry Local Pharmaceutical Committee, Lilly UK and Novo Nordisk Limited completed a joint working project aimed at improving the outcomes of patients with diabetes who were taking injectable therapies. 

More information can be found in the attached document or by contacting: 

Lucy Chatwin 
lucy.chatwin@wmahsn.org 
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Overview summary:
This initiative aimed to improve understanding of the challenges pharmacies face in the adoption of technology enabled care services (TECS) focussing on efficient medicines utilisation and adherence.  
 
20 pharmacies from North Staffordshire were approached with 17 agreeing and 5 remaining through to completion.  The patient cohort was defined as those with prescriptions for COPD, asthma, diabetes type 2, diuretics, NSAIDs or back pain with protocols developed by the WMAHSN LTC Network.

Further details on the study can be accessed here
Challenge identified and actions taken :
The challenge was how pharmacists might utilise TECS to add value to the delivery of the New Medicine Service (NMS) and Medicines Use Review (MUR) and Prescription Intervention Service at the point of dispensing, in the integrated care of patients. 

The aim was to improve patient convenience, experience and increase understanding of their conditions and thus improve patient participation in self care with subsequent clinical benefits and associated cost benefit in medication usage. 

The project focussed on:
  • Recruitment of community pharmacies then agreeing a Memorandum of Understanding (MoU) detailing expectations under the project.  The MoU included a bursary of £500 for participation in training, identification and recruitment of patients, data capture and evaluation (Appendix 1);
  • Training to pharmacists followed by the licensing of pharmacies for Florence simple telehealth with ongoing on site support from local clinical telehealth facilitators and the Local Pharmaceutical Committee (LPC);
  • Protocols in the specified LTC's providing TECS introduction pathways (Appendix 2)
  • Florence and Manage Your Health aide memoirs
  • Baseline survey of participating pharmacies at project inception and a post participation survey (Appendix 3)
  • Patient feedback on Florence 
  • Patient feedback on the Manage your health app 
Impacts / outcomes: 
This was designed and delivered as a discovery project. As a consequence, the impacts and outcomes are limited to learning.  Based on critical reflection and consideration of the evaluation and surveys completed as project actions the project team identified where the project could have been more impactful in terms of retaining the participation of those pharmacies that expressed an interest. Then better retention and participation rates could have secured higher incidence of TECS adoption from the cohort of patients covered by the project.  These conclusions and the resulting recommendations recognise the small numbers involved and that further exemplar projects would be required before at scale roll out could be considered.
 
17 community pharmacies expressed an interest and progressed to training and receipt of the MoU and were deemed to be fit to participate – five of these accredited pharmacies went on to complete the project.  The number of interactions (contacts with patients) reached 88 realising 93 incidences of patients becoming engaged with or interested in TECS (patients could elect for either / both Florence and the Manage Your Health app).  The demographics of the patients reached during the project shows 5.7% (5) to be children (<20years old) and 19.3% (17) to be older adults (> 59 years old).  With an even distribution of participation by gender (42M / 46F) and by condition the willingness of patients to consider TECS when introduced by the pharmacist could be considered high as the 88 patients – based on participation data collected at the pharmacy – converted or stated an intention to convert to simple telehealth or an app.
 
The conversion rate supported the hypothesis that community pharmacies are in a position to introduce and generate adoption of TECS during their participation in a single patient focussed care plan.  However, if the project was to be replicated more attention would be required in the recruitment and preparation of the participating community pharmacy teams.
 
  • The MoU in itself was helpful for recording and agreeing the basis of participation but it could have contained more on the objectives and outcomes expected from participating pharmacies;
  • Experience showed that while the strategic involvement of the pharmacist(s) was fundamental to placing the project in context for the pharmacy the pharmacy staff (including counter staff) were better placed to manage the interactions with patients on the practicalities of enrolling with Florence or the downloading and then utilisation of the Manage Your Health app;
  • Training for the pharmacy team would be better delivered out of hours or by remote delivery (e.g. skype) as the day to day operations of the pharmacy made the delivery of training during opening hours problematic with frequent breaks in the training being required and on some occasions the training could not be completed within the time slot allotted for it;
  • The community pharmacies without exception had sufficient private space in which to interact with patients but they would benefit from more mobile IT to improve the content and value of the interactions e.g. by demonstrating TECS on an iPad to an interested customer;
  • In project planning, more could be done in helping community pharmacies understand patient flows and when this type of activity might best be done – during the project more than 40% of activity took place on a Friday with 20% on a Wednesday;
  • Survey at inception showed a healthy degree of scepticism on behalf of pharmacists as to the demand TECS would make on their colleagues but that TECS was an important and legitimate part of the pharmacy role. They agreed that the introduction of TECS into patient care was desirable and likely to improve their outcomes – the post participation survey illustrated that pharmacist time with patients was the key factor in patients adopting TECS (within the constraints of the project offer) and that TECS should be part of the pharmacy menu of services; and
  • Future initiatives would benefit from a much closer link with the outcome responsibilities placed on community pharmacies for NMS, MUR and the prescription intervention service as the project did not provide any causal link from the pharmacy activity to medication utilisation, adherence of cost effectiveness in prescribing.
 
It is worth noting that the demographics of the patient cohort recruited suggested significant levels of participation by older age groups generally considered to be ‘digitally excluded’. However, in the post participation telephone survey – albeit for small numbers – pharmacists reported patients not having a mobile phone (telehealth) or a smart phone or tablet (Manage Your Health app) as only occasional incidental occurrences.
Which local or national clinical or policy priorities does this innovation address:
Care and Quality Health and Well Being Health Education England’s Building a Digital Ready Workforce. https://hee.nhs.uk/our-work/developing-our-workforce/building-digital-re...
Supporting quote for the innovation from key stakeholders:
During the post participation survey the following comments were noted based on conversations with the participating pharmacists and pharmacy teams:
 
“Patients felt that the info on the Apps was reliable rather than just looking on the internet”
 
“I can see the benefits of using technology ………… new launches always take time, cannot expect new service to be instantly successful.  Once established and embedded expect it to be more successful”
 
“It would be good to have a self-service portal (in the pharmacy) i.e. tablet/lap top for patients to use to become familiar/comfortable”
 
“Pharmacist would have liked more telephone support”
 
“Delivering healthcare technology is easier than pharmacists believe …..”
 
“(The) Service is easy to sign up to but (I) just haven’t got the time. …….. apologies for lack of participation but owners not prepared to commit to staffing required”
 
“Try to link patients’ info and needs with the pharmacy from GPs.  Create better awareness – leaflets, posters, media and promotional material – poster/leaflet to encourage patient/customers and make aware
 
Please note:  These references are from notes taken during the post participation telephone survey and have been presented out of the context of that survey and the individual discussions that took place and, in some instances, represent multiple responses on the same or similar themes.
Plans for the future:
The learning from the initiative was substantial and consequently there would need to be significant redesign before it was run again.  There was much to commend the project recognising that it ran for a short time and yet the take up or conversion rate to the TECs offer was in itself significant and therefore of value in the context of what the project hoped to achieve.
 
The case for another initiative involving pharmacies and pharmacy teams is strong providing there is a greater emphasis placed on how their investment of time in introducing TECs impacts positively on pharmacy relative and important outcomes.  There is a valid argument for developing and introducing a currency for this work that is of value to pharmacies.
 
Since this initiative, Healthy Living Champions have been introduced into all pharmacies in Northern Staffordshire and it would make good sense to have them involved in this type of initiative in the future. Healthy Living Champions have a role to promote Public Health messages.
Tips for adoption:
The initiative brought home the importance of securing senior pharmacy managers support for the community pharmacists’ wider role, recognising that they need protected time to be effective.

Community pharmacists are motivated to use their knowledge to help patients, and projects like this one should capitalise on this.

If locations, such as pharmacies, are to be the focal point of introducing TECs to patients and the public promotion and support material for use on site is important.
 
Much is assumed about the digital awareness of professionals and employees in health and health care services – the initiative identified that greater digital awareness created by other programmes may help the future recruitment of willing participants from within clinical and healthcare teams and from the public and patients.
Contact for further information:
Tania Cork
Chief Operating Officer
North Staffs & Stoke LPC
taniacork@northstaffslpc.co.uk 
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Overview summary:
Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. 
Challenge identified and actions taken :
Evidence shows that 5-8% of unplanned admissions are due to medication issues and when patients are prescribed a new medicine, a third are non-adherent after 10 days and 30-50% of medicines are not taken as intended.  However on-going community pharmacist support has been shown to improve medicines adherence. 
In an attempt to improve medicine adherence, improve patient safety and improve patient outcomes, Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. The AHSN NENC supported the development and implementation of this framework across the region. The project is now gaining traction nationally.
Impacts / outcomes: 
Through active communication and participation in the national AHSN Medicines Optimisation network this work has been established as an exemplar model of communication between secondary care and community pharmacy.
  • Seven acute trusts are now making referrals to a potential 504 community pharmacies for follow up support with their medication after discharge from hospital;
  • Over 750 patients have received follow up support since the initiation of this service in July 2014;
  • Community pharmacists have reported nearly 90% of patients had a better understanding of their medicines as a result of their consultation and would be therefore more likely to adhere to their prescribed medicine regimes.
  • The project team have won two prestigious HSJ awards in 2015, in the categories for  ‘Enhancing Care by Sharing Data and Information’ and ' Most effective adoption and diffusion of best practice'
  • The work has directly contributed to the production of a Hospital referral to community pharmacy toolkit, distributed nationally by the Royal Pharmaceutical Society;
  • The Transfer of Care work initiated in the AHSN NENC has attracted national interest and has been adopted in a number of areas throughout the country.  
Which local or national clinical or policy priorities does this innovation address:
Health and well-being; patient experience.
Supporting quote for the innovation from key stakeholders:
At the HSJ Awards the project was described by judges as a "beautiful, simple solution that works...developed by clinical leaders who saw potential in existing functionality". The judges went on to praise how the Trust “genuinely demonstrated adoption and diffusion of innovative practice across the region” and that "Every hospital should be doing this."
Plans for the future:
  • Outcome measures collected through PharmOutcomes will help inform the direction and development of the project.
  • Further rollout of the project nationally will continue
  • The e-referral system is being further developed to involve GPs, doctors and nurses as well as pharmacists.
  • Development of Trust systems will facilitate the auto-population of the referral form, further speeding up the process.
  • The evidence base will be further enhanced through publication to the BMJ of research being undertaken by academics at Durham and Manchester Universities.
Tips for adoption:
Trust staff need the buy-in of community pharmacies.
The NENC region uses PharmOutcomes for E-referral and it helps if systems are complementary across regions but this is not a pre-requisite for the methodology to be adopted across Trusts.
Contact for further information:
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