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The Care Landscape in the NHS is undergoing a seismic shift as the number of people over 60 years of age is expected to reach 18.5 million by 2025. Advances in healthcare may be helping people to live longer than ever before but the reality is that many are burdened by long-term medical conditions.
By their early 60s, over 60 per cent of people will have been diagnosed with at least one long-term condition – a figure that rises to around 75 per cent by the age of 80 years of age. Change is clearly needed as the NHS faces up to one of the biggest challenges of this or any other generation.
One response to this has been the creation of sustainability and transformation partnerships [STPs] and accountable care organisations [ACOs]. Together, these and other NHS initiatives to improve service provision look set to become key drivers for the improvement of healthcare in older people.
STPs will form the basis for place-based planning and commissioning of services until March 2021 and encompass all areas of NHS spending in England. Accountable care systems (ACSs) and ACOs are a further step forward from STPs towards full integration of health and social care services and funding.
An ACS is often described as an evolved version of a STP, potentially covering a subset of STP geography where there is local collective responsibility for population health and resources. This facilitates increased local freedom and autonomy over the operation of local health systems and the funds that resource them. An ACO is where the commissioners in that area have a contract with a single organisation for the great majority of health and care services and for population health.
Robbie Turner, Royal Pharmaceutical Society director for England, has called for greater involvement of pharmacists in STPs, both at the planning and implementation stage. Engaging with pharmacy early will allow STPs to reap maximum benefit from the value that pharmacists can provide now and the opportunities for better quality they can offer in the future, he says.
“Making best use of medicines should be a key aim of all STPs, as they are one of the biggest investments in any STP budget. By improving the use of medicines across the health economy, there is substantial evidence that care is improved and costs are reduced. Pharmacists are also a resource to support workforce transformation. Significant benefits are already being seen in workplaces [with pharmacists] as diverse as emergency departments, general practice and care homes.”
Key areas for pharmacy intervention in older people’s healthcare under the umbrella of a STP could include:
Social care reforms, as well as proving a political hot potato, remain a key consideration in the overall picture of healthcare for older people and an important part of STPs. According to a recent report by the Health Foundation think-tank, social care must sit at the epicentre of any and all reforms aimed at improving older people’s health.
“The visible squeeze on NHS funding has added a powerful urgency to local plans to reform health and care services known as STPs… to think collectively about how to respond to the challenges of a growing and ageing population,” says the report.
“The plans contain ambitious proposals to close the gap between demand and available funding by improving the prevention of ill health; making more efficient use of hospital and specialist care; and by delivering care, when possible, closer to people’s homes.
“Successful implementation of these plans will require a robust social care sector. Social care is essential for people to lead as independent a life as possible, and ensure they can be moved out of hospital safely and quickly.”
There is clear scope for pharmacy’s role to overlap with some elements of social care for the elderly. Pharmacy support is particularly valuable when it comes to helping frail, vulnerable and older people to live independently.
Key services that pharmacy can offer in this area include:
Another important initiative is ‘Getting It Right First Time’ (GIRFT), which aims to improve the quality of care within the NHS by reducing unwarranted variations, bringing efficiencies and improving patient outcomes. Estimates suggest that the NHS could save £100 million if GIRFT methodology was adopted across the 140 NHS trusts.
GIRFT principles align closely with community pharmacy’s ‘making every contact count’ approach. Every encounter with an older person presents an opportunity to implement small but positive steps to improve their overall medication experience. For example, this could include ensuring that the dosage is optimal, asking about any side-effects, answering any questions the patient may have and taking positive steps to encourage adherence.
The likelihood of experiencing bladder weakness increases as a person gets older, says Donna Wilson, TENA training and brand manager. “As people age, medication and conditions such as diabetes or neurodegenerative diseases can affect the commonality of bladder weakness.”
With this is mind, a full range of bladder weakness products should be displayed in community pharmacies and teams should take time getting to know the needs of each patient so they can provide the best advice, she says.
Building on their existing remit as healthy living ambassadors, pharmacists can play a pivotal role in achieving one of the key aims of STPs – promoting good self-care and preventing ill health. Key responsibilities within the pharmacy remit include:
Pharmacists can further expand their role in older people’s healthcare by offering support and advice to other healthcare groups regarding the way medicines are used. This could include, for example, training for social care workers to ensure appropriate medicines administration and early detection of adverse effects, or working with care home staff to ensure regulations regarding safe storage and disposal of medicines are met.
Person-centred care for older people recognises that their values and needs are individual even though their long-term conditions or health problems may be similar. “The attitudes and behaviours of pharmacy professionals can have an impact on patient outcomes, both positive and negative,” says Age UK.
“Understanding the individual needs and concerns of older people is key in delivering person-centred care, a core element of the new standards.”
Examples of person-centred care in real-life community pharmacy practice include:
In tailoring pharmacy provision to meet the needs of elderly patients, it is also important to adapt communications to ensure pharmacy services and support remain fully accessible to customers who are not online. Recent data from Age UK suggests there are still 4.2 million people aged 65 years or over who have never used the internet.
Another key area for pharmacy is supporting patients with dementia and engaging with their family and carers. Age UK recommends ensuring that the pharmacy “is accessible to older people, especially those living with dementia, by providing a welcoming environment, a clear layout and having dementiafriendly trained staff ”.
In residential care, several STPs across England are already seeing the positive effects of pharmacy integration in the review and support of the estimated 405,000 care home residents. Particular challenges in this patient population include inappropriate medicines use, with an estimated £24m lost every year due to medicines wastage in care homes in England alone.
According to the RPS, “pharmacists, as part of the multidisciplinary team, should assume overall responsibility for medicines and their use in care homes. This will result in significant benefits to care home residents, care home providers and the NHS.
Pharmacists, as experts in medicines, can play a significant role in reducing the use of unnecessary and sometimes harmful drugs, particularly through regular reviews of the efficacy and safety of medicines taken by care home residents.”
The RPS estimates that cost savings of around £3m per STP could be achieved if a pharmacist-led clinical medicines review service was commissioned and implemented. This equates to total savings to the NHS of £135m (£65m from adjustment to current medications and £70m from reduced hospital admissions).
Merck Consumer Health’s WE100 initiative aims to help older people stay healthy and remain more active members of society for longer. The initiative has highlighted five risk factors for ill health among older people: loneliness, social exclusion, social isolation, poor diet and low physical activity.
As part of the initiative, an e-learning module for pharmacy teams has been produced. ‘Promoting long healthy lives: the role of the pharmacy’ can be found at: pharmacymagazine.co.uk/promoting-long-healthylives-the-role-of-pharmacy.
There is clear scope for pharmacy to overlap with elements of social care for the elderly