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Service toolkit: Discharge Medicines Service

Patients transferring from hospital to community settings are at increased risk of medication-related harm, something the Discharge Medicines Service aims to tackle head on.

The NHS Discharge Medicines Service (DMS) aims to reduce medication-related harm associated with discharge from hospital by improving communication between secondary and primary care, and encouraging timely medicines reconciliation.

As an Essential Service under the Community Pharmacy Contractual Framework since February 2021, all community pharmacies in England must provide the DMS. There are three stages to the service:

Provision and background

The following should be undertaken:

  • Reviewing new medication regimen, identifying changes to existing medicines and appropriateness of new items, using as context any test results and issues highlighted by the hospital (such as intentional non-adherence)
  • Any concerns or issues should be resolved and a record kept to facilitate stages 2 and 3
  • Previously ordered prescriptions for the patient should also be checked to see if they are still appropriate, paying particular attention to electronic repeat prescriptions.

The following should be undertaken:

  • Check against details established at stage 1, resolving any discrepancies with the GP practice and keeping an appropriate record to facilitate stage 3.

The following should be undertaken:

  • Confidential discussion to check the patient’s (and/or carer’s) understanding of their medication regimen and any supporting advice and information, with records maintained as appropriate. See panel on opposite page for more information.

The expectation is that all patients referred to the pharmacy will receive all three stages, whether sequentially or in parallel, although there is contingency for only part of the service to be provided (see funding panel). A service checklist has been produced by PSNC (now CPE), plus a separate implementation checklist. 

Over half of hospitals in England were already participating in referral programmes ahead of the DMS launch as part of the Transfer of Care Around Medicines initiative, which this service replaced. 

Research has shown that patients who receive medication support after transfer of care are less likely to be readmitted and community pharmacists have demonstrated their effectiveness in this area. The DMS also has the potential to improve team working and relationships across healthcare systems.

How do referrals work?

NHS trusts are expected to identify patients who will benefit from the DMS and refer accordingly, including – as a minimum – the following information:

  • Patient details including registered GP, and NHS and hospital numbers
  • All medicines being taken on discharge, including name, strength, form, dosing, duration and reason for prescribing
  • Medication changes, including items stopped and dosing alterations, plus rationale
  • Contact details for referring clinician in case of queries.

Local pharmaceutical committees hold details of which NHS trusts issue referrals (or have plans to do so) and the referral method they use. NHS England has made funding available to ICBs to facilitate structured electronic DMS referrals rather than more manual routes such as NHSmail, and set Commissioning for Quality and Innovation (CQUIN) targets to encourage continued engagement.

Patients may also be referred from care homes. Note that a patient provided with a copy of their discharge information cannot trigger provision of the DMS as this is not regarded as a referral from a NHS provider.

Funding and conditions of service

The following fees have been agreed for the service:

  • Set-up fee of £400 (paid in 2021 to all NHS pharmacies in England)
  • A full service fee of £35 for each patient for whom a discharge referral is received
  • Where only part of the service can be provided, each stage attracts a partial payment:
    • Stage 1 - £12
    • Stage 2 - £11
    • Stage 3 - £12.

Note that the conditions under which these can be claimed (broadly: patient uncontactable, moves community pharmacy or withdraws consent, or pharmacy closure means complete service cannot be provided) are detailed in the Drug Tariff with the reason needing to be stated on the claim.

All fees must be claimed through the NHSBSA’s Manage Your Service (MYS) portal, providing summary data on each DMS intervention provided to not only support the claim, but also help evaluate the impact of the service.

All staff involved in providing the DMS must have the necessary knowledge and competence to undertake it safely, and are expected to have read the relevant NHS England guidance and DMS toolkit as a minimum – additional training e.g. from CPPE is available – before completing the DMS Declaration of Competence. Members of the pharmacy team must understand what the service entails (managers may find the CPE DMS briefing document helpful here).

Patient consultation

  • This stage should be conducted in the pharmacy’s consultation room, or by phone or videocall if appropriate
  • Adopt a shared decision-making approach
  • For new medicines: Explore whether the patient can identify them, understands what they are for, and knows how to take them to get the best outcomes. They should also understand any risks associated with the medicines and know what to do if they have concerns about side-effects
  • For all medicines: Check the patient understands how to get the optimum benefit from their medications (e.g. dosage timings) and is aware of any interactions and common side-effects
  • Check there are no barriers to adherence and whether the patient needs any further information to support their new medication regimen
  • Offer to dispose of any medicines that are no longer required to avoid potential confusion and prevent adverse events
  • Other pharmacy services can be provided as part of the DMS consultation if considered beneficial to the patient; for example, the New Medicine Service
  • Notes should be made – as appropriate – on the PMR and elsewhere if needed
  • Information of value to other healthcare professionals (e.g. the patient’s GP or PCN clinical pharmacist) should be communicated in order to support the person’s ongoing care.

Case study: Weldricks Dispensing Hub, Doncaster

Stephen Walls says the Weldricks home delivery and MDS hub in South Yorkshire, where he is senior pharmacist, has received well over 1,000 DMS referrals since the service launched. His top tip is to be alert to anything that could be a referral, keeping in mind that it has to come directly from a NHS provider, such as a hospital, rather than a patient or GP surgery.

“Any discharge communication could be a DMS referral not just through expected platforms such as PharmOutcomes, such as an email or even a phone call from a hospital – in which case we will ask for the information to be confirmed with follow-up documentation,” he says. 

“We also find that we often don’t do the stages sequentially: stage 1 is done immediately, but it often makes sense to check something with the patient before the prescription arrives, so we end up doing stage 3 before stage 2. We have also had many occasions where we haven’t completed all three stages – for example, if the patient is readmitted to hospital – and that’s fine under the service specification.”

The DMS has formalised something we, and many pharmacies, were already doing and, because there is now mandatory minimum information that has to be provided on discharge, it has given us the ability to pin down details of changes in a way that sometimes could be difficult, says Stephen. “It’s been very positive with all three pharmacists here finding it rewarding. We get a lot of interaction with patients and feel we make a real difference through using our clinical skills. 

“Also, because we are a dispensing hub, all our consultations are done over the phone, which patients like. They don’t need to worry about other people perhaps overhearing what they are saying or asking, which might be the case when on a hospital ward. They tend to be comfortable and settled at home, so we can have very open conversations.”

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