Introduction to the New Medicine Service

On October 1 this year the New Medicine Service (NMS) will be launched in England. Before you can provide the NMS, you must complete a self-assessment of readiness to demonstrate that you have the skills and knowledge necessary to deliver the NMS. You will need to be able to answer ‘yes' to all the questions listed below. C+D have produced a series of learning modules which will enable to get ready to deliver the NMS.

Are you eligible to provide the service?

• Are you accredited to provide Medicines Use Reviews (MURs)?

Do you understand the purpose and background of the service?

• Do you know why the service is being commissioned?
• Do you understand the evidence behind the service?

Do you understand the aims and intended outcomes of the service?

• • Do you understand the aim of the service to support patients taking a new medicine?
• • Do you understand what outcomes are required when providing this service?

Do you understand the service specification and how to deliver it effectively?

• •    Do you understand the service and how to provide it?
• •    Do you fully understand all aspects of the service?
• •    Are you competent in the clinical areas covered by the service?

You must fully understand the following aspects of the service:

• Recruitment/referral from another healthcare professional.
• Eligible clinical conditions/medicines.
• Opportunities to offer relevant healthy lifestyle advice.
• Obtaining and recording consent.
• Method of undertaking the intervention - face to face or telephone appointment.
• Intervention process - semi structured interview and next steps.
• Arranging the follow up appointment.
• Follow up - advice and support, next steps and action to be taken if you cannot contact the patient.
• Appropriate referral to the GP at the intervention and follow up stages.
• Record keeping for the pharmacy and reporting to the PCT (or successor organisation).

Have you considered the necessary communications that are required in order to provide the service?

• •    Have you reflected on your communication skills?
• •    Have you considered how you will communicate with pharmacy staff, patients and other local healthcare professionals?

What is the new medicine service?

• Do you know what the NMS is and where it fits into the community pharmacy contractual framework?
• Do you understand how the NMS is funded?

The NMS is one of the changes to the community pharmacy contractual framework that have been agreed between the NHS Employers organisation and the PSNC.  

The NMS is aimed at patients who have been prescribed a new medicine, and will provide support to these patients in order to maximise the benefits of the medicine that they have been prescribed.

The NMS is based on research that shows that an early intervention by a pharmacist can help to improve a patient's adherence to their medicines and reduce their use of other NHS resources. You can start delivering the NMS from 1st October 2011.

The other changes to the contractual framework are the requirement that at least 50 per cent of MURs must be performed on three agreed national target groups and changes to the clinical governance requirements.

By delivering the NMS, you have an opportunity to demonstrate the valuable contribution that community pharmacy can make to patient care by supporting people with long term medical conditions. The NMS is currently funded until the end of 2013, however funding is unlikely to be extended beyond this if there is a low uptake of providing this service, or if pharmacy cannot demonstrate that their interventions have a beneficial impact on patient care.

Funding for the NMS

Up to £55m will be made available for the NMS in both 2011/12 and 2012/13. From October 2011 to March 2012, the funding structure for NMS will be made up of a combination of a one-off fixed implementation payment and target payments (linked to prescription volume).

Each community pharmacy delivering the service will have access to an implementation payment of £750. The implementation payment will be the same for all pharmacies, regardless of prescription volume.  This payment will help with set up, training associated with delivering the service, data collection and publicity costs. To obtain their implementation payment, the community pharmacy must certify that the NMS has been delivered a minimum of 6 times prior to the 31 March 2012. 

The implementation payment can be claimed by pharmacy contractors once they have met certain conditions. The claim must be made to the NHS Business Services Authority (NHS BSA) using the NMS Implementation Payment Claim Form. The final date for submitting this claim to the NHS BSA is 5 April 2012.

You can download the NMS Implementation Payment Claim Form here.

The NHS BSA will make target payments to pharmacy contractors based on their declaration of the number of completed NMS in a month. The FP34C submission document has been revised by the NHS BSA and from October 2011 will contain a section where the number of NMS completed in the month can be declared. The NHS BSA will issue the updated FP34C submission documents to pharmacy contractors.

From October 2011, each pharmacy will also be eligible to receive monthly target payments. The size of the target payment will depend on how many NMS episodes have been completed in relation to the prescription volume of the individual pharmacy. Pharmacies will be paid each month for the highest target they achieve. Each month is considered separately and NMS completions from one month cannot be carried over to improve performance in later months.

From April 2012 to March 2013, the funding structure will comprise of target payments only. As before, the size of the target payment will depend on the number of NMS completions relative to the prescription volume of the individual pharmacy.

For more information on the funding for the NMS, click here.

To work out what your target payments will be each month, you can use the C+D NMS Payment Checker.

Are you eligible to provide the service?

•    Are you accredited to provide Medicines Use Reviews (MURs)?

In order to provide the NMS you must be accredited to provide Medicines Use Reviews (MURs).

If you are not accredited to provide MURS, C+D Training offers an MUR accreditation course, Skills for MURs. To find out more about Skills for MURS, click here.

As a pharmacist, you must complete a self-assessment of readiness form before you can deliver the NMS. A completed copy of this form should be given to the pharmacy contractor at any pharmacies where you provide the NMS.

You can find the self-assessment form on the PSNC website by clicking here.

You can either download and complete the form electronically, or you can print a PDF version of the form and complete by hand. You will also be also to download a pre-populated self-assessment form when you have successfully completed all four modules of the C+D NMS Toolkit.

Pharmacy contractors must ensure that their premises meet the required standard and that all the pharmacists providing the NMS have completed a self-assessment.

In order to deliver the NMS the pharmacy must have a consultation area which is at least at the level required for the provision of the MUR service. There are no exceptions to this requirement.

Information on the national standards that pharmacies must meet can be found here.

Before community pharmacies can begin providing the NMS they must inform the PCT of their intention to do so; this notification must be made using the NMS Pharmacy Contractor Declaration Form.

Do you understand the purpose and background of the service?

•    Do you know why the service is being commissioned?
•    Do you understand the evidence behind the service?
 

In England, about 15 million people have a long-term condition (LTC). Long-term conditions are those conditions that cannot, at present, be cured, but can be controlled by using medicines and other therapies. Although it can be difficult for some people to adjust to life with a long-term condition, there is often a great deal that can be done to manage symptoms and maintain quality of life.

The prescribing of a medicine is one of the most common interventions in healthcare. In England

there were 813.3 million NHS prescriptions dispensed by community pharmacies in 2009-10. The

optimal use of appropriately prescribed medicines is vital to the self-management of most long term conditions. However, reviews conducted across disease states and countries are consistent in estimating that a high proportion of prescribed medicines are not taken as recommended.

This represents a failure to translate the technological benefits of new medicines into health gain for individuals. Sub-optimal medicines use can lead to inadequate management of a long term condition and a cost to the patient, the NHS and society.

Research published in 2004 showed that 10 days after starting a new medicines:

• 7 per cent of patients had completely stopped taking the medicine (completely non-adherent).
• 30 per cent of patients still taking the medicine were non-adherent.
• 45 per cent of non-adherence was intentional (the remainder was unintentional).
• 61 per cent of patients expressed a substantial and sustained need for further information.
• 66 percent of patients still taking their medicine reported at least one problem with it:
• Side effects (50%)
• Concerns about the medication (43%)
• Difficulties with the practical aspects of taking the medication (7%)

Reference

A 2010 report by the Department of Health concluded that around £300 million of drugs are wasted in England alone each year, half of which is unnecessary. The better people understand their condition and its treatment, the more value they will derive from their medical care. These changes are being introduced as part of a national strategy to reduce medicines wastage and reduce the costs of caring for the 17.5m people in this country who have long-term conditions.

Delivering the NMS will support the overall NHS agenda. Quality, Innovation, Productivity and Prevention (QIPP) is a large scale transformational programme for the NHS, involving all NHS staff, clinicians, patients and the voluntary sector. The aim of QIPP is to improve the quality of care the NHS delivers whilst making efficiency savings which will be reinvested in frontline care.

Within QIPP, there are a number of national workstreams designed to support the NHS. One of these workstreams is ‘medicines use and procurement', which looks at efficient use of medicines, best practice in medicines management and how medicines waste and concordance can be improved. Community pharmacy has been identified as having a key role to play in this workstream. Delivering the NMS will contribute to the QIPP agenda by increasing patients adherence to their treatment and reducing medicines wastage.

You can find out more about the QIPP medicines use and procurement by clicking here.

Studies have already shown that pharmacists giving advice to patients receiving a new medicine for a chronic condition significantly improves their adherence to the medicine, and also reduces patient costs. You can read more about these studies using the links below:

Patient-centred advice is effective in improving adherence to medicines.  Clifford S et al. Pharm World Sci 2006;28:165-170

The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines. Elliott R A et al. Pharm World Sci 2008;30:17-23

 The New Medicine Service should:

• Help patients and carers manage newly prescribed medicines for a LTC and make shared decisions about their LTC.

• Recognise the important and expanding role of pharmacists in optimising the use of medicines.
• Increase patient adherence to treatment and consequently reduce medicines wastage and contribute to the Quality, Innovation, Productivity and Prevention (QIPP) agenda.

• Supplement and reinforce information provided by the GP and practice staff to help patients make informed choices about their care.

• Promote multidisciplinary working with the patient's GP practice.
• Link the use of newly prescribed medicines to lifestyle changes or other non-drug interventions to promote well being and promote health in people with LTCs.
• Promote and support self-management of LTCs, and increase access to advice to improve medicines adherence and knowledge of potential side-effects.
• Support integration with LTC services from other providers and provide appropriate signposting and referral to these services.
• Improve pharmacovigilance.
• Through increased adherence to treatment, reduce medicines related hospital admissions and improve quality of life for patients.

One of the main aims of the NMS is to improve patients' adherence to their medicines and reduce their use of other NHS resources.

The NICE definition of adherence is ‘the extent to which the patient's behaviour matches agreed recommendations from the prescriber'.

The terms adherence, compliance and concordance are often used interchangeably but each have different definitions.

Concordance can be described as the involvement of patients along with the prescriber in decision-making to improve patient compliance with medical advice.

Compliance is the extent to which a patient's behaviour matches the prescriber's advice. Both the patient and health care provider affect compliance, and therefore a positive relationship is the most important factor in improving compliance.

The World Health Organisation estimates that only around 50 per cent of patients with chronic conditions in developed countries follow treatment recommendations. It highlights that low rates of adherence to therapies for asthma, diabetes and hypertension are thought to contribute substantially to the human and economic burden of these conditions.

It is therefore clear that non-adherence to appropriately prescribed medicines is a global health problem of major relevance to the NHS. It has been suggested that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.

Non-adherence is often a hidden problem: undisclosed by patients and unrecognised by prescribers. People make decisions about the medicines they are prescribed and whether they are going to take them very soon after being prescribed the new medicine.

Non-adherence falls into two categories:

• Intentional – the patient decides not to follow the treatment recommendations. Reasons for intentional non-adherence include:
  • The patient's health beliefs
  • Concerns about the medicine and possible risks or side effects
  • Uncertainty about why they should take the medicine

• Unintentional – the patient wants to follow the treatment recommendations but has practical problems. Reasons for unintentional non-adherence include:
  • Inappropriate dosage form or device that the patient is unable to take or use
  • Difficulty in opening packets or bottles
  • Forgetfulness

Non-adherence is linked to patients' beliefs and preferences that influence motivation to start and continue treatment, as well as practical factors. It should not be seen as the patient's problem. It often results from an initial failure to agree the prescription fully with the patient or to identify and provide the support that patients need once the medicine has been dispensed.

It is essential that you record any issues identified during your discussion with each patient at both the intervention and follow up stages of the NMS. Issues should be recorded using the following standard descriptors:

1. Patient reports using the medicine as prescribed
2. Patient reports not using the medicine as prescribed
   1. Patient has not started using the medicine
   2. Patient is not using the medicine in line with the directions of the prescriber
   3. Patient reports missing a dose in the past 7 days
3. Patient reports need for more information about the medicine (information needs will be addressed by the pharmacist and recorded)
4. Patient reports side effects
5. Patient reports negative feelings about the medicine (the pharmacist should provide further details about this using a free text box)
6. Patient reports uncertainty on whether the medicine is working
7. Patient reports concern about remembering to take the medicine
8. Other – free text option

You must also record the outcome of your discussion with each patient at both the intervention and follow up stages of the NMS. The outcome should be recorded using the following standard descriptors:

1. ACTION TAKEN / TO BE TAKEN BY THE PHARMACIST

1. Information provided – interactions with other medicines
2. Information provided – why am I using the medicine / what is it for
3. Information provided – how to use the medicine
4. Information provided – correct dose of the medicine
5. Information provided – effects of the medicine on the body / how it works
6. Information provided – why should I take the medicine
7. Information provided – timing of the dose
8. Information provided – interpretation of side effect information
9. Advice provided – reminder strategies to support use of medicine
10. Advice provided – change to timing of doses to support adherence
11. Advice provided – how to manage or minimise side effects
12. Yellow care report submitted to MHRA
13. Reminder chart / MAR chart provided
14. Referral – patient's issues raised with the new medicine need to be considered by the prescriber. The reason(s) for the referral should be captured using the following standard descriptors:
    1. Drug interaction(s)
    2. Potential side effect(s) / adverse drug reaction preventing use of medicine
    3. Patient reports not using medicine any more
    4. Patient reports never having started using medicine
    5. Patient reports difficulty using the medicine
       1. Issue with device
       2. Issue with formulation
    6. Patient reports lack of efficacy
    7. Patient reports problem with dosage regimen
    8. Patient reports unresolved concern about the use of the medicine
    9. Other – free text option
15. Other action – free text option

1. ACTION FOR THE PATIENT TO TAKE
   1. Carry on using medicine as prescribed
   2. Use medicine as agreed during the intervention or follow up
   3. Yellow card report submitted to the MHRA
   4. Other action

REFLECT

What is the New Medicine Service (NMS)? Do you understand the purpose and background of the service? Do you understand the aims and intended outcomes of the service?

PLAN

This article explains what the NMS is and how it will be funded. It looks at the background behind the NMS and the aims and intended outcomes of this new pharmacy service, as well as what you need to do to be able to provide the service.

ACT

Find out more about the NMS from the PSNC website

Read this article and follow the links to gain a better understanding about how the NMS can improve patients' adherence with their medicines.

Download the self-assessment of readiness form from the PSNC website, and start to complete this.

EVALUATION

Do you understand what the NMS is and why it is being introduced? Do you understand what you need to do to be able to provide the NMS?