Getting ready for the NMS

NMS Toolkit MODULE 2

 

 

A key part of getting ready to deliver the NMS is making sure that you are familiar with the service specification and all aspects of delivering the 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?
•  
• The legal basis for the service is provided by the Secretary of State Directions. A service specification is published alongside the Directions.
• You can find the final service specification for the NMS here.

The PSNC has produced a presentation about the NMS which you can find here.

This presentation provides a useful summary of the NMS, and you can use parts of this presentation when discussing the NMS with your local GP practices and briefing the staff in your pharmacy.

 

This module covers the following aspects of the NMS:

• Involving the pharmacy team
• Communicating with local GP practices
• Patient recruitment
• Eligible clinical conditions and medicines
• Patient engagement
• Patient information leaflet
• Obtaining and recording consent
• Providing healthy lifestyle advice
• Intervention
• Undertaking the intervention
• The intervention process
• Follow up
• Arranging the follow up appointment
• The follow up process
• Appropriate referral to the patient's GP
• Record keeping and reporting

Involving the pharmacy team

All members of the pharmacy team are required to have an appropriate understanding of the NMS.  You could use some of the slides from the presentation that the PSNC has produced about the NMS to explain the NMS to the pharmacy team. You can find this presentation here.

 

When discussing the NMS with the pharmacy team, key points to cover include:

• What the NMS involves.
• The benefits that the NMS can provide to patients.
• The benefits of providing the NMS to the pharmacy.
• The roles that each member of the pharmacy team can play in delivering the NMS.

Although the intervention and follow up consultations must be carried out by a pharmacist, other members of the pharmacy team can play a key role in other aspects of the NMS. Elements of the NMS that could be carried out by other members of the pharmacy team include:

• Promoting the NMS to patients – explaining what the service is and the benefits to patients.
• Recruiting patients for the NMS.
• Identifying suitable patients from the pharmacy PMR.
• Booking appointments for the intervention and follow up consultations.
• Sending reminders to patients to attend their consultations.
• Following up patients who do not attend.

Each pharmacy must have a standard operating procedure (SOP) in place for the NMS. This should detail which members of the pharmacy team are responsible for which elements of the NMS. The NPA has produced a template for an SOP for the NMS which you can download here.

 

Communicating with local GP practices

As part of delivering the NMS, the pharmacy contractor or their representative is required to communicate with local GP practices about the service. This is important as GPs and other prescribers can refer patients to the pharmacy to take part in the NMS.

There may also be occasions during the provision of the NMS when pharmacists will need to refer patients to their GP, where an issue has arisen that cannot be solved by the pharmacist and the patient.

The working group for the NMS has published a short guide for GP practices outlining the changes to the pharmacy contract and a presentation about the NMS. These can be used in discussions with local GPs and their practice teams in these two documents - Briefing for GP practices and Presentation.
 

 

PATIENT RECRUITMENT

 

Patient presents a prescription for a new medicine OR patient referred by GP or other prescriber.

Is the new medicine to manage one of the following long term conditions:

• Asthma or COPD
• Type 2 diabetes
• Antiplatelet / anticoagulant therapy
• Hypertension

 

 

RECRUITMENT OF PATIENTS FOR THE NMS

 

Patients can be recruited for the NMS within the pharmacy when they present a prescription for a new medicine from the list of medicines for eligible conditions.

 

Patients could also be referred to the pharmacy to participate in the NMS by another healthcare professional when they are prescribed a medicine for the first time – this could be a GP or another prescriber. It is essential that you communicate with other local healthcare professionals about the NMS – what the service is and the benefits of the service to patients.

 

 

ELIGIBLE CLINICAL CONDITIONS AND MEDICINES

 

The four therapy areas or conditions selected to be included in the initial rollout of the NMS are:

 

• Asthma and COPD
• Type 2 diabetes
• Antiplatelet/anticoagulant therapy
• Hypertension

 

The medicines selected for inclusion in the NMS are those listed below. You should refer to the current version of the British National Formulary (BNF) in your pharmacy or online at www.bnf.org

 

 

 

Asthma and COPD

 

BNF Reference            BNF Subsection

3.1.1            Adrenoceptor agonists

3.1.2            Antimuscarinic bronchodilators

3.1.3            Theophylline

3.1.4            Compound bronchodilator preparations

3.2            Corticosteroids

3.3            Cromoglicate and related therapy, leukotriene receptor antagonists and phosphodiesterase type-4 inhibitors

 

Type 2 diabetes

 

BNF Reference            BNF Subsection

6.1.1.1            Short acting insulins *

6.1.1.2            Intermediate and long acting insulins *

6.1.2            Antidiabetic drugs

* Where the community pharmacist can determine that the medicine has been newly prescribed for a patient with type 2 diabetes

 

 

Antiplatelet/anticoagulant therapy

 

BNF Reference            BNF Subsection

2.8.2            Oral anticoagulants

2.9            Antiplatelet drugs

 

Hypertension

 

BNF Reference            BNF Subsection

2.2.1            Thiazides and related diuretics

2.4            Beta-adrenoceptor blocking drugs *

2.5.1            Vasodilator antihypertensive drugs

2.5.2            Centrally acting antihypertensive drugs

2.5.4            Alpha-adrenoceptor blocking drugs *

2.5.5            Drugs affecting the rennin-angiotensin system *

2.6.2            Calcium-channel blockers *

* Where the community pharmacist can determine that the medicine has been newly prescribed for a patient with hypertension

 

It is essential that you are competent in the clinical areas covered by the NMS. To support you, C+D will be publishing the Tools for NMS + MUR series of articles during September and October.

 

Asthma and COPD

 

• Update 1587: Corticosteroid inhalers
• MURs for patients with respiratory conditions

 

See also:

• Update 1572: Inhaler technique (May 21, 2011)
• Your role in COPD and Ten things you need to know: COPD (April 16, 2011)
• Update 1515: The management of COPD (February 27, 2010)
• Update 1514: Latest treatment options for managing asthma (February 20, 2010)
• Update 1513: Is it asthma or COPD? (February 13, 2010)

 

Type 2 diabetes

 

Coming up in the Tools for NMS + MUR series:

• Update 1589: Starting drugs for diabetes (due to be published October 8)
• Update 1590: Diabetic retinopathy (due to be published October 15)

 

See also:

• Update 1571: Insulin therapy (May 14, 2011)
• Update 1559: Non-alcoholic fatty liver disease (February 12, 2011)
• Ten things you need to know: Diabetes standards (April 16, 2011)

 

Antiplatelet/anticoagulant therapy

 

• Update 1586: Anticoagulants and antiplatelets (September 17)
• MURs for patients taking high-risk medicines (September 17)
• Update 1588: Gastrointestinal bleeds (due to be published October 1)

 

See also:

• Update 1562: Preventing venous thromboembolism (March 5, 2011)
• Update 1519: Managing patients on warfarin (April 27, 2010)

 

Hypertension

 

Coming up in the Tools for NMS + MUR series:

• MURs for patients taking high-risk medicines (September 17)
• Update 1591: Hypertension (due to be published October 22)

 

See also:

• Update 1564: The metabolic syndrome 1 (March 19, 2011)
• Update 1565: The metabolic syndrome 2 (March 26, 2011)
• Ten things you need to know about preventing CVD through diet (August 24, 2010)

 

The NPA have produced a series of ‘mini guides to conditions'. You can find these at www.npa.co.uk/NMS

 

 

 

PATIENT ENGAGEMENT

 

• Ask if this is the first time the patient has been prescribed this medicine.
• Provide advice about the medicine and its use.
• Provide opportunistic advice on healthy living.
• Provide information about the NMS.

 

• Does the patient agree to take part in the NMS?
• Has the patient signed a consent form?

If YES, agree and make an appointment for the NMS intervention.

 

PATIENT INFORMATION LEAFLET

 

Each pharmacy should have a patient information leaflet for the NMS, which describes the service and provides information about the patient consent arrangements. The PSNC and NHS Employers have developed text for use in a patient leaflet on the NMS – pharmacy contractors will be able to print their own leaflets using the standard wording as appropriate. The use of this standard wording is not a mandatory service requirement.

 

You can download the text for a patient leaflet from the PSNC website

www.psnc.org.uk

 

 

OBTAINING AND RECORDING CONSENT

 

The outline service specification for the NMS says that consent needs to be obtained from patients in order that information may be shared with their GP as necessary and with the Primary Care Trust (PCT) or successor organisation as part of clinical audit. Information will also need to be shared with the Primary Care Trust (PCT) and the NHS Business Services Authority to verify that the service has been delivered by the pharmacy as part of the post payment verification process.

 

You can find out more information on the consent requirements here.

You can download a template consent form here.

You can also download a template consent form and add your pharmacy logo from the PSNC website.

An alternative consent form which allows the patient's ethnicity to be recorded can be downloaded here.

 

 

PROVIDING HEALTHY LIFESTYLE ADVICE

 

Healthy living advice should be provided to patients participating in the NMS at each stage of the service – recruitment, intervention and follow up

 

Advice should cover the following areas where appropriate

 

• Diet and nutrition
• Smoking
• Physical activity
• Alcohol
• Sexual health
• Weight management

 

The C+D training course Well Being is a useful resource that can support you and your pharmacy staff when providing healthy lifestyle advice to your patients. You can find out more about this training course here.

 

 

INTERVENTION

 

Usually 7 – 14 days after patient engagement.

Confirm the patient understands the NMS and has consented to their information being shared.

Semi-structured interview:

• Assess adherence.
• Identify any problems and the need for further information or support.
• Provide advice and support.

Provide opportunistic advice on healthy living.

 

UNDERTAKING THE INTERVENTION – FACE TO FACE OR TELEPHONE APPOINTMENT?

 

The NMS intervention should take place 7 to 14 days after patient engagement.

 

Although ideally done face-to-face, NMS consultations can be performed over the phone. This is often more convenient for patients who work full-time or have family to look after, and for those patients who are house-bound. As with regular appointments, a specific time should be set for the phone consultation to take place. If you are unable to contact the patient at that pre-agreed time, at least one subsequent attempt must be made to do so.

 

This type of consultation may be convenient for many patients but it has a number of disadvantages including the lack of visual clues and non-verbal feedback. You, and the patient, will need to ensure that external disturbances are kept to a minimum. Before calling, make sure you are in a private area of the pharmacy where the conversation cannot be overheard, as confidentiality is still essential, and make sure you also have all the information you need to hand.

 

 

THE INTERVENTION PROCESS

 

The intervention process should take the form of a semi-structured interview to:

• Assess adherence
• Identify any problems and the need for further information or support
• Provide advice and support
• Provide opportunistic advice on healthy living

 

An interview schedule has been developed to support you during the intervention consultation.

 

Interview schedule questions for the NMS intervention

 

1. Have you had the chance to start taking your new medicine yet?
2. How are you getting on with it?
3. Are you having any problems with your new medicine, or concerns about taking it?
4. Do you think it is working? (Prompt: is this different from what you were expecting?)
5. Do you think you are getting any side effects or unexplained effects?
6. People often miss doses of their medicines, for a wide range of reasons. Have you missed any doses of your new medicine, or changed when you take it? (Prompt: When did you last miss a dose?)
7. Do you have anything else you would like to know about your new medicine or is there anything you would like me to go over again?

 

You can access the interview schedule with notes here.

There are three potential outcomes from the intervention consultation:

 

 

Is the patient adhering to their medicine regimen?

AGREE FOLLOW UP

 

Has a problem been identified that you can resolve?

AGREE SOLUTION AND ARRANGE FOLLOW UP

 

Has a problem been identified that you cannot resolve?

END OF SERVICE AND REFER THE PATIENT TO THEIR GP

 

You must keep a record of the intervention discussion and the outcome.

 

Interventions to increase adherence

(NICE clinical guideline 76, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence)

 

• If a patient is non-adherent with their medicines you should discuss this and try to establish if this is because of their beliefs or concerns (intentional non-adherence) or practical issues that they have (unintentional non-adherence).
• Address any beliefs and concerns that the patient has about their medicines.
• Interventions to overcome practical issues can be suggested if there is a specific need. Examples include:
• Suggesting that patients record their medicine-taking.
• Encouraging patients to monitor their condition.
• Simplifying the dosing regimen.
• Using alternative packaging.
• Using a multi-compartment medicines system.
• If side effects are a problem:
• Discuss the benefits, side effects and long term effects and how the patient would like to deal with side effects.
• Consider adjusting the dosage, switching to another medicine, and other strategies such as changing the timing of medicines.
• Ask if prescription costs are a problem and consider options for reducing costs.

 

 

 

 

FOLLOW UP

 

Usually 14 – 21 days after the intervention

• Reassess adherence and identify any problems.
• Provide advice and further support.
• Provide opportunistic advice on healthy living.

 

 

ARRANGING THE FOLLOW UP APPOINTMENT

 

The follow up appointment should be arranged between 14 and 21 days after the intervention.

 

 

THE FOLLOW UP PROCESS

 

The follow up consultation should also take the form of a semi-structured interview to:

• Reassess adherence and identify any problems
• Provide advice and further support
• Provide opportunistic advice on healthy living

 

An interview schedule has been developed to support you during the follow up consultation.

 

1. How have you been getting on with your new medicine since we last spoke? (Prompt: are you still taking it?)
2. Last time we spoke, you mentioned a few issues you'd been having with your new medicine. Shall we go through each of these and see how you're getting on?
3.  A) The first issue you mentioned was [refer to specific issue] – is that correct?

B) Did you try [the advice / solution recommended at the previous contact] to help with this issue?

1. Did you try anything else?
2. Did this help? (Prompt: how did it help?)
3. Is this still a problem or concern?

Repeat Questions 3-6 for each issue that the patient discussed at the Intervention stage

1. Have there been any other problems/concerns with your new medicine since we last spoke?
2. People often miss taking doses of their medicines, for a wide range of reasons. Since we last spoke, have you missed any doses of your new medicine, or changed when you take it? (Prompt: when did you last miss a dose?)

 

You can access the interview schedule with notes here.

 

There are two potential outcomes from the follow up consultation:

 

Is the patient adhering to their medicine regimen?

END OF NMS SERVICE

 

Has a problem been identified?

REFER PATIENT TO THE PRESCRIBER FOR REVIEW

 

You must keep a record of the follow up discussion and the outcome.

 

 

APPROPRIATE REFERRAL TO THE PATIENTS GP AT THE INTERVENTION AND FOLLOW UP STAGES

 

When you need to refer a patient to their GP, you should you the appropriate feedback form. You can download a patient referral form from the PSNC website here. The referral form should be sent to the GP practice and you should advise the patient that the practice will contact them where necessary. The NMS module in PharmaBase will also allow you to produce patient referral forms where appropriate.

 

If a referral is urgently required, it is best practice to phone the GP practice, and follow this up by sending a copy of the NMS Feedback form to the GP practice.

 

NEW MEDICINES SERVICE - WHEN IS IT COMPLETE?

 

Click here to see a range of NMS scenarios and when they can be classed as 'completed'.

 

RECORD KEEPING FOR THE PHARMACY AND REPORTING

 

Your pharmacy must keep records for each patient who participates in the NMS. Record keeping will support the delivery of the NMS as well as facilitating audit of the service.

 

Full details of the record keeping requirements for the NMS can be found here.

 

It is important that you keep accurate records of all the NMS consultations that you complete, at both the intervention and follow up stages of the service. This will ensure that you are meeting the requirements of the service, conducting the minimum number of consultations each month as well as enabling you to claim payment at the end of each month.

 

The NMS Reporting Template (for electronic submission to PCTs) can be downloaded from the PSNC website.

 

You can choose how you wish to keep records for the NMS – you can use either a paper-based or computer system. Whichever method you choose to use to keep your records of the NMS, you must ensure that you consider and take into account information governance requirements.

 

The NMS PharmaBase module will allow you to record the mandatory NMS data for each patient. If you do not have access to a computer in the consultation area, or do not wish to use it during your discussion with the patient, the following NMS Worksheets can be used to record notes during the Intervention and Follow up stages of the service and code the discussion with the patient; the coded data can then be recorded on PharmaBase.

 

NMS Intervention worksheet

NMS Follow up worksheet

 

The NMS module in PharmaBase is now available to pharmacy contractors. The module supports the NMS service and includes the following functions:

 

1. Patient registration
2. Printing consent forms
3. Scheduling interventions and follow ups using a pharmacy calendar
4. Printing a patient information leaflet and appointment reminder
5. Creating a task list of patient reminders to be provided prior to appointments
6. Recording the mandatory dataset for the intervention and follow up
7. Creating NMS Feedback forms to refer patients back to their GP practice
8. An ‘NMS dashboard' to allow the pharmacy team to keep track of their NMS activity during the month
9. Creating the quarterly reports for PCTs

 

You may find the following links useful when you are starting to use the NMS PharmaBase module:

 

Pharmabase quick start guide

PharmaBase NMS module presentation

 

The use of the NMS module in Pharmabase will also create a large dataset on the NMS which may be used as part of the academic evaluation of the service. Collation of this data is essential if community pharmacy is to be able to make the case for the ongoing commissioning of the service. Further details on the NMS module will be provided soon.

 

REFLECT

Do you understand the service specification for the New Medicine Service (NMS)? Do you understand how the service should be provided? Are you competent in all the clinical areas covered by the service?

 

PLAN

This article looks at the service specification for the NMS and the different aspects of providing the service. It contains links to other useful resources that will support you when you are getting ready to provide the NMS.

 

ACT

Read this article and follow the links to gain a better understanding of how the NMS should be delivered and what you need to do for each aspect of the service.

Read the service specification for the NMS

Update your knowledge of the clinical areas covered by the NMS and the medicines included in the NMS.

Refresh your knowledge of healthy living advice that you can provide to patients as part of the NMS.

Read the interview schedule for the NMS from the PSNC website

Read NICE clinical guideline 76, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence

Familiarise yourself with the record keeping and reporting requirements for the NMS.

 

 

EVALUTION

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