Mr Walls is a centralised delivery and monitored dosage system (MDS) hub pharmacist for Weldricks in Doncaster.

Last November, he picked up the patient safety award for the hub’s implementation of the DMS, at an Association of Independent Multiple pharmacies (AIMp) event that celebrated the achievements of its members.

Though the award came as “a little bit of a shock”, he tells C+D, he was pleased to win it as “pharmacy hasn't had a lot to shout about over the pandemic year”.

His dispensing hub has incorporated the service “into a very busy pharmacy workload” and received close to 400 referrals within the first year of implementing the DMS.

Mr Walls spoke with C+D last month about how he and his team are making a success of the hospital to pharmacy referral service.

“If some of my colleagues are out there waiting for a headed letter that says 'DMS referral' on it, they may be overlooking the opportunity to provide the service,” he says.

Ashley Cowen, sales and operations director at AAH, handing Mr Walls his trophy at the AIMp event in November 2021

 

 

When did you start providing the service?

The service has just been live for a year now, from February 15, 2021. But I don't think we saw any referrals until April.

 

So, it took a couple months to get going?

Reading through the literature, I think we were prepared for it, especially for the 12 referrals a year that it was expected that each individual pharmacy would get.

The service was pushed through quite quickly and it took a lot of people by surprise. I think a lot of people hadn't quite realised the intricacies of the fine print, on both sides: on the people writing the referral and us receiving it as well. We suddenly realised that the actual wording means that receipt of hospital discharge documents from a hospital trust via secure electronic means, must be treated as a referral under the DMS.

Where I work, half of it is domestic deliveries and the other half is MDSs, and we have about 3,000 MDS clients. So, every time one of those patients is admitted to hospital, the hospital will send us their discharge documents via NHS mail. Therefore, we very quickly realised that had to be treated as a DMS. That's why we're pushing about 400 DMS referrals within the first year of launch.

"We quickly realised that a lot of our MDS patients should be treated under the DMS"

 

That's a much higher number than estimated, right?

Yes. But there are many community pharmacies that haven't seen a single one, because they do not operate in the same way that we do. So, whereas some community pharmacies are feeling that the service doesn't apply to them, and it seems to be something that's been put into the contract as an essential service that they're never going to do, we're doing one every day. If not a new one, we're dealing with one we received the previous day and processing it. It’s a part of our everyday business now.

 

Can you walk me through the process of what goes on when you receive the referral? How long does it take to turn it around? And what's the process of supporting a patient with their medication?

The way we do it is slightly different in Doncaster. Stage one, receiving the documents, is the same no matter where you are. We're lucky that our local hospital will normally send the patient home with seven-day supply of medication. So, we automatically have a little bit of wriggle room to sort out ongoing care. 

We legally have to do stage one – the reconciliation of the hospital documents, checking them against what we had the patient on, the new medication that they're on, any changes, any discrepancies, any interactions that we feel have been overlooked – within 72 hours, that's part of the terms of service. But we will do it same day. It will be done in a couple of hours as soon as we get one, because the clock does start ticking. If you've got seven days to organise it, we want to get it done as quickly as possible.

So, stage one we do ASAP, as soon as we get it. And then that way, it allows dialogue either over the phone or emails with the hospital – "We had them on digoxin when they went in, but it doesn't appear to be on their discharge notes", and "it's not listed in the medication that's been stopped, has it been stopped? Is it an oversight?" – that sort of thing. It really has led to better dialogue and relations with our local hospitals. We've always worked with them very closely, but that sort of dialogue and conversation has definitely helped us to work together. They feel equally as comfortable contacting us as we do them.

Although the service is ‘stage one’, ‘stage two’, ‘stage three’, it's also not a linear service. There are times where stage three – the phone call to the client to check that they understand that changes and to answer any questions that they've got – we tend to do that after stage one. Because when the hospital sends them home with seven days’ worth of medication, they also send us 28 days’ worth of scripts to make up their first MDS tray for them, which we do. But stage two is checking the prescription that comes from their GP. So, they get the script from the hospital, which is going to be in line with the hospital discharge note because they've written it.

"I haven't had a single person that hasn't appreciated the phone call from our team"

So, the reason for stage two, reconciling the first script, is to check for any discrepancies, pick up anything that is missing between the hospital and their GP surgery, to pick up any loose ends there. We won't actually get a prescription for those people that have been discharged from their GP for five weeks afterwards, which then seems a little late to be ringing people checking how they feel about their new medication. So, we choose to do stage three, a phone call, to check how they're getting on, particularly if they're a new client to MDS trays and haven't used them before.

Hopefully, the hospital has included why those changes have been made on the discharge notes. They are supposed to, but it doesn't always happen. But if not, you have an educated guess and discuss with the patient why they were in hospital, and you can make an estimate as to why those medication changes have been made. And just reassure them of any side effects that are more common or things to look out for, or the best time of day to be taking them etc. They do appreciate that.

Because we're a DSP – so, we're not open to the public, we're quite a large industrial unit – all our stage three conversations take place over the phone. But a lot of people that are on our MDS trays probably wouldn't be getting out in the community anyway, so they wouldn't have that interaction with a pharmacy. By us phoning them and running through their medication, I haven't had a single person that hasn't appreciated it.

 

So, you've got good feedback from the patients that you're supporting?

They're really positive, really appreciative. Quite often, particularly after a long stay in hospital, as soon as a patient hears: "You're being discharged tomorrow", that's it. They don't listen to the rest of the conversation because they know they're going home. They’re not bothered about changes in their medication, or what's best time to take it. To contact someone a few days later, once they're back in their home environment, and just discuss it with them when they're comfortable, when they're in their own home in their own clothes, a lot of people appreciate someone taking the time to do it with them.

 

It must be a nice feeling knowing patients are receptive and appreciative of the service.

Yes. It's nothing we haven't been doing before, we would always reconcile a hospital discharge document if someone was on an MDS with us. We'd always check the next prescription that we got from the GP. But maybe the only thing we wouldn't have done previously is stage three, to have the phone conversation with the patient. But up until end of 2020, discharge medicine use reviews (MURs) were in place. So that's pretty much what we're doing with that phone call anyway, just going through people's medication, checking that they know what they're doing. I don't think it's anything new. I just think it's kind of a rebranding. And obviously, there's funding attached to it.

We've incorporated it into part of our working life because we have to: it's an essential service, we have to provide it. But I suppose you either build a wall or build a windmill, you go with it, or you fight it. So now we've embraced it and run with it.

 

You said you’ve received around 400 referrals in the first year?

At the last count we were at around 380. Easily one a day, but I think yesterday I got four. It differs; you have quiet days; you have busy days. Usually Fridays, when hospitals are wanting to clear their beds, are busy days.

"You can spend 20 minutes chasing clarification if you haven't got the right direct links to hospital staff"

And has the communication with the hospital been pretty consistent and up to date?

As a general rule, it's fine. The majority of our referrals come from Doncaster Royal Infirmary, and we have very good relationships with them. We have email addresses, phone numbers; if we need to speak to somebody to clarify something, it's done quickly. You're not going through a hospital switch board, finding out what patients were on, speaking to the ward sister who then refers you back to the pharmacist. You can spend 20 minutes chasing clarification on the strength of a medication if you haven't got those sorts of links, but we're thankful that we have. It has been good with the level of communication that we have between us.

 

Do you think there's a reason why it's worked so well, as opposed other pharmacies who are getting very few referrals?

I think it's purely because of the size of our operation, to be honest with you. I would say the number of DMS referrals that we get where it is specifically marked as part of the service are a lot lower than the ones that, as our commissioners say, we must interpret as a DMS. They're definitely fewer, but I don't think they're any less worthwhile by any stretch. 

I've never had a person who was unhappy that I'd call them to check that they were alright and understood the changes in their medication. The service is valuable and I'm perfectly happy to incorporate it into our workload. But I can see why some of my community colleagues feel it's irrelevant to them. I can perfectly understand that.

 

As far as the training that you were required to prep for the service goes, how was that to implement?

It was it was a year ago, but from what I recall, the only actual mandatory training was that you had to familiarise yourself with the NHS toolkit document. There was also a professional development pack. As a company, it was made part of our mandatory training to do it, but it wasn’t mandatory to be able to provide the service. It was enough to get us started.

Then it's the same as anything, if you do it often enough, it just becomes second nature. I think the training was adequate. But I myself, I learn from doing something, I don't learn from reading about it. I'm a practical learner and I think that's maybe where some of the frustration from my colleagues is because they've learnt the theory, but they can't practice it.