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Innovative pharmacy service delivery in ophthalmology

PHARMACY PRACTICE

Moorfields eye hospital has established innovative service models of care through its satellite pharmacies, teaching events and engaging with primary care

 

Amani El-Bushra
Associate Chief Pharmacist – Clinical Services,
Governance and Medication Safety Officer

Edward Hindle
Lead Antimicrobial Pharmacist
Sarah Thomas
Lead Pharmacist for Satellite Services and Contracts
Moorfields Eye Hospital, London, UK

 

Moorfields is one of the world’s leading eye hospitals, providing excellence in eye care, research and education for over 200 years. Together with our academic partners at the UCL Institute of Ophthalmology, we continue to be at the forefront of innovative breakthroughs in eye and vision research and developments.


Single-specialty networked model
Moorfields operates a networked model of care in a variety of healthcare settings at 32 sites in and around London. Alongside the hospital in central London, other satellite locations are grouped into four separate categories in distinct geographical locations with the aim of providing care closer to the patient’s home: district hubs co-located with general hospital services; local surgical centres; community-based outpatient clinics; and partnership, where Moorfields offers medical and professional support to eye services managed by other organisations.


In December 2016, National Health Service (NHS) England announced £500,000 funding for Moorfields' new care model vanguard. The aim is to explore opportunities and risks associated with running such a model of service and to develop a single specialty networked care toolkit that shares the Trust’s experience and best practices in delivering networked care, sharing learning from other healthcare providers nationally and internationally, and providing support to other organisations that might want to implement a similar model of care with the aim of supporting longer term sustainability and patient benefit across the NHS.


Pharmacy services
We deliver a comprehensive pharmacy service to all clinics, wards, in-patients, theatres and day-case units including those at our satellite locations. Delivering a comprehensive pharmacy service under this networked model with the same high quality of care across such a vast geographical area can be a challenge.


It necessitates complex contracts and agreements at each location taking into account local requirements, patient population and input from over 75 clinical commissioning groups (CCGs).


Outpatient efficiencies
As part of our pharmacy department Five Year Plan, we have built on the role of link pharmacists in order to integrate pharmacy at clinical service levels with support delivered to various services at Moorfields such as Accident and Emergency, glaucoma, medical retina and ocular oncology.


We are also working on standardisation of treatment pathways, improving patient flow in clinics and enhancing their experience by redeployment of pharmacy staff, increasing the number of clinic-based pharmacists and developing the role of non-medical prescribing pharmacists in defined clinical areas, such as uveitis. This is in line with Lord Carter’s recommendations for a more efficient pharmacy service in hospitals and also reinforces the progressively diverse role that pharmacists are playing within the NHS.


Innovative satellite models of service delivery
Moorfields’ pharmacy constantly searches for innovative ways to overcome the challenges of providing a high quality consistent service to all patients across the multi-centre setting, through responding to high-level Trust developments and new satellite openings, providing robust options appraisals for how pharmacy can be provided to new services, and seeking to improve upon existing models.


Learning from models and service applications within other healthcare and non-healthcare organisations, both in the UK and elsewhere is essential, as is responding to local needs and incidents cross-site, and considering political, economic and environmental changes. Examples of how Moorfields has introduced novel models are discussed below.


Service provision from host-site hospital and third party community pharmacies
A pharmacy provision appraisal always seeks the opportunity for a host-site hospital community to provide a stock and dispensing service to Moorfields outpatients and/or theatres and daycare, and there are many considerations taken into account to appraise this provision.


Considerations include discussions around pharmacy registration and staffing, wholesalers dealers licence, Home Office license, provision of resuscitation medicines, medical gases, opening times, location of services relative to the Moorfields unit, key performance indicators for waiting times and stock supplies, procurement, governance, incident reporting, quality audits, formulary processes, any additional provisions to spoke satellites, and ability to maintain the service should activity grow.


If feasible, a service proposal is agreed with associated costings, a service level agreement (SLA) is signed, and is reviewed by both parties periodically. Moorfields leads on setting up the service with the host-site, and provides full training to all host-site staff involved with specialist training at the main Moorfields site, as well as operational guides, resource materials and references. Local Moorfields staff are introduced and also trained to ensure smooth running and relations once the service is set up.


Adopting this methodical and organised approach has enabled Moorfields to lead and collaborate with many host-sites including Croydon Health Services, Lloyds Pharmacy at Croydon Health Services, Northwick Park Hospital, Darent Valley Hospital, and community pharmacies including Chopra’s Pharmacy, Salus Pharmacy, Well-Chem Pharmacy and Woodlands Pharmacy.


Implementation of satellite pharmacies
Moorfields’ first satellite pharmacy model was established at Ealing Hospital several years ago.


At St George’s Hospital, after security risks associated with FP10HNC prescriptions, a Moorfields satellite pharmacy was established in 2013 with a team of three pharmacists providing a full pharmacy service for outpatient clinics, theatres, ward and daycare.


Similarly in 2014, Moorfields appraised existing provision to the Northwick Park Hospital satellite unit, and established a satellite pharmacy within the unit to provide a full service. At all sites, the model changes have significantly improved the running of the service, resulting in better waiting times, enhanced patient experience and staff feedback, and reduced associated risks, ensuring a safe and efficient pharmacy service compared with previous models.


Prescription collection and delivery services
In 2015, as part of service improvement in an established unit using FP10HNCs with no viable host-site service, we evaluated how community models could be adapted for our hospital environment, and adapted the model used by one of our community pharmacy partners.


Under SLA and patient agreement, the Moorfields-trained community pharmacy team collect hospital prescriptions from the clinic daily, dispense and deliver the medicines to the patient’s preferred address either the same day, if urgent, or the following day. The patient is counselled by the clinical team in clinic, and receives a follow-up telephone call from the community pharmacy a few days later to discuss and provide extra counselling if necessary and/or to help identity any issues to the clinical team.


Clinic stock procurement and delivery services
Moorfields has introduced innovative ways to transport stock to its satellite sites. In the absence of a host-site service or satellite pharmacy that procures stocks, robust SLAs have been sought from our community partners to provide a safe and efficient stock ordering and delivery service to Moorfields units in the same locality.


Integrated pharmacy services located within clinic environment
Where the above options are not possible, we explore other novel models to avoid using FP10HNCs and nurse supply of medicines. Currently we are piloting a Moorfields pharmacist integrated within an established busy clinic providing a near-patient and near-clinical staff service via a specialist pharmacy dispensing trolley. The pilot is very successful, significantly reducing clinic and prescription waiting times,
associated risks, and increasing patient experience.


Shared learning and teaching
We have identified the need for more collaboration with providers, commissioners and other healthcare professionals to reduce variation and share learning and good practices relating to medicines optimisation and improving patients’ self-management of long-term conditions.


Clinical governance half-days
The pharmacy team at Moorfields has been a key contributor to clinical governance half-day teaching events. These events are an opportunity for the pharmacy team to present audit findings, feedback on medication incidents, and discuss local prescribing practices with each service. They are also an opportunity to explore how we can collaboratively improve the quality of our services in the future in accordance with local and national agendas.


The pharmacy department has also run a similar clinical governance-inspired half-day event for the whole department to discuss pharmacy-specific issues and explore how we are to deliver our services in the future in accordance with local and national agendas.


Medicines-related education and training
Moorfields pharmacy team has always been at the forefront in providing education and training to other healthcare professionals in areas such as medical induction, medicines awareness and administration of medicines. The aim is to improve compliance with local and national guidance relating to the safe storage, security and handling of medicines, improving prescribing practices, ensuring patient safety, and minimising the risks of incidents and medication errors.


At the latest CQC inspection, the Trust scored an overall good rating with several areas of practice highlighted, such as the safe management of medicines and the good multidisciplinary team working involving staff from a range of specialties.


Collaboration and engagement with primary care
Moorfields pharmacy supports better relationships with primary care providers through improved engagement with CCGs, GPs and community pharmacies. The aim is to provide better ophthalmic education and training to this cohort of staff.


Moorfields pharmacy has led on the delivery of eye health teaching sessions to community pharmacists with the aim of improving responding to symptoms, and has also been involved with the education and training of local GPs through various presentations and provision of information and working collaboratively with local CCGs in order to improve performance, quality, safety and transition of care for our patients.


Joint education and training
The pharmacy team have collaborated with Moorfields doctors, nurses and ophthalmic technicians in various QIPP projects in order to develop medicines-related teaching material, training packages, competencies and assessments for various Moorfields staff groups. We aim to develop IT skills within pharmacy in order to make better use of electronic and software systems and app technologies that can be used to deliver these teaching programmes.


One such example is the uveitis training for ophthalmic technicians where Moorfields pharmacy has contributed to the development of the material used to teach ophthalmic technicians allowing them to better understand and identify the various medicines and eye drops used to treat this condition. This project is still underway and once completed, the agreed training material will also be available for easy access via a mobile, tablet or personal computer.


#KnowYourDrops campaign
Having identified the need for better support to patients with long-term ophthalmic conditions, the #KnowYourDrops campaign was launched by Moorfields pharmacy in summer of 2016. The campaign consists of one-day events at each of our Moorfields sites where the pharmacy team, in collaboration with the International Glaucoma Association, can engage with patients and promote and encourage good eye drop compliance and provide support to patients, carers and staff regarding best techniques for administering eye drops and eye ointments.


Innovation to help meet national agenda
In addition to establishing innovative service models to meet the needs of the organisation, the Pharmacy team also seek innovative ways to help meet national agenda.


Antimicrobial resistance has been high on the national agenda for a number of years. The phenomena have attracted comment from world leaders, international health organisations and prompted the Chief Medical Officer in England to write a children’s book – ‘The Drugs don’t Work’ – a tale set in a future world without antibiotics.


At a local level, across the UK and overseas, antimicrobial pharmacists have been developing strategies to prevent the development of resistance. Such strategies involve conserving current antibiotics through stewardship programmes. Significant amounts of money have been centrally allocated in the UK to improve antimicrobial stewardship in primary and secondary care.


Using technology to adhere to national targets
At Moorfields, much of the national guidance and and associated CQUINs (commissioning for quality and innovation) relating to antimicrobial stewardship does not conveniently fit the model of care provided. The majority of patients who access services at Moorfields are treated as day case procedures. Nevertheless, as a large user of a specific group of antimicrobials, it is important that stewardship is not ‘just on the radar’ but a central focus of prescribing. To this end, Moorfields has enlisted the services of MicroGuide, a platform with which many Trusts in the UK will already be familiar. MicroGuide is a medical app that can be downloaded on a smartphone. Once downloaded, the user has access to their trust antimicrobial guidelines.


The benefits of having instant, free access to the most current guidelines cannot be overstated. This is particularly true for inexperienced prescribers, but also for seniors seeing less routine conditions. The alternative is to attempt to find guidance online, via cumbersome intranets or through out of date paper copies, if available. Time spent searching for guidance can be more effectively used with the patient. Using an app to obtain guidance ensures that recommendations are both up to date and specific to the host organisation. Many trusts make different recommendations for the same condition, taking into account local sensitivity data.


Challenges in implementing novel solutions
Many of the trusts that have uploaded antimicrobial guidelines are general hospitals. Moorfields is one of the first single speciality trusts to make antimicrobial guidance available on an app. This has presented challenges and opportunities. The Moorfields antimicrobial guidelines are the most comprehensive set of recommendations of their type produced by a UK hospital for ophthalmology.


The antimicrobial guidelines are developed by senior consultants from each of the subspecialties and are edited by the antimicrobial pharmacist. The guidelines are updated regularly and reviewed by a consultant microbiologist. For many of the conditions in the Moorfields guideline there are no national guidelines available. Adapting the guidelines for use in an ophthalmic specialty meant that the usual classification of body systems, for example, respiratory, GI, etc, had to be abandoned and headings such as cornea, medical retinal, etc, had to be created. However, being able to browse by ophthalmic subspecialty makes navigation simple.


Evaluation of app technology
Since launching the app, demand for use has been encouraging, peer-to-peer promotion playing an important role. In order to promote the app and its use, in-house posters have been created and events have been organised. A benefit of using the app is that those who run antimicrobial stewardship programmes can see how many times the antimicrobial guidelines are downloaded and accessed. Following launch, there was evidence of use from across the UK, as well as internationally, including Australia - far beyond the central London Moorfields hub.


Trust antimicrobial usage data for the quarter following app launch showed a downward trend in consumption. Identical audits, comparing antimicrobial prescribing with antimicrobial guidelines in high usage areas such as A&E, showed major improvement following the launch of the app. Having senior level buy in from, for example, medical directors also helped focus minds of clinicians, and although the reasons for these improvements in antimicrobial stewardship are multifactorial, the presence of an app is most certainly an important reason.


Conclusions
By applying a robust strategic approach and continually reviewing activity, best models of working practices can be identified, adapted and implemented to best meet the service needs.


The success of the MicroGuide app could lead to future projects to incorporate novel technologies in improving many aspects of clinical care. There is the possibility of whole prescribing guides being made available and the full potential of mobile technology in medicine has not yet been realised.

 

Key points

  • Introducing new ideas and technologies is a good mechanism to involve organisational leaders to drive improvement in practice.
  • Collaborative work is the key to innovation.
  • It is important to review processes and learn from ways of working in other (non-pharmacy) departments and within other National Health Service (NHS) organisations, as well as non-NHS and non-public organisations
  • Education and training is key to ensure improved services.
  • App technology is useful in disseminating guidelines to front-line staff to aid decision making.

 

References

  1. Winter G, Adcock H. Carter review calls for more clinical pharmacists to be deployed by NHS trusts. Pharm J 2016;296(7886):online DOI: 10.1211/PJ.2016.20200670. www.pharmaceutical-journal.com/news-and-analysis/carter-review-calls-for... (accessed April 2017).
  2. Carter P. An independent report for the Department of Health, 2016. Operational Productivity and performance in England NHS acute hospitals: Unwarranted variations. www.hfma.org.uk/docs/default- source/our-networks/healthcare-costing-for-value-institute/external -resources/operational_productivity_a (accessed April 2017).
  3. Moorfields Eye Hospital NHS Foundation Trust. Know Your Drops [online]. www.moorfields.nhs.uk/news/know-your-drops (accessed April 2017).

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