Medicines optimisation : a pharmacist’s contribution to delivery and education

This thesis describes the author’s publication history from 2001 to 2019, and relates this to their key career milestones from registration as a pharmacist in 1991. From a career output of over 80 items published in a variety of media, eleven key publications form the basis of four publication themes, which the author has related to the concept of medicines optimisation. An exemplar case is used to illustrate these publication themes, arranged into four chapters: a) improving the patient experience and supporting medication adherence b) providing safe care: medication review, polypharmacy and deprescribing c) making medicines optimisation part of routine practice through clinical education, and d) supporting safe practice through professional and personal development of healthcare staff. Following Chapter 1 (introduction), the second chapter discusses the author’s contribution to the medication adherence agenda which closely relates to their outputs encouraging the development of pharmacists’ consultation skills, particularly with patients who have a learning disability. The third chapter discusses the author’s published outputs in the areas of medication review, polypharmacy and deprescribing, the success of which they outline as contingent on the improved communication skills and person-centred approach described in Chapter 2. Chapters four and five discuss the author’s wide-ranging contribution as a clinical educator with a focus on developing others, which the author contends is an essential underpinning of the mission to deliver the benefits of medicines optimisation. The exemplar case from the introduction is briefly revisited to illustrate that the author’s publications directly relate to the challenges of the patient’s medication regime which in turn relate to three of the four Royal Pharmaceutical Society principles of medicines optimisation. The conclusion of this thesis includes a summary of the methodologies used in the key publications, and summarises the author’s belief that their career activity, leading to their publications, broadly align to the concept of medicines optimisation. Moreover, a recommendation can be made that education of all stakeholders should be explicitly mentioned in any future refinements of its definition

Improving Pharmacists’ Targeting of Patients for Medication Review and Deprescription

Background: In an acute hospital setting, a multi-disciplinary approach to medication review can improve prescribing and medicine selection in patients with frailty. There is a need for a clear understanding of the roles and responsibilities of pharmacists to ensure that interventions have the greatest impact on patient care. Aim: To use a consensus building process to produce guidance for pharmacists to support the identification of patients at risk from their medicines, and to articulate expected actions and escalation processes. Methods: A literature search was conducted and evidence used to establish a set of ten scenarios often encountered in hospitalised patients, with six or more possible actions. Four consultant physicians and four senior pharmacists ranked their levels of agreement with the listed actions. The process was redrafted and repeated until consensus was reached and interventions were defined. Outcome: Generalised guidance for reviewing older adults’ medicines was developed, alongside escalation processes that should be followed in a specific set of clinical situations. The panel agreed that both pharmacists and physicians have an active role to play in medication review, and face-to-face communication is always preferable to facilitate informed decision making. Only prescribers should deprescribe, however pharmacists who are not also trained as prescribers may temporarily “hold” medications in the best interests of the patient with appropriate documentation and a follow up discussion with the prescribing team. The consensus was that a combination of age, problematic polypharmacy, and the presence of medication-related problems, were the most important factors in the identification of patients who would benefit most from a comprehensive medication review. Conclusions: Guidance on the identification of patients on inappropriate medicines, and subsequent pharmacist-led intervention to prompt and promote deprescribing, has been developed for implementation in an acute hospital

Why we should understand the patient experience: clinical empathy and medicines optimisation

Objectives To critically discuss the need for pharmacists to underpin their consultations with appropriate ‘clinical empathy’ as part of effective medicines optimisation. Methods Use of literature around empathy, consultation and pharmacy practice to develop a case for greater clinical empathy in pharmacy consultations. Key findings Clinical empathy is defined from the literature and applied to pharmacy consultations, with a comparison to empathy in other clinical professions. Historical barriers to the embedding of clinical empathy into pharmacy consultations are also explored. Conclusions We challenge the pharmacy profession to consider how clinical empathy should underpin consultations with a series of introspective questions and provide some sample questions to support pharmacy consultations. We also make the case for appropriate education and professional development of consultation skills at undergraduate and postgraduate level. We contend that patients’ relationships with practitioners are critical, and a lack of empathy can impact the effectiveness of care