Guide to undertaking person-centred inpatient (ward) outpatient (clinic) and dispensary-based pharmacy consultations.

WHO uses the internationally accepted term 'person-centred care', also usedby the Royal Pharmaceutical Society in the UK, to highlight the importance of considering that patients are people first; they have families, communities and are living with conditions for which they receive healthcare. The challenge that faces pharmacy professionals is embedding a person-centred approach to pharmacy practice. In a hospital setting, there are specific processes that must be completed to optimise safe, efficient and effective practice, however thesetend to be professionally focused. The coaching model, GROW, supports more person-centred conversations and has been used successfully in health in the National Health Service (NHS) in the UK . Inin pharmacy, practitioners were challenged with the task of integratingperson-centred consultation techniques as part of the pharmacy processes they were required to complete within their everyday activities. Therefore, a set of person-centred questions were developed, using concepts from GROW and the Four E's, to create guides for practitioners to use within each of the pharmacy processes they commonly undertook. The guides were piloted with three pre-registration pharmacists and, following modification, were included in the skill development sessions described in a related publication in this issue 'A pilot study to evaluate knowledge of person-centred care (PCC), before and after a skill development programme, in a cohort of pre-registration pharmacists (PRPs) within a large London Hospital'. These guides are used by pharmacy staff in the author's organisation to support a person-centred approach to pharmacy practice.

Pilot study to evaluate knowledge of person-centred care, before and after a skill development programme, in a cohort of preregistration pharmacists within a large London hospital.

INTRODUCTION: Aperson-centred approach to healthcare encompasses personalised care, supporting the individual to recognise their strengths and promote their independence. Preregistration pharmacists , who arenew pharmacy graduates undertaking their training year of practice before qualification,may need support embedding this in practice. OBJECTIVE: To explore the knowledge and confidence in person-centred care (PCC) in a cohort of 12 preregistration pharmacists before and after receipt of an inhouse pharmacy-focused skill development programme using qualitative and quantitative measures. METHODS: Two half-day skill development sessions were delivered to 12 preregistration pharmacists. Assessment forms were completed before and after the skill development sessions, including quantitative data gathered via Likert scales and qualitative, narrative responses. Responses were coded and classified into themes. Participants submitted one written reflective account demonstrating the use of PCC in medicines-related patient consultations following completion of the skill development programme. RESULTS: Assessment forms were received from all participants. Self-reported knowledge of PCC improved from the start of the first session to the end of the second session. The average score for the understanding of PCC rose from 6.5 to 9.6 (Likert scale of 0-10) to the end of the second session. Qualitative analysis identified five person-centred themes, including active listening, using open questions, supporting and empowering patients, developing a shared agenda, and encouraging patients to take ownership of their medicines. CONCLUSIONS: Confidence and knowledge increased from the start of session 1 to the end of session 2. and analysis of the reflective accounts and themes also identified increased knowledge of PCC. This work aligns with previous hospital trust work, which identified that a training programme increased awareness and provided foundation knowledge. A short programme to develop PCC skills was effective in improving the PCC knowledge of 12 preregistration pharmacists. A review of pharmacists' written accounts of their consultations suggests that these skills were integrated into practice.

Developing person-centred consultation skills within a UK hospital pharmacy service: evaluation of a pilot practice-based support package for pharmacy staff.

A person-centred approach to care is central to NHS England's health policy agenda and a standard for pharmacy practice from the General Pharmaceutical Council. Health coaching is a method of delivering person-centred care. A pilot of a health coaching support package, including a 2-day course and practice-based follow-up, was delivered to 70 London North West Healthcare NHS Trust pharmacy staff between December 2015 and July 2017. OBJECTIVES: To evaluate the support package, identifying key themes from course feedback, evaluating staff perception and evidence of application in practice. To identify key benefits of the support package. METHODS: Qualitative analysis of written course feedback was undertaken to identify staff learning themes about person-centred care. The themes were used to design a survey, administered to support package recipients (staff), exploring staff perception of the package. Qualitative review of written examples highlighted use of person-centred themes in practice. RESULTS: Twelve person-centred themes emerged from 49 course evaluations forms, describing what participants learnt about patient-centred care. Of 24 surveys completed, respondents reported increased awareness of themes; however, use in practice varied between themes. Overall, respondents valued the support package and rated practice-support more highly than the course for ongoing development. Patient examples described the use of themes in practice. CONCLUSIONS: The support package increased awareness of person-centred themes, portrayed within the practice examples submitted. While the course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice.

Opportunities for collaboration between pharmacists and clinical pharmacologists to support medicines optimisation in the UK.

Medicines optimisation is a clinician-driven, person-centred ongoing process. Pharmacists and clinical pharmacologists have medicines-related expertise to deliver medication review which optimises clinical and cost-effective use of medication, aligned with patient preferences, contributing to improved health outcomes. There is a large pharmacy workforce, directly accessible to patients, who can provide expert medicines-related care on the high street, and increasingly in general practice and care homes settings. There are a small number of clinical pharmacologists in practice, mainly working in a hospital setting. Potential opportunities for collaboration are extensive, including local initiatives in collaborative education, formulary/medicines management, electronic prescribing, service evaluation, research, direct clinical services as well as strategic planning through the Regional Medicines Optimisation Committees. Pharmacists and clinical pharmacologists have complementary skill sets and through acknowledging the differences in their approaches and valuing their unique skills, health services can ensure that patients are signposted to appropriate services.

Patient-centred consultations in a dispensary setting: a learning journey.

BACKGROUND: Hospital dispensary consultations usually focus on telling your patients how to take medicines. However, patient views are not always considered. We suggest that the value of a consultation lies in helping patients get the best health outcome from their medicines and this requires more than education. Pharmacy teams need to think differently about the way in which consultations are undertaken in order to improve effectiveness of medicines. OBJECTIVES: To explore development of patient-centred consultations in a hospital dispensary environment using a health coaching approach. METHOD: In April 2014, London North West Hospitals NHS Trust Pharmacy Department commissioned a 2-day health coaching course for 18 pharmacists to improve patient focus in consultations. Using learning from the course and knowledge of dispensary processes, a flow chart was created to support management of the three categories of patient. Pharmacy staff trained to tailor their consultation to patient need using a coaching approach, including use of principles of the 4Es (Explore, Educate, Empower, Enable), a pharmacy-based model for short consultation. RESULTS: Preliminary findings from the new approach included improved staff satisfaction, improved skill mix and positive feedback from patients. The main perceived disadvantage of using the above consultation style was the fear of increasing the time for consultations, however, this appears unfounded. A need for a dedicated counselling area to improve privacy in consultations was identified. CONCLUSIONS: Provision of a patient-centred consultation framework in a dispensary environment, using a coaching approach, has improved focus on patient needs, continuing the journey towards patient-centred care.

Medicines reconciliation pilot at transfer of care: admission to a community-based early supported discharge ('step-down') and prevention of admission ('step-up') service.

INTRODUCTION: Early supported discharge ('step-down') and prevention of admission ('step-up') services require safe medicines reconciliation. Medication discrepancies at transfer of care are a potential cause of patient harm. There is currently no published work examining level of medication discrepancies and associated risk in this setting. OBJECTIVES: Working within a 'step-up' and 'step-down' integrated service based in the community, caring for patients in their home to:▸ quantify the number of medicines discrepancies and allergy status discrepancies▸ ascertain the type of discrepancies▸ assess the potential for harm caused by these discrepancies. METHODS: Medicines reconciliation was performed by two pharmacists for patients within the 'step-up' and 'step-down' service as well as patients recently discharged from hospital to a care home. The resulting medication history was compared with the original medication history documented in the service's notes. Allergy status and medication discrepancies were identified and the type of discrepancy was recorded. National Patient Safety Agency (NPSA) risk assessment was used to categorise the level of risk of each discrepancy. RESULTS: 20 out of the 54 patients (37%) did not have an allergy status recorded at baseline. Of the 573 medications listed for patients reviewed following medicines reconciliation, 317 (55%) had a medication discrepancy. There was an average of 5.87 (95% CI 4.53 to 7.18) medication discrepancies per patient of which 49% were classified (NPSA) as moderate, high or extreme risk. CONCLUSIONS: There was a high level of medication discrepancies in this service with implications for patient safety and cost. Such services would benefit from pharmacist-led medicines reconciliation.

Impact of an integrated medicines management service on preventable medicines-related readmission to hospital: a descriptive study.

BACKGROUND: Medication contributes to 5-20% of hospital admissions, of which half are considered preventable. An integrated medicines management service (IMMS) was developed at a large general hospital in London to identify and manage patients at risk of a preventable medicines-related readmission (PMRR) to reduce the risk of PMRR. OBJECTIVE: To investigate the effect of the pharmacy IMMS on the rate of PMRR within 30 days of the first discharge. METHOD: 744 patients were identified between October 2008 and October 2014, using the PREVENT tool. Patients at risk were managed by the IMMS with medication reconciliation, review, consultation and follow-up, as required. RESULTS: Of 744 patients, 119 were readmitted within 30 days of discharge, with a PMRR for 2 patients (1.7%). The main reason for referral to the service was to assess the need to start a compliance aid. Most interventions involved communication: 84% included patient consultations with 50% involving discussion with the patient's community pharmacist and 32% with their general practitioner surgery. CONCLUSIONS: An IMMS may be an effective method of reducing the rate of PMRR. Further work is needed to establish the cost-effectiveness of the service.

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.

Patient-centred management of polypharmacy: a process for practice.

Medicines are the most common intervention to improve health. The number of medicines taken by older people in the UK has been steadily increasing for the last three decades. Polypharmacy is a term that refers to either the prescribing or taking many medicines. Concerns about the risks of polypharmacy in primary and secondary care are growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased healthcare costs and non-adherence. In the UK, this can largely be attributed, over the last 20 years, to the greater availability of evidence-based treatments promoted through therapeutic guidelines which are designed for single conditions, rather than addressing the multimorbidity that affects many older people. There is also currently a paucity of evidence-based national guidance around reducing and stopping medication and incorporating the patient perspective. This paper reviews current UK literature around polypharmacy including a description of four key resources which all make use of international literature and all focus on the medication aspects of polypharmacy from a clinician's perspective. The patient-centred approach combines both clinical health professionals and patient perspective. Developed using existing resources, it is designed to assist with collaborative (patient and clinician based) medication review to inform decisions around deprescribing and address polypharmacy as part of overall strategies to optimise medicines for the patient. Presented as a diagrammatic representation in seven steps, it also includes guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely.