Lee Hollman

R i ve r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

4 8   W o r t h i n g   R o a d  

H o r s h a m    

W e s t   S u s s e x  

R H 1 2   I U D  

T : 0 1 4 0 3   2 7 4 7 0 0  

F : 0 1 4 0 3   2 2 1 9 9 9  

19 May 2014 

Dear Sir, 

Background to the Regulation 28  Report 

I write following the Coroner’s inquest into the death of a former patient, Lee 

Hollman,  who  died  on  23rd  February  2013.  The  inquest  was  undertaken  by 

the Assistant Coroner, Dr Karen Henderson, on 13th March 2014 at Horsham 

Magistrates Court.   

Riverside Surgery was named as an Interested Person by the Coroner and I 

attended to provide an account of the care provided to Mr Hollman.  

During  the  course  of  the  inquest,  the  Coroner  noted  a  number  of  matters 

which, although not causative of Mr Hollman’s death, were of concern.  I refer 

you  to  a  copy  of  my  letter  to  the  Coroner  dated  for  full  details  of  the 

background to this case.  

The Coroner concluded that Mr Hollman took his own life and issued a report 

under Regulation 28 to prevent future deaths in relation to Riverside Surgery’s 

This surgery is working with Horsham & Mid-Sussex CCG 

 
 
 
 
 
                                                      
 
                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 prescribing policy.   I enclose a copy of the Regulation 28 Report, as directed 

to the CCG and Royal College of General Practitioners (RCGP). 

NHS England Invovlement 

Soon after the event of Mr Hollman’s death, the surgery met and submitted a 

Significant  Incident  Report.  Copies  of  this  report  have  been  forwarded  on  to 

The Surrey and Sussex Area Team of NHS England as well as to the CCG.  

Prior  to  the  Coroner’s  inquest  I  disclosed  my  involvement  to  my  appointed 

Responsible Officer 

, and self-referred to the Performance 

Screening  Group  of  The  Surrey  and  Sussex  Area  Team  of  NHS  England.  I 

have also discussed my professional performance with my Clinical Appraiser 

Addressing the Coroner's concerns  

As a surgery we are keen to learn from this tragic event and have reflected at 

great  length  on  the  medication  errors  which  occurred.  The  policy  for  the 

issuing of repeat medications has been reviewed and re-written, particularly in 

respect to psychotropic medications.  I enclose the new policy for your review.  

We recognise that patients on  psychotropic medications are vulnerable,  may 

have altered awareness, suffer compliance difficulties and may exhibit suicidal 

ideation.  Therefore,  increased  vigilance  and  review  of  these  medications  is 

required.  The  new  process  for  providing  a  patient  with  psychotropic 

medication provides an additional review by the prescribing doctor to ensure 

that the medication prescribed is at the correct dose and that risk of harm is 

reduced. 

I  have outlined below how  the  Riverside  Surgery  has addressed  each of the 

areas of concern highlighted by the Coroner: 

Page 2 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

 
 
 
 
 
 
 
 
 
 
 
 
 
 1.  Failure  to  maintain  sufficiently  accurate  and  updated  medical 

records. 

The medication prescribing process for patients under the care of the CMHT 

has been revised in the following key respects: 

1.  Upon  seeing  a  patient  recently  reviewed  by  the  CMHT,  we  consider 

whether we are  in possession of the most up to date correspondence 

and  record  any  issues  arising.  This  informs  further  collaboration  with 

the  CMHT  and  promotes  timely  communication  between  the  two 

organisations.  

2.  Correspondence received from the CMHT is sent to the GP responsible 

for ongoing prescribing of medications. The Repeat Prescribing Policy 

stipulates that any change in medication for a patient under the care of 

the CMHT may be made only upon receipt of correspondence from the 

CMHT confirming the new prescription. Any medication change is then 

recorded in the patient records.   

3.  When  a  repeat  prescription  is  stopped,  the  clinical  IT  system  (TPP 

SystmOne)  requires  the  user  to  input  the  reason  why  that  repeat  has 

been  stopped.  This  reason  will  subsequently  reappear  when  any 

attempt  is  made  to  reinstate  the  repeat  prescription.  This  will  prompt 

the  reviewing  GP  to  check  the  recent  medication  list  on  the  surgery’s 

clinical IT system against the CMHT medication list.  

These  processes  ensures  that  information  about  a  patient’s  mental  health 

medication  is  contemporaneous.  Thus  ensuring  the  medical  records  are 

accurate and can be relied upon to guide the prescribing of medication safely. 

Page 3 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  Failure to remove Trazodone from the repeat prescription record. 

The  new  measures  outlined  above  ensure  that  any  changes  to  prescribed 

medications are properly recorded, with reasons given. The new system also 

promotes increased vigilance of medication changes by the CMHT. Increased 

communication  with  the  CMHT  ensures  that  the  correct  medications  are 

prescribed and issued to the patient. 

3.  Failure  to  delete  the  old  dosage  of  Quetiapine  from  the  relevant 

medical records. 

The key aspects of the new procedure are as follows: 

1.  There  is  now  a  restriction  of  psychotropic  medication  to  1  month  of 

issue. Previously such medication could be issued for up to  6 months 

at a time. After each month a GP is required to re-issue the medication. 

During  this  process,  the  GP  will  review  the  prescription  in  light  of  the 

most  recent  clinical  correspondence  from  the  CMHT.  Administrative 

staff can  no longer print out an authorised repeat of medication. 

2.  We  have  updated  the  IT  system  to  reinforce  the  policy.  To  illustrate 

this, I enclose screen shots showing the stages of the issuing process. 

The intention of this change is to reduce the risk of human error.  

3.  A GP now reviews the medication being prescribed whenever relevant 

correspondence is received by the CMHT or when the patient requests 

medication.  This  increases  the  number  of  reviews  by  a  GP  to  ensure 

the correct medication and dose are prescribed at the correct time.  

Page 4 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  The lack of an effective system to issue repeat prescriptions. 

The revised repeat prescribing protocol addresses concerns about the issuing 

of  the  repeat  prescriptions.  This  has  been  disseminated  to  all  clinical  and 

administrative  staff,  with  a  change  in  the  Clinical  IT  system  functioning  to 

support the correct implementation of this policy.  

The  coroner  raised  particular  concerns  regarding  the  Duty  Doctor  having  to 

sign  all  the  repeat  prescriptions  for  a  particular  day.  We  have  subsequently 

reviewed this practice and now have allocated the  signing of prescriptions to 

the  issuing  GP,  who  is  likely  to  be  more  familiar  with  the  patient  and  their 

medication.    The  significantly  reduces  the  number  of  prescriptions  that  each 

GP will sign on any given day by 66-80% (based on 3-4 GPs on duty).  

Prescriptions that run onto multiple sheets will be stapled together, so to avoid 

being  separated.  This  is  important  for  ensuring  that  multiple  doses  of  the 

same medication are visible for review when signing. 

5.  Failure to review patients within their own guidelines with regard 

to repeat prescriptions. 

Throughout  the  year  the  GP’s  have  and  continue  to  hold  specific  Mental 

Health  Reviews.  In  the  most  recent  Quality  Outcome  Framework  (QOF  - 

2013/2014)  review  of  our  clinical  records  confirmed  that  reviews  were  being 

carried out in accordance with the relevant guidelines.   

Increasing  our  communication  and  collaborative  working  with  the  CMHT  is 

ongoing.  Increasing  the  number  of  steps  in  the  issuing  of  mental  health 

medications  produces  a  higher  number  of  reviews  of  the  patient  record  and 

their medications by the GP.  

Page 5 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

 
 
 
 
 
 
 
 
 
 
 
 
 In addition to the annual mental health review performed by the surgery, there 

are  regular  reviews  in  different  forms  that  mental  health  patients  receive. 

These  are  review  of  specialist  consultations 

through  correspondence 

submitted by the CMHT, case review meetings with the Mental Health Liaison 

Practitioner  and  face  to  face  reviews  with  the  patient.  This  translates  to 

ongoing  and  regular  review  of  those  patients  with  mental  health  problems 

seen by the CMHT along established practice guidelines.  

Improved liaison with the Community Mental Health Team 

The  practice  met  with  representatives  from  the  Horsham  Community  Mental 
Health Team  (CMHT) on  10th  March  2014  to  discuss  care  of  patients  and to 

improve  communication  between  our  two  organisations.  We  are  also  due  to 

meet  shortly  with 

the  recently  appointed  Consultant  Psychiatrist 

I  enclose  the  minutes  of  our  recent  meeting  with  our  Mental 

Health Liaison Practitioner.  

a GP at the practice, has been in contact with Ms. 

Prescribing  Advisor,  Medicines  Management  Team  at  the  Horsham  &  Mid 

Sussex CCG to discuss further the prescribing of mental health medications, 

the communication between Horsham CMHT and Riverside Surgery. We are 

expecting further communication from 

ATS Clinical Lead NWS 

for Sussex Partnership NHS Trust in this regard.  

Conclusion 

We hope that the changes introduced at the Riverside Surgery and referred to 

above will prevent any repetition of the errors that occurred in this case.  The 

processes  we  have  adopted  and  are  in  the  process  of  adopting  will  reduce 

risk and significantly reduce the chance of similar problems from recurring.  

Page 6 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k  

 
 
 
 
 
 
 
 
 
 
 
 
 We  have  significantly  modified  our  policies  and  processes  to  safeguard  our 

patients safety and to promote high quality patient care at Riverside Surgery.  

On behalf of Riverside Surgery, 

Yours faithfully 

MB ChB, MRCGP, DCH 

GMC: 6118767 

GP Principal 

Page 7 of 7 

R i v e r s i d e   S u r g e r y              
w w w . r i v e r s i d e s u r g e r y h o r s h a m . c o . u k

RC Royal College of
G P General Practitioners

Professor Nigel Mathers FRCGP 42 MAY 2014
Honorary Secretary

Ms Karen Henderson agnnmenensiciliit
Assistant Coroner, WestSussex —

Coroner's Office

West Sussex Record Office

Orchard Street

Chichester

West Sussex

PO19 1DD

7 May 2014

Dear Ms Henderson

Inquest into the death of Lee Hollman — RCGP response

Thank you for your letter seeking comments from the Royal College of General Practitioners on factors
relating to general practitioner care following the inquest you conducted into the death of Lee Hollman.

On behalf of the College, | set out below a brief description of the remit of the Royal College of General
Practitioners. | also provide some detailed comment on the specific concerns you raise in your report
with regard to systems within a general practice for managing and monitoring the practice’s interface
with external organisations, records management and communications with colleagues.

The role of the College

The Royal College of General Practitioners is a registered charity under Royal Charter and is the
largest membership organisation in the United Kingdom solely for GPs. Founded in 1952, it has
approaching 50,000 members who are committed to improving patient care, developing their own skills
and promoting general practice as a discipline. We are an independent professional body with
enormous expertise in patient-centred generalist clinical care. Through our General Practice
Foundation, established by the RCGP in 2009, we also maintain close links with other professionals
working in General Practice, such as practice managers, practice nurses and physician assistants.

As well as running the postgraduate Membership examination (MRCGP) which is now required for
doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its
members, and these continuing programmes are also available to non-members of the College.
However, not all GPs are members of the College, and older GPs may never have joined. The General
Medical Council holds the register of all who are considered able to practise as GPs, and it is to the
GMC that revalidated doctors will be notified..

Similarly, it is not for us to comment on the performance of any individual GP and the information set
out below is solely to show you what we do in the context of training and advice to our Members.

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org-uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

RCGP Education and Training

Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3
year programme of vocational training for general practice, based on the College’s GP Curriculum.
(The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the
College’s Membership Examination (MRCGP) and is relevant to GPs throughout their career, including
preparation for revalidation) _http://www.rcegp.org.uk/gp-training-and-exams/gp-curriculum-

overview.aspx

The death of Lee Hollman raises issues about the need for strictly accurate medical record-keeping in
GP practices, GP workload, the need for close working relationships between GPs and pharmacists
and the duty of the doctor to conduct regular medication reviews with patients as part of a sound
practice repeat prescribing system. Best practice calls for patients with long-term conditions to be given
medication review appointments at regular six-monthly or yearly intervals.

Record-keeping

Addressing your concern about failures in maintaining accurate and updated medical records and,
more specifically the failure to remove Trazodone from the repeat prescription record and the failure to
delete the the ‘old’ dosage of Quetiapine from the record, the key importance of accurate record-
keeping is stressed in the section of The Curriculum entitled “Being a General Practitioner”:

http:/Awww.regp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-
2012/RCGP-Curriculum-1-Being-a-GP.ashx

“This means that as a GP you should:
1.1.3 Use an organised approach to the management of chronic conditions

1.5 Make available to your patients the appropriate services within the healthcare system

This means that as a GP you should:

1.5.2 Develop your organisational skills for record-keeping, information management, teamwork,
running a practice and auditing the quality of care”

The importance of record-keeping in the practice is further developed in the section entitled “Patient
safety and quality of care” where you will also see highlighted the importance of close collaboration
with medical colleagues and other healthcare professionals

http://www. regp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-
2012/RCGP-Curriculum-2-02-Patient-Safety-and-Quality-Of-Care.ashx

| refer you to page 9 in particular:

“1.13 Demonstrate an understanding of the connection between good data entry and improved patient
health outcomes

1.14 Demonstrate how to use information management and technology (IM&T) to share information and
co-ordinate patient care with other health

professionals

1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system
to be fit for sharing with different health professionals in different organisations

1.23 Understand the concept of variation in clinical care, how it is determined and measured and what
actions might need to be taken to address inappropriate variation, for example in referrals, prescribing,
admissions

1. 30 Demonstrate an understanding of the principles of medicines management”

Pages 10 and 11 further develop this theme:

“This means that as a GP you should:
3.1 Compare the systems and processes in place in your practice to identify and manage risk in the
primary care setting and compare these with other practices

3.3 Be aware of the limitations of your own skills in risk management and illustrate that you understand
when the skills of colleagues trained more extensively in risk management should be called upon

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Royal Highness the Duke ef Edinburgh Registered charity number 223106

Page 11:

4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals
are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you
can work to minimise these”

Other sections of The GP Curriculum of particular relevance in this case are given below:

“3.10 Care of people with mental health problems

http://www.regp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-
2012/RCGP-Curriculum-3-10-Mental-Health-Problems.ashx”

This section includes the need for the general practitioner to be able to assess and manage
risk/suicidal ideation.

3.14 Care of people who misuse drugs and alcohol

Section 3.14 of the GP Curriculum on the Care of people who misuse drugs and alcohol, whilst not
directly relevant, highlights some interesting points about GP awareness of prescribing problems.

http://www.rcegp.org.uk/gp-training-and-exams/~/media/Files/GP-training-and-exams/Curriculum-
2012/RCGP-Curriculum-3-14-Drug-and-Alcohol-Misuse.ashx”

In particular, the general practitioner should:

“3.1 Always be aware of possible drug- or alcohol-related problems with almost any presenting problem
or prescribing issue

3.4 Be aware of common long-term effects of drug and alcohol misuse including reasons for drug-
related deaths

3.6 Be aware of urgent and important issues of safety including risks to self or others and the need for
urgent medical or psychiatric care”

Relationship between GPs and Pharmacists

The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together.
At its meeting on 18 June 2011, the RCGP Council approved a joint statement drawn up by RCGP
members and the members of the Royal Pharmaceutical Society setting out guidelines for good working
relationships between GPs and pharmacists. A copy is attached to this letter as an appendix. You will

see from the paper that one of the “building blocks for change” suggested is: “Better transfer and
sharing of patient information facilitated by improved inter-professional IT links.”

Repeat Prescribing

Guidance for doctors, including general practitioners, on repeat prescribing is set out in the GMC’s
document: “Good practice in prescribing and managing medicines and devices (2013)”

http://www.gme-uk.org/guidance/ethical_guidance/14316.asp

“Prescribing guidance: Repeat prescribing and prescribing with repeats”

http://www.gmce-uk.org/guidance/ethical_guidance/14325.asp

Relevant extracts are set out below:

“55. You are responsible for any prescription you sign, including repeat prescriptions for medicines
initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and
appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat
prescribing.

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

56. As with any prescription, you should agree with the patient what medicines are appropriate and how
their condition will be managed, including a date for review. You should make clear why regular reviews
are important and explain to the patient what they should do if they:

a. suffer side effects or adverse reactions, or

b. stop taking the medicines before the agreed review date (or a set number of repeats have been
issued).

You must make clear records of these discussions and your reasons for repeat prescribing.*

57. You must be satisfied that procedures for prescribing with repeats and for generating repeat
prescriptions are secure and that:

a. the right patient is issued with the correct prescription

b. the correct dose is prescribed, particularly for patients whose dose varies during the course of
treatment

c. the patient's condition is monitored, taking account of medicine usage and effects

d. only staff who are competent to do so prepare repeat prescriptions for authorisation

e. patients who need further examination or assessment are reviewed by an appropriate healthcare
professional

f. any changes to the patient's medicines are critically reviewed and quickly incorporated into their
record.

58. At each review, you should confirm that the patient is taking their medicines as directed, and check
that the medicines are still needed, effective and tolerated. This may be particularly important following
a hospital stay, or changes to medicines following a hospital or home visit. You should also consider
whether requests for repeat prescriptions received earlier or later than expected may indicate poor
adherence, leading to inadequate therapy or adverse effects.

59. When you issue repeat prescriptions or prescribe with repeats, you should make sure that
procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You
should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can
contact them if necessary.”

| hope you find these comments helpful.

Yours sincerely

Honorary —_

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Royal Highness the Duke of Edinburgh Registered charity number 223106

Appendix 1

Joint Statement by The Royal Pharmaceutical Society with the Royal College of
General Practitioners: Breaking down the barriers — how community pharmacists
and GPs can work together to improve patient care

Introduction

1. This joint statement sets out the background, summarises the evidence and makes
recommendations for the benefits to patients of improved liaison between community
pharmacists and general practitioners. Over the last 20 years successive policy
changes have moved the pharmacist's role from primarily one of dispenser towards a
generic health care provider advising patients on their use of prescribed medicines,
self care and lifestyle as well as other innovative services. However these changes
often seem to have been introduced in isolation from other primary care services,
especially general practice, thereby minimising opportunities for enhanced patient
benefit. General Practitioners are similarly taking on a broader role, particularly in
England, to commission services as part of the recent White Paper thinking “Equity
and Excellence: Liberating the NHS”. GPs are also working with a range of primary
care practitioners to deliver services to their local communities and recognising the
skills and experience of the full range of healthcare professionals is key to the
thinking in this statement.

2. Patients may be surprised when they discover that their community pharmacist and
their GP do not share the same clinical record and that the community pharmacist is
not always an integral part of the primary care team. Pharmacists play a key role in
the long-term management of patients with chronic disease and can see the patient
as often as the general practitioner. Many members of the public and patients see the
pharmacist as a first port of call for advice, not just on their medicines but also on
their underlying health problems. This is particularly true for men seeking advice on
health issues.

3. Whilst many GPs do work closely with their local pharmacist, a culture change is
recommended between GPs, pharmacists and the public to allow the collaborative
partnership between general practice and community pharmacy to deliver its
potential.

Building Blocks for Change
4. Some key building blocks need to be agreed to underpin new working relationships.
These should include:

e Better transfer and sharing of patient information facilitated by improved inter-
professional IT links.

e Shared standards and ways of working to ensure consistency of services and
information to the public (for example in areas such as screening and diagnosis
and pharmacy-led treatments and advice).

e Joint education and training at undergraduate and postgraduate level could
facilitate greater trust and understanding of the professions’ respective and
complementary skills and expertise.

e Standard setting/clinical guidance on the provision of over-the-counter
medicines where these medicines have doubtful value.

5. There are a number of key areas where joint working between community
pharmacists and GPs will produce better and safer patient care.
For example:
e End of Life Care
e Care of patients with long term conditions
Royal College of General Practitioners 30 Euston Square London NW1 2FB

Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp-org.uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

Care of complex “poly-pharmacy” patients
Care of patients with substance misuse

Care of patients with life-style related ill health
Supporting patient self-care.

How working together can improve patient care and safety

6. The benefits to patients and practitioners of joint working in these and other key areas
are summarised here. A separate paper sets out the evidence underpinning our
recommendations.

7. Better use of Medication Use Reviews (MURs)' by pharmacists can reduce
duplication of effort by the primary care team as well as improve patient care through
reducing errors and improving adherence to treatment.

8. Pharmacist prescribers working closely with GPs and practice nurses, can similarly
contribute to better patient management and can also help improve the quality and
outcome of patient management in a range of long term conditions’.

By working together more closely, GPs and pharmacists will be able __ to deliver
better healthcare to vulnerable groups such as those in care homes or elderly
patients taking anti-psychotic medicine.

9. Community pharmacists working with general practices and specialist palliative care
teams can ensure reliable and prompt medicine supply, and supportive advice
(especially about analgesia) for patients, lay carers and other members of health care
team.

10. Pharmacists with the appropriate expertise, working with drug misusers, can increase
retention within treatment by a structured supportive approach, and those with
prescribing and drug misuse qualifications can contribute to community detoxification
by adjusting doses.

11. GPs and pharmacists can support life-style change and self care.

Recommendations
12. Our recommendations to deliver this broad and important agenda for service redesign
at the general practice — community pharmacy interface follows:

Managing long term conditions
13. Patients can already benefit from being able to receive timely and accessible help
from pharmacies in understanding and using medicines . Access to this should be
promoted and resource more effectively targeted to patient need. An example of how
this can work is the New Medicine Service being introduced in England.

14. Improvements should be made to improve the sharing of information between the
pharmacist and the GP/practice.

15. Patients should have a choice where medicine reviews® take place, with consultation
between the professions and communications systems in place to support this
process.

' A Medicines Use Review of a patient's medicines including items that are regularly prescribed, used
only when necessary and those obtained for the purpose of self care. Its aim is to improve
understanding of how, why and when medicines should be taken.

? Evaluation of supplementary prescribing in nursing and pharmacy. Bissell et al 2008; Evaluation of
nurse and pharmacist independent prescribing. Latter et al 2010 (forthcoming)

° Medicine reviews are: ‘a structured critical examination of a patient's medicines with the objective of
reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising
the number of medication-related problems.’ Room for Review. A guide to medication review; the
agenda for patients, practitioners and managers.

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

16. GPs and pharmacists when working together should be able to map their work
against agreed national standards according to local circumstances driven by patient
needs.

17. Locally agreed protocols relating to medicine reviews should reflect agreed
standards. From the patient perspective, care should be delivered to the same
standard by whoever is undertaking the task.

18. The same quality standards should be used for GPs and pharmacists when
undertaking medication reviews.

19. There should be better use of ‘repeat dispensing” to increase efficiency, reduce
practice workload and increase patient convenience as well as increased value for
money.

20. Working with patients, GPs and carers can benefit their patients with long-term
conditions and complex medication regimes by utilising the pharmacist independent
prescriber’ jointly working with the GP and patient working in collaboration.

21. Pharmacists should be able to refer to services commissioned by the GP consortia
using the same demand management criteria and guidelines as GPs and within
agreed care pathways.

22. Pharmacists to be able to refer patients to local GPs and pharmacists with special
interest services and to agreed parts of the care pathway. Pharmacists referring
across to the patient’s GP in accordance with agreed local care pathways/protocols.

23. National arrangements for patients and carers to be able to access a supply of their
regular medicine/s in an emergency’.

Care for the frail elderly
24. Improved joint working between GPs and pharmacists for patients who reside in care
homes, for example, pharmacists to attend care-homes alongside GPs to undertake
joint medication review, pharmacists to review medication being prescribed to
patients who reside in care homes.

25. Pharmacists to participate in medication reviews for house-bound patients.

End of life care
26. Patients and their carers to have better access to medicines required for palliative
care. This includes working with out-of-hours providers to ensure access across the
whole 24 hours.

27. Pharmacists to form part of the out-of-hours team for palliative care, with a pharmacy
on-call rota.

28. Improve the sharing of information between GP, palliative care service and
community pharmacist throughout end-of-life care.

Care for drug misusers
29. Drug misusers to continue to have convenient access to supervised administration of
substitution treatments and to be encouraged to make greater use of these
interactions for other health interventions.

4 Part of the Community Pharmacy Contractual Framework in England & Wales, and of the Chronic
Medication Service in Scotland

5 Pharmacists who have completed the appropriate training and can prescribe any licensed medicine for
any medical condition within their competence.

® Scotland already has a national scheme for patients to obtain an emergency supply of NHS medicines
Royal College of General Practitioners 30 Euston Square Londen NW1 2FB

Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org-uk

Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

30. Pharmacists with the appropriate expertise to contribute more to care planning and
review of treatment objectives building on the knowledge of the drug misuser
acquired through daily contact.

31. Pharmacist prescribers working within a locally agreed shared care protocol may be
used to titrate doses, including during dose induction and detoxification.

32. Pharmacists to use the opportunities afforded by supervised administration to
promote other health interventions, including blood-borne virus testing and
immunization’; flu vaccination, in addition to appropriate counseling.

Preventing ill health
33. GPs and pharmacists to collaborate in providing cardiovascular risk assessment,
including on-site cholesterol monitoring.

34. Pharmacists to ensure convenient public access to evidence-based preventive
interventions including, for example ‘Stop Smoking’ services, emergency hormonal
contraception, Chlamydia testing & treatment®, and vaccinations. All delivered to the
same quality standards.

35. Pharmacists with appropriate expertise to become providers of travel vaccinations
and malaria prevention treatments and make recommendations as to what travel
vaccinations are required/recommended. Furthermore, pharmacists could provide
advice on ailments contracted abroad, including traveler diarrhoea and sexually
transmitted disease. This service must be supported by suitable communications
between pharmacists and GPs to ensure that patient records are updated
accordingly.

36. Better publicity for the public on how to access services (e.g. emergency hormonal
contraception)

Supporting self care
37. Patients to be able to conveniently access advice and or treatment for common minor
illnesses including outside opening times of general practices.

38. GPs, nurses and pharmacists working together as part of a coordinated team across
practices.

39. A pharmacy NHS Minor Ailments Service® to support GPs in urgent care and out-of-
hours provision.

40. Pharmacists should also be supported to participate in the provision of out-of-hours
services

41. More effective promotion to the public and others who can encourage use of
pharmacies for minor ailments and encourage self-care.

42. Levers and incentives
Levers and incentives should be considered in order to expedite the changes
described above. These should be applied at various levels namely: individual
pharmacy and practice level, at local professional group level, and at national level.

” Immunisations are already provided by pharmacies in some areas (eg Isle of Wight ‘Pharmacy Fix’
service) with underpinning training and arrangements for dealing with anaphylaxis

5 Supply of emergency hormonal contraception and provision of Chlamydia testing are part of the Public
Health component of the pharmacy contract in Scotland and provided by all pharmacies.

° A national Minor Ailments Service has been in place in Scotland since 2006. Currently 60% of PCTs in
England commission this.
Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

National level
43. Itis essential for patient safety that relevant patient information can flow both ways
between general practices and pharmacies and IT systems in England and Wales
need to enable this’®.

44. Ethical issues in sharing patient information need to be identified and resolved with
input from patients and service users. A joint code of ethics addressing issues such
as consent and confidentiality will be agreed by both professional bodies to facilitate
this.

45. Joint national guidance should be produced with input from patients and the public on
evidence based recommendations for non-prescription (OTC) medicines by all health
professionals.

46. Identify outcomes for pharmacy contribution to patient care methods of measurement.

47. Explore new models of commissioning pharmacy input which requires joint working
with general practice e.g. the Chronic Medication Service in Scotland.

48. Consult stakeholders on how best to achieve continuity of pharmacy care, including
patient registration at pharmacies; shared records.

Local level
49. Wider commissioning of the Healthy Living Pharmacy"' model or its equivalent

50. Share and disseminate examples and models of shared practice

Communication at local and national levels
51. Explore better ways of communicating between GPs and pharmacists. For example:

e Meetings between Local Pharmaceutical Committee (LPC), Local Medical
Committee ( LMC)

e RCGP faculties / RPS local practice fora should be encouraged to discuss health
needs and how joint working can improve the provision of healthcare and encourage
better self-care.

e Both organizations consider it essential for the individual and specific needs of the
public and patients in Scotland, Wales and Northern Ireland to be recognized and
addressed by practitioners in everything they do at national and local levels.

e Shared learning events for the primary health care team, including pharmacists

e Shared Critical Event analysis

e Periodic joint practice level meetings where this is feasible

52. Professional bodies for general practice and pharmacy to meet regularly and provide
leadership on joint working for members.

Sharing information
53. Consultation process on the following areas:

54. Pharmacists to have access, with consent, to the patient's medical record.

55. Consider the issues around pharmacist access to the Summary Care Record

56. Identify mechanism for the pharmacist being able to record clinically significant Over
The Counter sales and NHS Minor Ailment scheme consultations and, with the
patient's consent, sharing with the practice. This should also include other public
health priorities such as immunization.

1° The Chronic Medication Service in Scotland includes electronic communication between the patient's
nominated pharmacy and their GP practice

11 The ‘Healthy Living Pharmacy’ model has been successfully piloted in Portsmouth City. The contract
has three levels requiring which require increasing Clinical input from the pharmacist.

12 Emergency Care Summary in Scotland

Royal College of General Practitioners 30 Euston Square London NW1 2FB

Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www. regp.org. uk

Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106

Shared standards and ways of working
57. Pharmacies and GP practices to work to common quality standards for screening and
diagnostic testing

58. Joint development of shared formularies for prescribing and supply for common
conditions

59. Systematic use of patient feedback to assure adequacy of privacy and facilities in
pharmacy consultation areas

Education and training

60. Both bodies recognize and are committed to how GPs and pharmacists can learn
with and from each other starting at undergraduate level and continuing throughout
their professional careers. Both bodies will work together to explore continued
opportunities for joint learning

Moving forward
61. Action is now needed from individual clinicians, local professional groups, NHS
organisations, national bodies and patients to shape how local care develops. The
Royal College of General Practitioners and the Royal Pharmaceutical Society will
start this process by:
a. Bringing together an invited multi-stakeholder group to explore the
recommendations in this paper and identify actions needed.
b. Setting up a joint working group including patients and service users to take an
agreed work programme forward.

Royal College of General Practitioners 30 Euston Square London NW1 2FB
Tel 020 3188 7400 Fax 020 3188 7401 Email info@regp.org.uk Web www.regp.org.uk
Patron: His Reyal Highness the Duke of Edinburgh Registered charity number 223106