By Martin England, Pharmacy Services Director, Ashtons Hospital Pharmacy Services
It is now 26 years since the then Health Secretary, Virginia Bottomley, successfully argued in favour of providing hospices with a prescribing budget, instead of using NHS prescriptions to obtain medication. This gave hospices the opportunity to purchase stock medication instead of using patients’ own supplies of medication. Having a budget for medication had many advantages and was more cost effective due to a significant reduction in waste.
Since this medication budget was introduced most hospices purchase their medication for inpatients from a hospital or community pharmacy. In addition, obtaining clinical advice and support from a specialist palliative care pharmacist regarding medicines management became more commonplace.
Approximately 200 specialist palliative care pharmacists in the UK provide hospices with an input which includes advice about treatment choices, potential adverse drug interactions and other medication issues.
Requirement for a Wholesale Dealer’s Licence
However, one issue that has become increasingly significant due to recent regulatory changes, is the legal requirement that all pharmacy providers of stock medication must have a Wholesale Dealer’s Licence which is issued by the MHRA. Pharmacists can continue to dispense for individual named patients, but cannot provide stock medication without this license.
In addition, a separate Home Office licence is also required for any pharmacy that supplies controlled drugs as stock.
Some hospices have had to change their pharmacy provider as a result of this regulatory requirement.
The implications surrounding the Wholesale Dealer’s Licence for stock medication and the Home Office licence for controlled drugs, is not just one of legality. There are also quality implications that must be considered. These licences are in place to help protect the supply chain from substandard products. All registered providers who obtain these licenses are inspected, and therefore, have to maintain the quality standards and meet the requirements demanded by the MHRA and the Home Office. This also goes a long way to protecting the supply from counterfeit drugs.
Complex medication regimens
Due to the nature of palliative care, the treatment that hospices provide is often complex. It is common for multiple drugs to be prescribed and frequent changes to doses and drugs. Often there will be unusual combination of drugs and a requirement for doses that are higher than the usual recommendations. It is also common for palliative care to require medicines to be used off-licence. All of this requires careful monitoring and management, which is where the assistance of a specialist palliative care pharmacist is of most value.
The complexity of treatment has, in recent years, been further increased by a substantial rise in the number of drugs that are available. This is particularly true of pain killers, which are used extensively by hospices. This wider variety of medication can also be used in an increasing number of ways, e.g. fentanyl.
This increase in choice and complexity has made the need for a specialist pharmacy input more vital than ever. This may include advice on the most appropriate drugs and doses, assistance to avoid potentially harmful drug interactions, or simply ensuring all administration of medication is recorded correctly and in line with best practice, in order to meet all the required regulations and standards.
Palliative care in the community
As outlined by the Gold Standards Framework, approximately two thirds of people die in hospital (55% for cancer patients) and the number of people choosing to die in a hospice is increasing. However, it is still true that most people would prefer to die at home.
Care in the community is a significant consideration when treating patients with a terminal illness. In fact, 50% of hospice patients will be discharged at some point, and on average 90% of the final year of life is spent at home.
Providing palliative care in the community raises some special challenges. There are a number of gaps in community care that can arise, including access to the right equipment, the need for 24 hour care and night sitters. In relation to medication, the biggest challenges revolve around the speed with which medication can be accessed and managing changes to both the medicines and doses being used to provide the most effective treatment.
It can often take several days for medication to reach the required patient in the community due to inbuilt delays when ordering the prescription from a GP and the community pharmacist dispensing it. The nurses providing the care would also often lack any support from a specialist pharmacist.
It is beneficial for hospices to maintain close and effective relationships with their pharmacist and the NHS or agencies providing the care the community. Helping to improve palliative care services in the community can help patients to remain in their home if they wish to and help reduce the impact on resources for both hospitals and hospices.
Syringe drivers are a convenient and reliable way of helping to control pain, sickness and other symptoms, making them particularly useful in palliative care. Also known as a continuous subcutaneous infusion, syringe drivers involve an injection that is fixed in place and delivers a steady flow of medication continuously under the skin. This is an alternative to regular, repeated injections. They are also particularly useful for patients suffering with dysphagia and the inability to take medication orally.
While they provide a reliable and effective way of delivering regular medication over a period of time, syringe drivers do come with their own challenges. Not only is it important to ensure that the infusion is effective and avoids interactions, but particular care should be taken to ensure the concentration of irritant drugs, such as cyclizine, is not too strong. Sometimes a replacement may be necessary. In the case of cyclizine, this could be substituted by haloperidol, for instance.
End of life care and medication
The role that hospices play within palliative care is, without question, a crucial part of the system as a whole. They not only provide caring and supportive treatment for their patients, but often support their families through a very difficult period of their lives. Managing complex medication regimens effectively and safely is an important part of this, helping to ensure the patient receives the best treatment possible and distress for the families kept to a minimum.
This is where a pharmacist can provide a vital input. With the complexity of treatment and the increasing choice of medication, as well as an ever expanding set of regulations and standards, managing medication is more complicated than ever. Pharmacist help provides the final ingredient that is required to maintain a high level of care within a hospice and to help ensure the required regulations and standards relating to medicines management are met.
For anyone with an interest in palliative care drugs, including doctors, nurses and pharmacists, www.palliativedrugs.com is an essential information resource, including a wide range of information about indications, routes, and the administration of multiple drugs by continuous subcutaneous infusion.
Information on the website includes the palliative care formulary, which is available via an online subscription service (http://www.palliativedrugs.com/palliative-care-formulary.html), or as a printed book. Some hospices have developed their own formularies.
Further information about the Wholesale Dealer’s License and how to apply is available via the MHRA’s website: https://www.gov.uk/guidance/apply-for-manufacturer-or-wholesaler-of-medicines-licences