Parts of this chapter are reproduced or adapted with permission from Campling et al.48 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.
This chapter draws together the findings from the study phases. The chapter will highlight key features associated with service models that influence patients’ and carers’ ability to swiftly and efficiently access medicines at home during the last year of life. A number of overarching influential issues will be discussed, drawing out where and how these are problematic and what needs to be considered by policy-makers, commissioners, health service managers and practitioners to improve medicines access.
Synthesis of findings: characteristics of service delivery models
The study was framed with reference to systems thinking, a perspective that acknowledges complexity and recognises the multiplicity of actors, the ever-changing context and that systems interact over time to create new patterns.28 We recognised that the process of accessing a medicine (defined as prescribing, dispensing, supplying and providing associated information about medicines) necessarily involves a number of components, stages, processes and different HCPs.
Systems thinking operates to make a system explicit, including charting the relationships and connections between system components. Understanding a system is a prerequisite to identifying where to intervene to strengthen it and will aid understanding of interventions’ knock-on effects elsewhere in the system, as well as the intended and unintended consequences. The study design has enabled us to provide an overall description of the system of accessing palliative care medicines in the community, and the relationships between service delivery models and system components (see Appendix 31, Table 43). Data about these different components and relationships drew on the perspectives of all the actors (i.e. GPs, specialist palliative care nurses, CNs, CPs, patients and carers, and commissioners) across different sectors of the health economy (i.e. primary care, community care, community pharmacy and hospice care), as well as WDs engaged in the supply chain of medicines into community pharmacies. Our findings confirmed that accessing medicines is a process characterised by complexity, not only because of the various stages, processes and actors involved, but also because these cross the boundaries of private–public health-care provision (i.e. non-NHS hospice care, community pharmacies and the commercial sector in the supply chain). Furthermore, our data showed that patients were also accessing medicines and medical supplies from other sources, not just primary care, but secondary and private paid-for care too. Systems are also characterised by interdependency.28 In the medicines access process, this was observed in the inter-relationships of HCP team members and service delivery sectors. For example, if a GP prescriber was unaware of the community pharmacy stock of particular palliative medicines, a mismatch between a prescription and stock sometimes occurred, leading to a delay in dispensing at the community pharmacy. HCPs rated integrated working highly as a solution to some of the current problems with access, further reinforcing the interdependency of components of this system. This is played out against a clinical context of rapidly changing symptoms and often pain and emotional distress, creating an urgent need for the supply of medicines into the home. Therefore, this distinguishes the system of palliative medicines access from other systems of medicines supply, such as those required to support the management of long-term illnesses. Although it shares some components (e.g. the request for a prescription or re-prescription from a prescriber and dispensing of the medicine from a community pharmacy) the system of palliative medicines supply is underpinned by less stable symptoms than those typically experienced in long-term illnesses, such as hypertension or asthma. The time frame of illness experience is also more compressed and the physical and emotional distress of managing palliative care is arguably greater, particularly as pain is a common symptom. At the same time, palliative care service provision is somewhat uniquely characterised by a complexity not seen in medicines supply systems for long-term illnesses, that is care delivery by charity-funded hospice-employed HCPs is a more prominent feature, creating extra interorganisational communication difficulties, as exemplified in disparate IT systems. Those employed by charity-funded hospices also have less access to DHSC-resourced training and development, despite making a significant contribution to care delivery to NHS patients. The CD nature of some palliative medicines also shapes the distinctiveness of this system of access, which is comparative to medicines supply for long-term illnesses or non-pharmaceutical provision at EoL. For example, we found that the limited shelf life of CDs inhibited some CPs from keeping them in stock. The systems complexity of the medicines access process is associated with a number of key features in our findings, which are discussed further below, together with their implications for policy and practice.
Systems thinking deploys explicit models, with assumptions laid out that can be calibrated to data and repeated by others.27 There are a number of tools that can be used to map events and/or processes and how these are connected, and these tools illustrate and analyse connections between people and processes.27 In Chapter 5 we referenced logic models to show the mechanisms of actions arising from the characteristics of each service delivery model studied and highlighted how these are shaped by moderating and mediating factors to produce patient and service outcomes. To synthesise our overall study findings and draw together features of service delivery and how these influence the system of medicines access, we constructed an overarching logic model using stages and components of the access process experienced by patients (see Appendix 31, Table 43).
Appendix 31, Table 43, shows how the service delivery models we studied are associated with factors that operate to support or impede the system components of the access process. It can be seen that some models appear to be operating better than others to support timely patient access to medicines. The traditional model of GP services as the main prescription provider has limitations and needs to be seen in the context of this being an overstretched service, with declining GP numbers and rising demand. We also found that GP services were associated with higher service (prescription) costs than a CNS prescriber service and higher total resource use costs than the TSL. CNS prescribers appeared to reduce the burden of access work on patients and carers and provide good information about EoL medicines and services, with fewer apparent delays experienced in acquiring medicines. Nevertheless, this model was not operating to its full potential because of CNS prescribers’ lack of access to electronic prescribing systems and deficiencies in the community pharmacy service. The TSL model also appeared to offer advantages by being available as a single point of contact at times of need, particularly OOH, shifting the work of access off patients and carers and using shared records and access to a local network of HCPs’ services to speed the access process. Although the TSL service had the greatest service costs, our data suggested that it may in fact be the most cost-effective. However, it should be noted that patient data in this site were limited and further research is required on similar OOH telephone support services to support these findings. In addition, our findings also show that community pharmacy services, in general, as well as community pharmacy-delivered commissioned services for palliative care, currently operate with a number of limitations that will need to be rectified if they are to deliver their potential.
Although our foci have been on ‘service delivery models’ and studying these in-depth has enabled a comprehensive understanding of each to emerge, in reality these may be combined as components experienced by patients as parts of a medicines access system. All patients will continue to receive medicines services from a general practice with whom they are registered. Our data suggest that combining this GP service with a CNS prescriber service delivery element, where the CNS may work in conjunction with or replace the GP service as the main prescriber, is likely to be advantageous in supporting medicines access and is likely to be less costly. Our data also suggest that the addition of a TSL service alongside GP services for patients receiving palliative care is likely to reduce burden on patients and carers, speed medicines access and may also be cost-effective. However, even with a shift to develop greater nurse prescriber and TSL services, all patients will continue to need to use a community pharmacy service as part of the access process. Therefore, the factors that currently work to limit the effectiveness of community pharmacy will need addressing to fully maximise the potential of any new services. In addition, in keeping with a systems thinking approach, consideration will need to be given to the impact of any intervention on each of the persons and processes in the system that we have described here.
Medicines access: key issues
Health-care professional survey respondents considered that pain levels of patients on their caseloads would be significantly better if access to medicines was improved. In addition, many HCPs in our study told us that accessing medicines at EoL is a critically important issue and one that they worked hard to try to address. Study findings highlight a number of overarching key issues operating to influence the access process and HCPs’ ability to support it.
Increased points of access through diversifying the prescriber workforce
Our data highlighted that, for many, GP services remain the dominant model for EoL patients to access new scripts and, yet, this is a service that can be characterised by burdensome and delayed access, as well as being more costly relative to other community-based services. In the context of a declining GP workforce and rising patient demand, the policy drive to diversify primary care service skill mix is already under way, with initiatives such as advanced clinical practitioner roles, GP practice-employed paramedics and PCN-attached pharmacists all increasingly part of primary and community care service delivery.69 Our findings suggest that a more distributed model of prescribing is also required, rather than one in which prescribing authority is invested in a single professional group (i.e. GPs). Enabling more specialist palliative care nurses to prescribe would benefit patients seeking to access medicines in the last year of life. Most specialist nurse prescribers in our survey considered themselves competent and prescribed frequently for patients, and in the CNS prescriber case site they offered good information and facilitated the co-ordination of services for patients. However, fewer than a half of CNS participants in our survey were trained as prescribers. CNSs are often employed by part or wholly charity-funded hospices. Although CNSs are a vital part of EoL care delivery, if they are less able to access NHS funding for prescribing training courses and backfill, then this limits their potential contribution to faster access to medicines for patients.
Community nurses also form a key component of EoL care delivery and further research is required to understand the potential of the CN workforce to prescribe palliative care medicines and the impact that this might have on the access process. Relatively large numbers of PCPs in our study were qualified as prescribers and also had good access to shared patient records. Although many PCPs were engaged in advising palliative care patients about medicines and/or undertaking medicines reviews, most reported that they did not feel highly competent prescribing in this area and were not prescribing often. Greater consideration could be given to further developing the role of PCPs who are interested in specialising in this area, with consideration of PCN population care needs.
Streamlined co-ordination required to access medicines
The often significant degree of co-ordination required to access medicines was apparent within all elements of service delivery that we studied. Characterised as a complex systems process inherent in the logistics of accessing medicines was the need to communicate with numerous different HCPs who are operating in different sectors of health-care delivery against a backdrop of urgent medicines need. Co-ordinating access was undertaken by HCPs and/or patients and carers. Some degree of co-ordination and liaison will inevitably be required across interfaces of health-care and delivery systems, and for some patients and carers this may be a desired part of self-management. However, the work of co-ordination was often overly lengthy and burdensome, and sometimes caused distress. Access points and processes for obtaining new or repeat medicines were not always clear to patients, and HCPs sometimes lacked awareness of services available to support access. Co-ordination was also often hidden work. At the TSL service site, staff reported that the work required to supply an EoL medicine to a patient was often deliberately hidden to reduce patient distress. We found considerable unseen work undertaken by CPs to support the supply chain of medicines into their pharmacies. The work of co-ordination appeared to be compensating for deficiencies in the access chain elsewhere, notably accessibility of GP services when they were the main prescribing service and community pharmacies when stock of EoL medicines was unreliable. The hidden work of co-ordination has been observed in hospital contexts. Allen70 observed the invisible work of nurses as focal actors, creating a myriad of processes to sustain networks through which care was organised and often acting as a countervailing force to very loosely organised health systems.70 The effort and time spent in co-ordinating access could be streamlined if more nurses were able to prescribe directly to patients, if all HCPs were able to access shared electronic records and if community pharmacy stocks were more reliable. Many HCPs in the study survey also recommended better integration of the MDT as one of their top solutions to medicines access problems. Combined with a more streamlined process, the use of a named responsible clinician or care co-ordinator, in line with national recommendations,24 might work to shift the focus of access away from reliance on GP services, reduce duplication of work across HCPs, and make a single point of contact for patients and HCPs, as well as make the work of co-ordination more evident. However, named care co-ordinators are only likely to be effective with improved interprofessional communication systems and, in particular, shared access to electronic records, including in the home. The TSL also appeared to offer a good service for EoL patients, providing an accessible single point of contact, particularly OOH, which functioned to offer the information-giving and co-ordination role that CNSs undertake in the home. However, the limited data collected on this service model, as well as its distinct features (i.e. being part of a larger digital hub with shared access to electronic records), mean that further research is required to evaluate the impact and cost-effectiveness of TSL services more generally.
Any recommendations for named care co-ordinators or single points of access need to be taken forward with cognisance of the often complex current organisational context in which EoL care is delivered. In keeping with our description of its complexity highlighted above, others71,72 have also illuminated the particular multiplicity of professional groups operating across different domains, sectors and levels of care in this context. The task of co-ordination might also be made more difficult by contested decisions about who should take on these roles. Although interprofessional rivalries were not an overt finding in this study, this has been found to be a feature of care delivery in the EoL context elsewhere,71,73 and this may, therefore, influence the feasibility, legitimacy and effectiveness of any appointed care co-ordinator roles. It may also constrain the development and contribution of nurse and pharmacist prescribing in this context. The reluctance of the medical profession to relinquish the authority associated with its long-held, unique prescribing role has been noted.74 However, as we move increasingly to a multiprofessional primary care and prescriber workforce, we might expect any such attitudes to be diminishing and to be less of a constraint.
The importance of patient–professional and interprofessional relationships
Underpinning the co-ordination work required to access medicines were pre-existing relationships between HCPs and patients and carers, and between HCPs in a locality. Where relationships existed, this exerted traction on the access process, generating commitment to action and speeding up the processes involved. Such relationships were evident in that some GPs (case 1) spent effort working outside usual systems to enable patients to stay in contact with them, CNSs and TSL support staff contacted other known HCPs in their local networks to initiate scripts or check stock and, in community pharmacy relationships with local HCPs, helped ensure the availability of stock. In contrast, where relationships were absent, this hindered elements of the access process. For example, commissioners of community pharmacy-delivered palliative care reported difficulties with awareness and continuity of services as a result of CP staff turnover and locums, and some CPs expressed the difficulty that they no longer had relationships with WDs.
The importance of continuity of care for patients is widely recognised, including at EoL.75,76 We have found that relationships formed when care is continuous support access to medicines. As demands on the health-care system increase, and in the face of staff turnover, there is great potential for discontinuity and further fragmentation of care, which will likely increase the effort and length of medicines access processes.
The study also found that there is potential for greater awareness by some HCPs of other HCPs’ services. HCPs’ lack of awareness means that signposting patients to such services, as well as HCPs’ own use of them, may be less than optimal. Attention to opportunities for interprofessional communication is warranted. Workshop participants told us that management of care delivery during the COVID-19 pandemic had forged ways of doing this, for example daily general practice–CP calls, including using video technology. This is an example of a more widespread trend in the increase in, and ease of, staff–staff interaction supported by digital technology noted to have occurred during the pandemic.77
Systems to support fast, electronic communication and information transfer
Access to shared patient records was a key area of HCP dissatisfaction to emerge from the study. CNSs, in particular, were dissatisfied with their current access, but all professional groups expressed relatively high levels of dissatisfaction about this. Respondents also identified shared records access as one of the top four solutions to problems with current service delivery. In addition, survey data suggested that HCPs’ access to shared records was a significant determinant of pain levels of patients on their caseload. The TSL service operated with full access to shared records, which was an important factor in its apparent success.
Health-care professional access to records when faced with a patient needing a medicine is essential for safe and accurate prescribing, which needs to be based on full knowledge of clinical and medicines history. Universal access across community service delivery interfaces (i.e. primary, community and hospice care), as well as with secondary care and between in-hours and OOH service delivery, is warranted. This access is also required in the home setting. The potential of CNS prescribers will only be unleashed if they are able to access patient records to support prescribing. Hospices are external to mainstream NHS IT systems, but during the study we did identify examples of localities where hospice-based CNSs were sharing patient records with other HCPs. Workshop participants also suggested patient-held records as a solution, a practice that has been more widely endorsed.78 Changes ushered in by the COVID-19 pandemic may also offer important learning here. Research77 has highlighted that the increased sharing of patient data enabled during this time was welcomed, and was supported by a streamlining of bureaucracy, increased tolerance of risk and responsiveness of digital suppliers to meet local needs. Urgent attention needs to be given to ways of integrating current and future IT systems to support shared access, not least because movement to a more multiprofessional prescriber workforce will result in an even greater need for interprofessional communication and co-ordination. Reflecting on the scale and pace of digital change in general practice during the pandemic, The King’s Fund77 recommend a review of procurement processes and a focus on the interoperability of systems by suppliers and national bodies.
The study also highlighted current inequity in access to EPS, with a majority of current nurse and PCP prescribers able to issue handwritten scripts only. The impact of this was apparent, with CNSs often needing to refer back to GPs to prescribe as a mechanism of transfer of scripts to pharmacy and, therefore, delaying patient access to medicines.
Given the multiple system components involved in the medicines access process, streamlined cross-system communication through both interprofessional access to electronic shared patient records and EPS available to all is critical to support timely access to EoL medicines.
Community pharmacy: community pharmacist integration and reliable medicines stock
Study findings highlighted a number of problems with the current community pharmacy service delivery to support access to EoL medicines. Some of these problems appear to emanate from CPs’ lack of integration within primary and community care MDTs and, therefore, within the patient palliative care pathway, from identification of EoL status through to death. For example, many pharmacists reported that they lacked awareness of patients’ palliative care status, which influenced their ability to help patients access medicines. In addition, prescriptions from GPs did not always match medicines in stock, which sometimes created a need to source medicines from other pharmacies. Calls have repeatedly been made for greater integration of CPs within health-care teams.79 In palliative care, RPS Wales25 recommend that CPs have greater access to patient records. In addition, workshop participants cited examples of improved collaboration with CPs through daily COVID-19-related interprofessional calls and CPs’ enhanced access to SCRs during this time. Study findings suggest that encouragement could be given to sustaining such innovations beyond the pandemic in the interests of hastening access to medicines and enabling CPs to fulfil a greater information-giving role to palliative care patients. This will need to be considered alongside redesigns in supply chain systems to free up CPs from the current onerous work they are doing to source medicines, especially in times of shortages.
Lack of reliable stock of the right medicines in community pharmacies was also a key finding, even sometimes at pharmacies commissioned to provide stocks of palliative care medicines. This caused work for both patients/carers and HCPs trying to source stock from other pharmacies and, thereby, delayed access and increased potential for distress. CNSs pre-empted problems caused by lack of stock by handwriting individual scripts for medicines so that patients could use different pharmacies for dispensing different items. Many CPs reported that they limited their stock of palliative care medicines because of medicines’ expiry dates. Mismatches between scripts received and medicines held, as well as CPs being unable to anticipate patient need, also contributed to this problem.
Additional problems with community pharmacy-commissioned services were an insufficient number of pharmacies in some areas, low HCP awareness of services, medicines’ lists were sometimes long and varied between and within services, not all pharmacies offered OOH services and pharmacies were not usually evenly geographically spread. Consequently, community pharmacy-commissioned services were often not local to EoL patients who could not, therefore, take advantage of them. Workshop participants endorsed the idea of a new commissioned service entailing a small and standardised core list of palliative care medicines universally held by all community pharmacies. Participants were also clear that many more pharmacies had been commissioned to provide stocks of palliative care medicines since the pandemic, and an evaluation of this will be of value. Other practices developed during the COVID-19 pandemic may also offer solutions. In the light of the demand for palliative care medicines and community-based care, workshop participants gave examples of localities where community medicines hubs (e.g. at local hospitals) were available 24/7 together with minimum delivery times and medicines couriered to patients’ homes. Furthermore, any learning from the legislation permitting reuse of CDs in care homes during the pandemic could be applied to CD reuse in other settings to offset wastage and speed access in some instances.
Even with greater diversification and expansion of the prescriber workforce, supported by streamlined systems for better communication and co-ordination, ease and speed of medicines access in all service delivery models will depend, in part, on community pharmacies functioning more effectively.
Consideration of the above may result in what we see as a gold-standard service delivery (i.e. patients who are well informed in managing their medicines and who know who their single point of contact is and how to contact them when new or repeat medicines are required). This gold-standard service delivery would allow for the right HCP to be easily and quickly contactable, patient records to be accessible (and checked) and medicines to be safely prescribed for a patient using electronic systems, including remotely in patients’ homes. Subsequently, the prescription would be smoothly transferred to the community pharmacy, which immediately dispenses the medicines from stock held and medicines would be delivered swiftly to the patient’s home, a process that is inclusive of OOH needs for medicines.
Strengths and limitations
A key strength of the study was its utilisation of a mixed-methods and multiple-phase design, as well as its use of views of multiple stakeholders, to produce a comprehensive and multifaceted evaluation of a complex health service and delivery issue. The use of integrated phases allowed us to investigate further key issues that emerged in previous phases as the study progressed. The online survey enabled us to gather large-scale data on HCPs’ current practices and influences in operation, and case studies provided complementary in-depth data, including the perspectives of patients and carers from an often hard-to-reach group, as well as illustrations of causal mechanisms at work. The study also included a health economics evaluation to enable assessments of costs and resource use of the different models. The study was designed to enable us to capture the views of all actors in the access process, from upstream WDs and service commissioners to CPs, other HCPs and patients/carers managing medicines in the home.
Our target numbers of HCPs completing the online survey were significantly exceeded in all but the CN group, despite extra recruitment efforts focused on the latter. Nevertheless, because of the survey method of distribution, response rates were not able to be calculated and respondents may not be representative of these HCP groups more generally. It is possible that some GPs, CPs, PCPs and CNs who participated were more likely to have had an interest in EoL care and, therefore, higher than typical levels of EoL medicines access activity and competence might have been reported.
In phase 3, patient recruitment was slightly lower than targeted in two case sites because of the lack of regular identification of patients on EoL registers and many not being cared for at home. In addition, at all sites, details of medicines prescribed recorded in patient records were not sufficiently comprehensive to enable timelines of medicines access actions and influences to be drawn up for all patients as we envisaged.
Despite CP recruitment challenges in phases 3 and 4, we spent time following up respondents, using snowballing, as well as local and national pharmacist networks, to overcome these challenges. This meant that, together with the CP and PCP sample size in the survey, the study captured the views of this important but often hard-to-reach and under-researched group. Commissioners and WDs were also hard to reach and recruit and, despite much time and effort spent in following up WD leads in particular, sample sizes for these groups were undertarget. Data were collected in the build-up to Brexit, which may have influenced recruitment. Insights were gained from interviews with these under-researched groups. It is acknowledged, however, that the interviewees recruited may not have represented the full range of views of the groups they represent.
The study included self-report measures to capture professionals’ and patients’ experiences. We applied methodological principles to reduce bias and enhance rigour, including the use of multiple methods and triangulation. The use of CRNs to recruit GPs and some CPs may have resulted in participants and/or service delivery configurations that differed from those operating outside these networks.
We did not include the views of pharmaceutical manufacturers in seeking to understand the supply chain of medicines into community pharmacies. Experience in this study suggests that pharmaceutical manufacturers may have proved time-consuming and difficult to recruit, requiring a longer and more costly study. It may also have been useful to have included more specialist HCPs, in particular those in the secondary sector, to further understand their contribution and influences on access experiences, as well as other actors now playing a part in community EoL medicines provision, such as paramedic prescribers.
Conclusions
To the best of our knowledge, the ActMed study is the first study to undertake a large-scale, in-depth evaluation of medicines access through the lens of service delivery models that form components of an often complex system. A mixed-methods design was used and multistakeholder views investigated to reveal current practice, as well as factors operating to support or impede the access process. We have highlighted where good practice is in operation, as well as components of the service system that are currently delaying access, causing unnecessary effort for many HCPs and increasing the potential for patient and carer distress when they are unable to obtain medicines in good time and with minimal effort.
Implications for policy, service development and practice
Study findings on the operation of service delivery models, influences on HCPs’ contributions and the current contribution of the nurse and pharmacist workforce to accessing EoL medicines in the community point to the following implications:
Greater consideration should be given by service delivery commissioners and managers to implementing named EoL care co-ordinators, in line with current EoL recommendations,
20,24 who would act as single points of contact for patients to initiate new or repeat prescriptions.
Strategic prioritisation by service delivery organisations of training for more CNSs to enable them to prescribe medicines independently to patients is needed. Funding also needs to be made available from Health Education England to hospices for the costs of HEI courses, as well as backfill costs, given hospice-employed CNSs’ important contributions to patient care and the potential benefits and cost-effectiveness of this model of service delivery compared with a GP services-prescribing model.
Consideration should also be given by Health Education England and community trusts to prioritising upskilling of larger numbers of the CN workforce to enable them to independently prescribe palliative care medicines and to support patients and their carers to manage these.
NHS Digital and local IT system suppliers need to work together to ensure that there is greater harmonisation of local IT systems so that all HCPs have access to shared electronic patient records across organisational interfaces.
NHS Digital and local IT system suppliers also need to work together to reduce current inequities in professionals’ access to EPS and ensure that all prescribing nurses and pharmacists working in the community have access to electronic prescribing systems, including in patients’ homes.
Commissioning TSL services might offer single-point-of-contact, cost-effective models of provision that work both in-hours and OOH to locally co-ordinate medicines access systems and processes, as well as acting as information-giving hubs about EoL medicines and services for patients and carers.
NHSE&I and other national policy-making bodies, such as RPS, as well as local CCGs and PCNs, should continue to drive the integration of CPs within the wider community and primary health-care teams and facilitate pharmacist embeddedness in the patient palliative care pathway, with access to information about patients’ palliative care status, with patient consent, via enhanced SCR or patient record access.
NHSE&I should consider a new model of commissioning community pharmacy services for palliative care, one that involves a smaller, rationalised, commonly agreed and widely recognised core list of medicines. National and local commissioners also need to ensure larger numbers of, and a more even distribution of, pharmacies or other community hubs holding a stock of palliative medicines, which is also accessible OOH and able to be delivered swiftly and free of charge to patients’ homes.
At a local level, primary, community and specialist palliative care service commissioners and managers should promote interprofessional awareness of EoL services, in particular those available OOH, in commissioned pharmacy services and those provided by specialist palliative care providers, including CNS prescribing.
Pharmaceutical WDs and their trade association should engage with CPs both individually and collectively for two-way communication about practices that best support efficient and equitable distribution of stock. In particular, both parties should consider more efficient and effective methods of sourcing medicines in short supply to free up pharmacist time to fulfil their potential in their professional, patient-facing role.
As above, given the complex system of medicines access as we have characterised it, action on any of these implications needs to be planned and consequences for each component of the system modelled to achieve maximum benefit. Similarly, a systems approach to further research (see Further research) is also recommended.
Further research
Potential areas for further research include:
a study to understand the feasibility, processes and impact of introducing and formalising a named EoL care co-ordinator role
further evaluation of the impact and cost-effectiveness of TSL and other similar OOH services on EoL medicines access, given the promising signals that were evidenced in this study
an evaluation of the impact on medicines access experiences, costs and outcomes of increasing the numbers of nurses and pharmacists prescribing for EoL patients being cared for at home
an evaluation of the impact and cost-effectiveness of new commissioned community pharmacy-delivered palliative medicines services
a full economic evaluation of service models in the light of their substantial budget impact over the eligible patient population
an evaluation of the impact on medicines access of good practice models in electronic shared records access, including the service requirements necessary to support greater shared access and how these might best be rolled out across health system interfaces.
