Long Term Conditions Collaborative: Improving Care Pathways

A resource to improve care pathways for those with long term conditions.


Improvement Actions:

  • Improve delivery of pharmaceutical care
  • Use independent and supplementary prescribing, where appropriate, to make medicines more accessible to people
  • Work with local community pharmacies


Pharmacists are ideally placed to support people to manage their conditions. Poor adherence is known to occur in about 50% of people on multiple drugs and is particularly common in people with lower health literacy. Associated healthcare costs and premature morbidity/mortality are now at epidemic proportions. Medicines are frequently not taken as prescribed, due to multiple and complex reasons including adverse drug reactions ( ADR). ADR are often implicated in hospital admissions. These issues can be addressed through proactive medication reviews which include checking control of symptoms, side effects and concordance with prescribed drugs. Pharmaceutical Care is already delivered successfully by pharmacists working within CHCPs/Practices and through joint working with community pharmacies.

With the advent of the Chronic Medication Service, people with long term conditions will be registered with an individual pharmacy with a view to their pharmaceutical care needs being identified and supported. Serial prescriptions will be issued by the GP with plans for the pharmacist to carry out monitoring in between.

Many pharmacists currently run clinics as supplementary and independent prescribers. They work with patient groups with long term conditions like diabetes and COPD, and those with obesity and substance misuse problems. Pharmacists can play a key role in reviewing these patients medication and contributing to their treatment plans. Prescribing allows them additional flexibility to adjust as well as review the treatment plans and to prescribe for acute exacerbations where appropriate.

Reconciliation of medication at times of transfer in and out of hospital is important for safe and effective pathways. Medication management has an essential role in the care management for many people with complex conditions, for example in relation to multiple medication with high risk of adverse events and emergency admissions to hospital. Medication is also an important element of anticipatory care planning - ensuring that the person has access to 'just in case' drugs for anticipated flare ups. Providing a supply of antibiotics and steroids for patients with COPD is such an example of anticipatory prescribing.

As all these roles develop it is essential that pharmacists are seen as part of the healthcare team. They need access to relevant clinical data and need to be included in education and development programmes about long term conditions, self management and behaviour change to help people better manage their symptoms. Long term conditions commissioners should seek to engage pharmacists in managing long term conditions.


Falls prevention

In Edinburgh and in Glasgow people prescribed multiple medication and who are at risk of, or have had a fall, now routinely benefit from a medication review. In Edinburgh the reviews are provided by integrated care pharmacists or primary care pharmacists with communication with the community pharmacist. The NHS Greater Glasgow & Clyde ( GG&C) pharmacy team link with community pharmacists to refer people who require ongoing support. The community pharmacists are provided with training, remuneration, standardised intervention checklists and are supported by the practice or Falls team.

Community heart failure service

The GG&C heart failure nurse liaison service ( HFNLS) provides community-based structured education over eight weeks to stable newly diagnosed heart failure patients. This service also offers the opportunity for sessions with the community Heart Failure pharmacist in a choice of local community pharmacy premises. The session is designed to enable people to manage their condition better and includes basic education on heart failure medication, adherence support, symptom recognition and non pharmacological management issues (diet, salt intake etc).


The pathway in Forth Valley allows patients improved access to antibiotics and steroid medication through community pharmacy.

Contact: Katrina Kilpatrick, Forth Valley. Katrina.kilpatrick@fvpc.scot.nhs.uk

Targeted support for people in areas of deprivation

In three GG&CCHCPs, community pharmacists identify patients within the Keep Well programme who have multiple co-morbidities, polypharmacy and struggle to take their medicines regularly. The pharmacists carry out a structured intervention when the person collects their medicines from the pharmacy. Evaluation demonstrates improved prescription collection, and onward referrals to other services or professionals as necessary.

Home carers

Dumfries and Galloway's 'Care at Home' and Grampian's Carers' Medicines Management Project provide guidelines, training packages and support for home care workers and others assisting people to manage their medicines.

Contacts: catherine.smith4@nhs.net and wendyrobertson@nhs.net

Tackling Health Inequalities in South Asian Diabetic Patients ( NHSGG&C)

MELTS (minority ethnic long term medicines service) is an open referral service for any minority ethnic person who wishes a medication review. The referral route can be self referral, or by a family member or any primary or secondary care healthcare professional.

Contacts: Alia Gilani/Richard Lowrie, NHS Greater Glasgow & Clyde Pharmacy Prescribing Support alia.gilani@ggc.scot.nhs.ukrichard.lowrie@ggc.scot.nhs.uk

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