Transfer of Care Webkit

Transfer of care is when a patient moves from one health care setting to the next, and is seen as key to achieving an integrated, patient centric service where patients get the best outcomes from their medicines. Community pharmacy has the skills and the opportunity to be more involved with an integrated care pathway, designed to support patients manage their health.

This webkit, and the linked documents, aim to support the integration of community pharmacy services within a local transfer of care pathway, to link to key national documents, offer links to best practice in local areas and offer our own guide to setting up such a service. 

Setting the Scene

Introduction to the Transfer of Care Webkit

Transfer of care (ToC) can be defined as when a patient transfers between care providers, for example the transfer from hospital back in to primary care. During this time there is an increased risk of confusion or unintentional errors with medicines. This has been highlighted by the Royal Pharmaceutical Society, in their recently published report “Hospital referral to community pharmacy: An implementation tool kit”, which aids commissioners and pharmacy leaders in health economies to make a case for change and to implement a referral system.

Supporting the transfer of a patients care enables the delivery of an integrated, patient centric service that helps patients to maximum benefit from their medicines. Community pharmacy are a key professional group and ToC presents the opportunity to utilise their skills to provide integrated services that are designed to support patients to manage their health. On the back of the RPS report, this document aims to further support the development of a transfer of care service with the integration of community pharmacy. 
The need for the NHS to get the most out of prescribed medicines is particularly important in this time of austerity. Community pharmacy has a role to play in supporting patients with effective medicines use, and this is a key feature of the medicines optimisation agenda. NHS England commissions two community pharmacy services as a part of the national contract to support this strategy: medicine use reviews (MURs); and the new medicine service (NMS). 
The ToC project is a part of the PrescQIPP NHS programme. The overriding objective of the project is to proactively help NHS organisations to improve medicines-related care to patients, through the delivery of robust, accessible and evidence-based resources.
Most contemporary national themes in the NHS promote collaboration with the pharmaceutical industry in order to deliver improved patient outcomes, including efforts to provide more cost efficient care. The author of this resource, Allison Hogg, works for Napp Pharmaceuticals, and has been seconded in to PrescQIPP for 18 months as the Transfer of Care Project Manager:
“My objective for this secondment was to establish a local transfer of care service that supports patients to get the best from their medicines following a discharge from hospital, and to do this through utilisation of the skills within community pharmacy. By researching best practice examples from across the country and learning from my own experience, this has enabled me to share the successes and the common challenges in an implementation resource for areas interested in initiating a ToC service.”

What is 'Transfer of Care'

Transfer of care is the movement of a patient from one health care setting to another, for example from a hospital back in to the community. The risk of miscommunication and unintended changes to medications is a significant problem when patients move between care providers, and it is estimated that between 30% and 70% of patients have either an error or unintentional change to their medicines when their care is transferred. To minimise the risk of errors and to ensure patients get the best outcomes from their medicines, integration between health care providers is key.
The objective of a ‘transfer of care service’ is to support patients who have recently been discharged from hospital in order for them to get the most from their medicines, by integration with community pharmacy services.

Why is 'Transfer of Care' Important?

In the following sections we will introduce some of the key themes that highlight the importance of transfer of care in our current environment. We will look at the economic challenge within the NHS, as well as the policy that is the driving force towards better integration between health providers to improve patient outcomes.

The £20 billion challenge the NHS currently faces is seen as the toughest challenge since its creation in 1948, and estimates suggest that this will increase to £30 billion in 2015. In order to meet the increasing demand on health care from an ageing population and drive up quality with reduced resources, the NHS will have to find ways of becoming more efficient and productive. As reported in the RPS document Now or Never: Shaping Pharmacy for the Future, “A crucial part of achieving sustainable changes will be to ensure that resources and professionals are being used to optimum capacity, and in ways that have the greatest positive impact for patients.”

Guidance - Patient Safety Alert – Stage One: Warning

In August 2014, NHS England released a patient safety alert that warned all NHS organisations, other providers of NHS funded care and the social care sector, of the “risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care”. The alert highlights how NHS England intend to respond, “NHS England is leading a national programme of work to support organisations in improving the communication and management of information at handover by building on successful local and national initiatives already in place” (

The information gathered within this document can contribute to the web-based best practice resource that NHS England plan to develop, along with a series of webinars to facilitate system wide learning on this subject.

At the centre of NHS policy, systems and published guidance, the drive should primarily be to improve patient safety and outcomes, and this in turn will contribute to addressing the economic challenge.

Guidance - CQC Essential Standards

The Care Quality Commission (CQC) considers that managing medicines when a patient transfers from one setting to another is central to safe, high-quality care. Effective management of medicines is a requirement of the CQC essential standards of quality and safety (Outcome 9) alongside cooperation with other providers when care is transferred (Outcome 6). Improving the secure transfer of information about medicines across all care settings should reduce incidents of avoidable harm to patients, and contribute to a reduction in avoidable medicines related admissions and readmissions to hospital. (Outcome 21).

The CQC essential standards of quality: 
  • Outcome 6: Cooperating with other providers - People should get safe and coordinated care when they move between different services.
  • Outcome 9: Management of medicines - People should be given the medicines they need when they need them, and in a safe way.
  • Outcome 21: Records - Personal records, including medical records, should be accurate and kept safe and confidential.

Guidance - NHS Outcomes Framework

The NHS Outcomes Framework drives up quality throughout the NHS by encouraging a change in culture and behaviour focused on health outcomes not process. The indicators highlighted in the document are grouped around five domains, which set out the high-level national outcomes that the NHS should be aiming to improve. For each domain there are a small number of overarching indicators followed by a number of improvement areas. It is within these points that we can see how the drive for integration and utilisation of skills in all NHS organisations can support the priority improvement areas highlighted by the NHS.

Guidance - Medicines Optimisation

It has been reported that the total UK medicines bill in 2011 was £13.6 billion. In this time of economic pressure, it is crucial that patients get the best quality outcomes from their medicines and the NHS gets the most out of their medicine spend. The NHS is encouraging a noticeable shift from medicines management, focusing on process and systems, to medicines optimisation, focusing on outcomes and patients. The Royal Pharmaceutical Society reports some alarming statistics in their document Medicines Optimisation: Helping patients to make the most of medicines’:

Do patients take their medicines?

  • Only 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need;
  • Ten days after starting a medicine, almost a third of patients are already non-adherent – of these 55% don’t realise they are not taking their medicines correctly, whilst 45% are intentionally non-adherent.

Is the NHS getting best value from medicines?

  • In primary care around £300 million per year of medicines are wasted (this is likely to be a conservative estimate) of which £150 million is avoidable;
  • At least 6% of emergency re-admissions are caused by avoidable adverse reactions to medicines.

Medicines optimisation focuses on the patient and ensuring that the right patients get the right choice of medicine, at the right time. The goal of medicines optimisation is to help patients to:

  • Improve their outcomes;
  • Take their medicines correctly;
  • Avoid taking unnecessary medicines;
  • Reduce wastage of medicines;
  • Improve medicines safety

However, the medicines optimisation approach will require multidisciplinary team working to an extent that has not been seen previously. By improving safety, adherence to treatment and reducing waste, medicines optimisation will help to ensure that, by working together, all healthcare professionals support patients to get the best possible outcomes from their medicines. This presents an opportunity for pharmacists to become more involved within an integrated care pathway designed to support patients manage their health.

So how does medicines optimisation link to the NHS Outcomes Framework? As you can see in the diagram below, the medicine optimisation principles are described and can be measured in terms of effectiveness, safety and patient experience, which link directly to the NHS Outcomes Framework.

Enabling Community Pharmacy

In this section we will look at why community pharmacy provides an excellent opportunity to become more involved in the management of patients health and specifically in supporting patients with long-term conditions.

In the document ‘Now or Never: Shaping Pharmacy for the Future’, the Royal Pharmaceutical Society comment on the importance of community pharmacy involvement:
“The NHS is engaged in an urgent search for ways to provide better standards of care in the face of unprecedented pressure on budget, and justifiably intense scrutiny of quality. Only by adapting to the needs of patients with long-term conditions and preventable illnesses can this be achieved. Pharmacists have a vital role in helping the NHS make the shift from acute to integrated care, fulfilling the pressing need to do more for less”. 

The community pharmacy profession in the UK are an under-utilised resource with skills and expertise on medicines and their use. We know that 30-50% of medication is not used according to prescriber instructions, which is particularly prevalent for many long-term conditions such as diabetes, depression and asthma. When we also consider that these conditions are associated with high risk of hospitalisation, it is clear to see the impact that community pharmacy could have in supporting these patients to manage their health.  

The community pharmacy contractual framework that is already in place supports advanced services such as Medicine Use Reviews (MURs) and the New Medicine Service (NMS). MURs are structured adherence-centred reviews with patients on multiple medicines, particularly those receiving medicine for long-term conditions. The aim of the service is to improve patient knowledge, adherence and use of their medicines. Three national target groups have been identified to guide the selection of patients to whom the service is delivered. The three target groups are:

  • Patients taking high risk medicines
  • Patients recently discharged from hospital
  • Patients prescribed certain respiratory medicines

As detailed in the Now or Never: Shaping Pharmacy for the Future document, “Whilst MURs undoubtedly provide benefits to patients when used in an integrated way, there have been criticisms levelled at the way in which the national commission of the service focuses on bald numbers of reviews, and not on any assessment of patient outcomes, nor integration with other local primary care services”.

The NMS supports people with long-term conditions newly prescribed a medicine to help improve medicines adherence. The service is split in to three stages:

  • Patient engagement
  • Intervention
  • Follow up
Reducing medication errors causing harm has already been identified as an improvement area in the NHS Outcomes Framework under Treating and caring for people in a safe environment and protecting them from avoidable harm. The community pharmacy interventions detailed above support this strategy along with contributing to the quality and efficiency targets set by NHS England. Some of the activities that community pharmacy already deliver can be found in the table below.
NHS England states that Primary care services face increasingly unsustainable pressures, and that community pharmacy can play its role in the NHS transformational agenda by:
  • Providing a range of clinical and public health services that will deliver improved health and consistently high quality;
  • Playing a stronger role in the management of LTCs;
  • Playing a significant role in a new approach to urgent and emergency care and access to general practice;
  • Providing services that will contribute more to out of hospital care; 
  • Supporting the delivery of improved efficiencies across a range of services.
By developing the role of the community pharmacy team to provide personalised care, they can play an even stronger role at the heart of more integrated out of hospital services, provide a greater role in healthy living advice, improving health and reducing health inequalities and deliver excellent patient experience which helps people to get the most from their medicines.
Clare Howard, former Deputy Chief Pharmacist, commented that community pharmacy presents an opportunity to the NHS, “better value in the use of medicines through better informed and more involved patients. Pharmacists working with doctors and other health professionals, have an important and expanding role in optimising the use of medicine and in supporting better health”. 
Clare Howard also encourages community pharmacists to consider the following:
  • Recognise that adherence is a major problem;
  • Recognise your role in the solution;
  • Engage with medicines optimisation;
  • Engage with LPNs;
  • Support awareness raising with prescribers;
  • Accept that the default position of non-adherence is more realistic;
  • Collaboration and calibration - can we work together and measure? 
  • Be a part of the local urgent and emergency care review.
Since the introduction of these services, the potential benefit of utilising the skills within community pharmacy, as part of an integrated service, is evident. However, there has been criticism of the lack of integration between community pharmacy services and other local health services, including when a patient’s care is transferred from one healthcare setting to another. 

Recommendations for Enabling Transfer of Care

The Royal Pharmaceutical Society Recommendations

On 10 December 2014, the Royal Pharmaceutical Society launched Hospital referral to community pharmacy: An Innovators’ Toolkit to support the NHS in England. This is the first publication to be delivered by the Innovators’ Forum, a leadership group set up in response to the report Now or Never: Shaping pharmacy for the future.

Going forward, this document will be circulated to every CCG Medicines Optimisation lead, every Chief Pharmacist, every LPN and LPC lead in NHS England to start conversations in each health locality as to how effective referrals at scale can be made. At PrescQIPP we believe that this document will be an incredibly important tool to improve the enablement of community pharmacy in its role reviewing patients and fully support and endorse its guidance.The document can be found below via the following link:

External Link:

PrescQIPP Practical Guide to Establishing a Transfer of Care Service

tocdocfrontPrescQIPP has published a pragmatic step by step guide to implementing a Transfer of Care service, with key recommendations and considerations, to successfully implement a transfer of care service as detailed in the Royal Pharmaceutical Society report “Hospital referral to community pharmacy: An implementation toolkit”. The document recommends a number of steps (with lots of tips covered in detail):

1. Assign a Project Lead
2. Project Lead to research the local environment
3. Project Lead to engage with local stakeholders
4. Develop a project group with key stakeholders
5. Complete a risk assessment
6. Outline the existing service models
7. Design the service pathway
8. Establish a baseline criteria to measure perfomance
9. Complete a needs assessment of relevant parties
10. Service launch event
11. Project group review meeting
12. Monitor the effectiveness of service
13. Upscale the service
The document can be downloaded below:
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N.B. This document will be publicly available on 15th February 2015

Best Practice From Across the Country

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