Pharmacists have the potential to deliver a far wider range of services than at present - but the opportunity will be missed if primary care trusts do not act, writes Graham Clews
- Many pharmacists feel that the level of pharmacy services commissioning envisaged by last year’s white paper has not yet happened.
- They say that pharmacy tends to suffer from “pilot-itis” and is not made a priority by PCTs.
- Solid financial backing would minimise pharmacists’ risk when offering new services.
Four years ago, NHS pharmacy contractors began work under a new contract that split the services provided into three categories.
Essential services had to be provided by all contractors, advanced services could be offered where pharmacists were sufficiently accredited, and enhanced services allowed provision of services commissioned by primary care trusts according to local need.
Three years later, the publication of the 2008 white paper Pharmacy in England: building on strengths - delivering the future outlined how pharmacies could help contribute to the shift towards more treatment in the community, and self management of long term conditions, by encouraging a move among pharmacists from dispensing to clinical services.
The third tier of services provided by pharmacists - enhanced services - can be tailored to local demands, and it was hoped they would be the vanguard. Although they can be determined locally, they fit into 10 broad categories: needle exchange; stopping smoking; medication review; minor ailment services; out of hours services; supervision of administration of medicines; compliance support; provision of specialist drugs; support and advice for care homes on drugs; and supplementary prescribing by pharmacists.
The feeling among the pharmacy profession is that PCTs commissioned on average one or two services across the trust, which has risen to somewhere between five and 10 services. But the white paper envisaged many more.
Royal Pharmaceutical Society of Great Britain director for England Howard Duff believes the white paper did not “twist the arm” of PCTs to commission further, and more widely, from community pharmacists.
NHS Employers has since published guidance for PCTs on the pharmaceutical needs assessment, outlining PCTs’ responsibility to identify what is needed at a local level as part of the PCT’s joint strategic needs assessment.
Pharmaceutical needs assessments should encourage wider commissioning of services from pharmacies, and be used by PCTs in decisions on applications to provide services and for workforce development.
Mr Duff says the worry is that, although the needs assessment guidelines, world class commissioning guidance and the white paper are aimed at board level and will land on chief executives’ desks, they are often passed on to the senior member of staff with “pharmacy” in their title, usually the PCT’s medicines manager, who is not in a position to take a strategic overview.
Stephen Fishwick, head of external relations at the National Pharmacy Association, which represents community pharmacy owners, says a lot of the background work has been done to form the basis of service redevelopment and planned investment among pharmacies, but very little of it is yet visible on the high street.
“Pharmacy tends to suffer from ‘pilot-itis’, with PCTs tending to invest for a short period,” he says. “And if contractors are to invest in staff and premises they need confidence that any contracts are going to be sustained.”
He lists three factors - imagination, sustained investment and sheer effort - that will be needed from PCTs if they are genuinely to increase the range and volume of services commissioned from pharmacists.
“The Department of Health’s world class commissioning framework says commissioners should communicate with the market not as a mere funder but as an investor - a richer and more involved relationship that will give PCTs a rounder view of the provider base and its linkages,” he says. “This can only be a good thing for those providers whose contribution and potential is currently often overlooked, due to low awareness about their true significance to the health system.
“PCTs need to be able to think very broadly about their commissioning and decommissioning decisions, basing them on a projection of the consequences for the whole health and social care system, now and in the foreseeable future.”
Rob Darracott is chief executive of the Company Chemists’ Association, which represents the major chain pharmacies including Lloyds Pharmacy, Boots and Superdrug, as well as the major supermarket players: Tesco, Sainsbury’s, Asda and Morrisons.
He says PCTs receive a huge amount of instructions and guidance from the centre on what may or may not help the successful commissioning of a wider range of services from pharmacists. But in among the broad policy outlines, the nitty gritty is often forgotten. Pharmacies have a legal requirement for a pharmacist to be present, for instance, so it is difficult for a small, independent ones to fit in commissioning meetings with the PCT.
Howard Duff says the white paper was a ringing endorsement of increasing diversification among pharmacies. The problem is that the pharmaceutical services negotiating committee, which represents the 11,000 pharmacy contractors in England and Wales, and NHS Employers, on behalf of the Department of Health, are still working on its implementation.
Mr Duff says PCTs need to do more planning and make the business case for greater commissioning from pharmacies as financial savings can be made. This is happening, he believes, just not fast enough.
Quick to change
Harmonisation of training is also needed. In the NHS North West area, all PCTs have agreed to recognise training provided by neighbouring PCTs.
But in other parts of the country, a pharmacist may receive initial training when a PCT commissions a new service, but ongoing training is rare. The relatively high turnover among pharmacists means that within a short time of the new service being commissioned, the pharmacy providing it will be short of staff with the necessary skills, and those pharmacists who move on will be unable to use their new skills elsewhere.
The royal society’s English pharmacy board is working on harmonising this accreditation.
NHS North West is recognised also as a leading player in greater commissioning of primary care services from pharmacists. Chief executive Mike Farrar wrote to all PCTs across the region inviting them to take part in a pilot jointly led by the NHS Institute for Innovation and Improvement and the royal society, to deliver a pharmacy weight management service.
Central Lancashire PCT worked with representatives from pharmacy, general practice, commissioning, finance/”>finance, public health, and dietetics to set up the service, which includes assessment and issue awareness among patients, and advice and support sessions on eating and exercise.
Anne Adams, who runs the royal society’s Leading Across Boundaries scheme, says commissioning the service was not without its problems, but the presence of top-down (from the SHA chief executive) and bottom-up support, from pharmacists and GPs, made it possible.
Mr Duff says there are problems on both sides contributing to the slow progress in most of the country. While many community pharmacies are keen to enhance their patient-facing clinical role, others simply are not interested in providing extra services
Both the big chains and the small independent pharmacists have their advantages. The independents can be flexible, quick to change, and in some cases, highly innovative. Larger chains can offer a wider range of skills, the will and drive to move forward, and the ability to deliver across large parts of the country.
Chicken and egg
One stumbling block has been mixed success with the national, not locally commissioned, advanced tier service of the medicines use review (see box).
With this service pharmacists review use of medicines, prescribed and non-prescribed, usually for patients with long term conditions on multiple medicines.
The aim is to encourage patients to better understand their condition, and their treatment, and it was also seen as an incentive for pharmacists to provide consultation spaces that are appropriate for confidential appointments and which could then be used for provision of other services in the future. Criticism from GPs and some bad press have left some pharmacists loath to expand even further.
An aspiration in the pharmacy white paper was the creation of healthy living centres, which would increase the public health role of community pharmacists.
Hampshire local pharmaceutical committee chief officer Mike Holden sits on the Department of Health’s pharmacy public health leadership forum, and locally he is working on a model for healthy living centres as a “scoping exercise” that can be adapted by PCTs around the country. For him, the “chicken and egg” nature of the provision of premises, and extra investment in training, is one of the key problems.
“From a pharmacist’s point of view, do we do extra work and hope we get commissioned, or do we do it the other way round and wait until we get commissioned?” he asks.
If pharmacies wait to be commissioned before they make any significant investments, there may be one or two years’ lead time in terms of workforce, training, or premises before the commissioned service can be up and running: not ideal for PCTs.
Mr Holden says there are conversations going on at a national level on how this problem can be addressed.
The National Pharmacy Association is researching pharmacy contractors’ views on local commissioning of pharmacy services. The early data suggests PCTs can release more energy from pharmacists by looking at routine administration, and taking a strategic view of benefits of service redesign.
“Lots of these guys are small independent contractors, and they don’t have big back office functions,” says Mr Fishwick. “The procurement process can often be unmanageable - the documentation involved, and particularly the speed of turnaround required, can be too much and monitoring of any contracts can be very time consuming”.
To ensure pharmacists have the confidence to move into new areas, it will be vital for them to have the support and the financial help to minimise their risk.
“The efficient operation of the NHS market requires that no provider group should expect commissioners to cosset them,” says Mr Fishwick. “Nevertheless, commissioners should not be bystanders to the fortunes of their key providers. World class commissioning states that PCTs should give providers direct support for innovation and change where necessary.”
One of the solutions, he believes, is that the needs assessment will create a “genuine linkage” between PCTs’ commissioning arms and pharmacists. For too long, he says, pharmacy services have been put into a “medicines box”, and have been “completely disconnected” from the core work of PCTs.
“There is an urgency to all this, as it’s been a while since the first noises were made about pharmacy taking on a more central role in the health service,” he says.
“The pharmacy profession wants to grasp the challenges set out in the pharmacy white paper, but they do have a shelf life, and if these proposals are not capitalised on, pharmacists will have no choice but to return to their retail business and that would be a great shame for the NHS.”
100 club: opening the market
The number of pharmacies has increased by around 500 over the past five years or so, which is good news for patients, who have easier access to more pharmacies, often with longer opening hours.
The number of core contractual hours that pharmacies must open is 40, but one problem for PCTs wanting to commission extra services from pharmacies is the 100-hour exemption to PCTs’ control of entry.
PCTs currently have to decide whether an application to open a pharmacy is “necessary and desirable”.
But, under regulations introduced in 2005 to stimulate the market and provide a better out of hours service, if a pharmacy agrees to open for 100 hours the PCT must waive this test.
Some pharmacists complain that the staffing requirements for 100-hour pharmacies can skew workforce arrangements, and that 100-hour pharmacists tend to be in out of town shopping centres, making them less accessible to many patients with low income, or disability.
The National Patient Association has called for a moratorium on the exemption, and head of external relations Stephen Fishwick says it is about encouraging confidence.
“Pharmacists will wonder why they should risk investing, in premises particularly, if they know a 100-hour pharmacy could plonk itself down next door, and strip away their patients, and their relationship with local GPs,” he says.
Company Chemists’ Association chief executive Rob Darracott says his members have conflicting views on the 100-hour exemption, but “when the new needs assessments are in place that will ensure there is a level of rigour in the process that perhaps was not there in the past”.
New model: targeting patients in the North West
The medicines use review service has been evaluated across the NHS North West area by its pharmacy workforce development group, and a new model has been commissioned by Trafford primary care trust.
Under the new system, pharmacists are helped to identify target patients.
Trafford PCT head of pharmacy services Harriet Lewis says the type of patients targeted - those with cardiovascular, respiratory, or diabetic problems - is no surprise, and is part of the PCT’s commissioning strategy to integrate the service into the whole health economy.
Pharmacists have training to help improve their relationship with GPs, and GPs are encouraged to inform patients who may benefit from the system of its existence.
On the Wirral, the PCT has commissioned an alcohol screening and brief intervention service from pharmacies. Pharmacy staff, rather than pharmacists themselves, offer patients what is called an “alcohol quiz” on an opportunistic basis, with pharmacies paid per screening.
NHS Wirral community pharmacy lead Tee Weinronk says a similar scheme was tried at another PCT, but with less success.
The difference is that the Wirral’s service provides all the training for pharmacy staff, she says, and the PCT ensured that one or two pharmacies in the area acted as “standard bearers” for the scheme.