CLINICAL MANAGEMENT

Published: 07/04/2005, Volume II5, No. 5949 Page 26 27 28

The new pharmacy contract, which went live last week, envisages a future of 'health resource centres' rather than corner shops dispensing medicines. But money for developing enhanced services will have to be found out of existing PCT budgets. Ann Dix reports

Greenlight Pharmacy, in the heart of the Bangladeshi community near London's Euston station, is not your standard high street chemist.

Gone are the perfumes and tights. In their place is a private consulting area where people can seek health advice or have regular health checks for blood pressure or cholesterol.

Qualified Bangladeshi translators are on hand, and a seminar room, seating up to 30 people, is used for health education and support groups.

This transformation, from a retail outlet that dispenses medicines to a fully fledged health resource centre for the community, began six years ago, says pharmacist John Foreman. Health services provided under contract to local NHS and other community health and social care organisations include smoking-cessation clinics, treatment for minor ailments and the monitoring and medicines management of people with longterm conditions, including housebound patients.

Public health is a major part of the role. 'A lot of our work is about behaviour changes and supporting people to change their lifestyle. It is about enabling self-care, ' says Mr Foreman.

Another significant benefit is the access pharmacists have to people who do not normally come into contact with the health service. 'We provide good access and people trust us. We see everyone who comes in as an opportunity.' It is a model that will be encouraged by the new pharmacy contract, which went live last week.

However, Mr Foreman stresses that it will not be suitable for everyone. 'We have been creative and managed to get lots of funding, ' he says. 'But it has taken years to establish community links and build it into a viable business. Some pharmacists will want to stick with retailing and prescriptions.' Heralded by the government as 'a new era for community pharmacy', the contract will reward pharmacists for the range and quality of services they provide rather than the volume of medicines they dispense. This will encourage them to broaden their services, including taking on some of the work previously done by GPs and other health professionals.

Into the fold

Bringing community pharmacists into the heart of the NHS will also increase the range of providers available to health commissioners, helping them meet local needs and deliver on national targets. Pharmacists will contribute to NHS service provision in four main areas: selfcare; management of long-term conditions; public health; and improving access to services.

Primary care trusts will have a key role in implementing and monitoring the new contract, supporting pharmacy contractors and developing new pharmacy services to meet local needs.

Implementation starts now, but PCTs have until October to put arrangements in place.

Michael Levitan is secretary of the Middlesex Group of Local Pharmaceutical Committees, representing 550 pharmacies across nine PCTs in north-west and north-central London. He stresses that the contract will require a 'considerable amount of work by PCTs', but that those in his patch are rising to the challenge. 'There is a determination to get this right and make full use of the new flexibilities of the contract, ' he says.

But he adds: 'It will require a bit of a cultural shift for pharmacists who, without being disparaging, are used to being ignored.' Mr Levitan believes the benefits will be considerable: 'It will give greater flexibility for managing patients in the right place and at the right time, ' particularly when you add to the mix practice-based commissioning, the development of pharmacists with special interests and new and expanding freedoms for pharmacists to become supplementary and independent prescribers.

It may also include pharmacists providing services in areas where there is a shortage of GPs, or filling gaps in out-of-hours provision. This is especially relevant in London, where the GP recruitment problem is particularly acute, he says.

Ripe for development

A major opportunity is offered by the fact that pharmacists come into contact with patients across different practice populations, he says. This makes their role in the management of long-term conditions 'a huge area ripe for development, particularly for respiratory diseases such as chronic obstructive pulmonary disease and asthma, where patient care can be poor'.

'But patients have to be comfortable in accessing services in this way and satisfied that they are of equivalent quality, and this will come down to PCTs' training and accreditation, ' says Mr Levitan.

One potential barrier could be funding. The government has allocated£1.766bn to fund the core contract, but money for developing enhanced services to meet local needs will have to be found from PCTs' existing budgets.

National Pharmaceutical Association NHS liaison manager Neal Patel says it is right that pharmacy 'should compete on a level playing field with other services'.

'It is up to us to show that we can do it better or that we can reach patients that others can't - even perhaps that we can do it cheaper, ' he says.

But others, like Hillingdon PCT pharmaceutical adviser Shailen Rao, are disappointed that money has not been ringfenced for developing enhanced services. Mr Rao, who has led on an innovative service for people with diabetes (see box, page 27), says the contract gives 'a better chance of continuing existing services' but fears that 'without ringfenced funding the potential for innovation across the country will get stifled'.

South East Hertfordshire PCT chief pharmacist Heather Gray agrees that 'implementing the contract is not going to be cheap or easy for PCTs'.

But she argues that essential services, such as health promotion campaigns and repeat prescriptions, will have to be paid for under the contract anyway, so it is worth PCTs investing upfront to get it right. Developing pharmacist-run services such as out-of-hours might also be more cost-effective in the long run.

In many cases, the contract provides a formal framework for roles that pharmacists are already providing. At Brighton and Hove City PCT, for example, pharmacists have provided needle exchange and methadone services for heroine addicts for years. Other services include emergency hormonal contraception, smoking cessation and a minor ailments scheme that is being funded as an enhanced service under the new general medical services contract.

PCT head of medicines management Jane Moffatt puts it down to the enthusiasm of local community pharmacies combined with the PCT 'trying to be more creative and holistic about who is the best person to deliver services'.

She says the contract will bring a new discipline to what they are doing, which up until now has been rather ad hoc.

'It will be a learning exercise on both sides.

We will need to be more sharp and rigorous about what we are contracting for and how we are monitoring it. If we are investing money in training we will also be looking for pharmacists to come into the arrangements with commitment, and we will need to look at skill mix and staffing levels.'

As a measure of the PCT's own commitment, chief executive Gary Needle recently spent a day visiting local pharmacists. Ms Moffatt says one of the areas they are focusing on is how pharmacists might help in managing people with long-term conditions - for example, using targeted health promotion campaigns. 'We are also looking at what help and guidance we can give to community pharmacists as to where medication review is best targeted, and then give them training.'

Valerie Shaw is chief pharmacist for Greater Peterborough primary care partnership, which comprises two PCTs and adult social care. 'We use community pharmacy a lot already, ' she says.

'We have a few innovative ones, but the challenge will be to engage them all. They will need a lot of nurturing and guidance. We are asking them to make changes to 20 or 30 years of working.'

Generic workforce

One initiative has been to deploy community pharmacists in hospital dispensaries to increase their clinical skills, who have 'then been happy to work with GPs'. The idea is to create a 'generic workforce' capable of providing follow-up for patients who have been discharged from hospital, she explains. There are also plans to develop an electronic discharge record that will tell the pharmacist which drugs the patient is taking.

Another project has been the piloting of a minor ailments scheme in a deprived area of Peterborough. This has been so successful, particularly in controlling the spread of head lice, that it is now set to be rolled out to all deprived areas in October, she says. She adds that future initiatives are likely to be Cambridge-wide, with a major focus on long-term conditions.

But for PCTs that have lost out in the new funding allocations, the pharmacy contract may be a missed opportunity. East Yorkshire PCT has a well-established programme of community pharmacy projects, targeted to local priorities and carried out in collaboration with three neighbouring PCTs. Recent developments include a chlamydia testing service, set up in September last year, and training pharmacist technicians to deliver smoking cessation counselling.

But, as East Yorkshire PCT head of prescribing and medicines management Jackie Matthews explains, 'it is unclear in the current financial climate, because we are a net loser in the way that the funding mechanism has been set up, whether we will be allowed to continue existing services, let alone develop new ones'.

'The pharmacy contract is very exciting, but the downside for us is that there is no money for service development, ' she says. 'It is like being asked to do something with your hands tied behind your back.'

AT YOUR SERVICE THE NEW PHARMACY CONTRACT

The contract introduces three levels of services: essential and advanced, which form the national contract; and enhanced, which will be commissioned by primary care trusts.

Essential services have to be provided by all community pharmacy contractors. Examples are repeat dispensing, health promotion (including six health promotion campaigns a year) and support for self-care for patients with minor ailments.

Advanced services can only be provided by accredited pharmacists - eg medicines review.

Enhanced services will be commissioned by the PCT according to the needs of its population. Examples are minor ailments, needle exchange and supervised methadone for drug misusers, smoking-cessation clinics and supplementary prescribing.

EDUCATE TO ACCUMULATE

THE RISE OF THE COMMUNITY PHARMACIST

A diabetes health improvement programme by Hillingdon primary care trust is showing the potential of community pharmacists in the management of longterm conditions.

Education by pharmacists is improving patients' understanding of the disease and medicines, with big benefits.

First piloted in four pharmacies as part of a diabetes care model in 2002, it has now been extended to 10 pharmacies.

PCT senior pharmaceutical adviser diabetes lead Shailen Rao explains that the primary objective was to improve patients' compliance with their medicines.

The real issue

'Patients whose symptoms were out of control were often having their medication increased, when the real problem was that they were not taking it properly, ' he says.

'If you do not tackle patients' understanding of the disease you will not do anything about their understanding of the medicine, ' he explains.

'It is about uncovering their beliefs.' Patients seem to open up to a pharmacist, he says, perhaps because they find it less intimidating than seeing a doctor.' 'It is more of a partnership, and the setting is less scary.' Patients are recruited in the pharmacy or by referral, and are monitor pharmacists also test and them.

Steady progress

From referral to first follow-up appointment, the proportion of patients with poor understanding of the disease fell from 31 to 13 per cent, while those with poor understanding of their medication fell from 35 to 14 per cent.

Patients also showed improvements in glucose and cholesterol levels, either due to the intervention or because, as a result of the service, 'GPs were looking after them better', says Mr Rao.

The PCT funds the service from its medicines management budget. It now plans to make it an enhanced service under the new pharmacy contract and is training four pharmacists to be supplementary prescribers.

LIFE BLOOD NNOVATIONS IN ANTI-COAGULATION

In Stanley, county Durham, trained community pharmacists have been running an anti-coagulation service for the past seven years.

Pharmacist Noel Dixon says: 'Patients love it because It is local. Because the clinics start at 8.30am it also means people do not have to miss work.' He and his two colleagues see around 400 patients, as well as 90 domicilary cases, referred from GPs and secondary care.

Patients are given a simple finger prick test, then the pharmacist adjusts their warfarin dose and makes the appropriate record.

The information to GPs is now much better because the pharmacists send them regular updates, which they did not get before, he says.

The service complies with British Haematological Society guidelines. 'The important thing is that, a) the training is appropriate and b) there is enough cover for holiday and sickness, ' says Mr Dixon.

Roll with it 'The PCT is now planning to roll it out through general medical services as an enhanced service because the local hospital no longer wants to provide the service, ' he says.

'It is a way of moving services from secondary to primary care without putting more pressure on GP surgeries.' He adds that his own job satisfaction has increased. 'It is a nice thing to do. You get a lot of patient contact and you see people in their own homes.'

Find out more

Department of Health - medicines, pharmacy and industry

www. dh. gov.uk/policyAndGuidance/Medicines PharmacyAndIndustry/fs/en

Pharmaceutical Society negotiating committee www. psnc. org. uk/contract

NHS Confederation www. nhsconfed. org/pharmacy

NHS Modernisation Agency - national primary and care trust development programme www. natpact. nhs. uk/cms/301. php

Key points

The new pharmacy contract awards pharmacists for range and quality of services, not volume of medicines dispensed.

Pharmacists' cross-area access to pat ients makes them well placed to take a lead role in the management of long-term conditions.

Funding may be a barrier to development under the new contract, as money for developing local enhanced services must come from existing primary care trust budgets.