Community pharmacy services have attracted little management attention but are arguably the most accessible face of the NHS. Six million people visit them every day and the role of pharmacists in managing minor and chronic illness is set to increase significantly.
Local pharmaceutical services (LPS) pilots, introduced in the 2001 Health and Social Care Act, could reshape high street pharmacy. This initiative was heralded in the recent pharmacy strategy, and follows personal medical services (PMS) and personal dental services (PDS) pilots.
1The government has shown its commitment to local, rather than national, contracting for family health services. This is significant because local contracts end collective bargaining between the government and professions, and the monopoly GPs and pharmacy contractors have enjoyed providing primary care. They also introduce local cash limits and, therefore, greater local discretion over service delivery.
Pharmacy contractors are struggling with change.
The independent, pharmacist-owned pharmacy is being replaced by 'multiples'. Contractors of all sizes are suffering from competition from supermarkets, and the removal of resale price maintenance on a range of proprietary medicines may sound the death knell for small pharmacies unable to compete.
2Regulations for LPS pilots are still to be confirmed, but the framework holds a number of surprises.
Controversially, LPS schemes may offer nonpharmacy services to the NHS (but not GP and dental services). Examples might include sophisticated diagnostic testing or specialist nursing.
This could be packaged into an integrated chronic disease management service that includes 'medicines management' and routine assessment and treatment.
It offers an entry point to NHS services for large, forprofit pharmacy companies. This was hinted at when PMS was introduced, but ultimately rejected as 'too risky'. The government is unlikely to have such qualms about extending the role of the private sector.
Primary care trusts can also offer LPS pilots, promising greater control over prescribing budgets.A PCT-led scheme could monitor prescribing protocols at the point of supply. It could also purchase its own medicines - retaining the discounts usually enjoyed by retail pharmacies and reinvesting in patient care.
Such radical ideas are unlikely to enter the mainstream quickly. But LPS pilots also give the opportunity to make more modest changes. Under the national contract, pharmacists' income is largely determined by the volume of prescriptions dispensed. But this does not make the most of their skills. LPS pilots could encourage pharmacists to make a greater contribution. This could include providing more care to specific populations, such as people with asthma, and managing the ongoing drug therapy of people with multiple medications.
Local contracts could also ensure rigorous quality standards, clinical governance and continual professional development. PMS pilots have suggested that local contracts encourage a greater use of skill-mix; the development of new organisational types; and a focus on disadvantaged groups.
These issues are highly relevant to community pharmacy services. By law, a pharmacist must be present when pharmaceuticals are dispensed. But it could be more efficient to use trained dispensing assistants. In addition, independent pharmacies could group together to jointly employ additional pharmacists to free them to provide enhanced services. Local incentives could also ensure pharmacies in deprived areas were secure.
LPS is an opportunity to think creatively (see box).
Like PMS pilots, additional resources will be required, but whether money for more staff will be available, as it was to PMS pilots, is unknown.However, LPS pilots also present a challenge to pharmacists themselves.
The profession has long sought to convince government of its potential.
3It appears the government has listened; now is the time to act.
Creative review: models for local pharmaceutical services pilots
The single contractor model A complete transfer from the national contract.Funding transferred from the national 'global sum'.Dispensing and other services specified in a local contract with agreed quality standards.
The cluster model A group of pharmacies contract jointly to provide a full range of community pharmacy services.
Primary care trust model A PCT develops a comprehensive community pharmacy service that could be attached to a primary care centre.Pharmacists may be directly employed or sub-contracted and the PCT would purchase pharmaceuticals dispensed, retaining any 'profit'.
The client group model Individuals or groups of pharmacies contracted to provide services to identified client groups.This could include other disease management elements such as diagnosis, routine assessment and treatment.