The Pharmaceutical Journal Vol 263 No 7063 p406-407
September 18, 1999 News

A new primary care pharmacy company in the Midlands

Mr Andrew Burr, a member of the Council of the Royal Pharmaceutical Society, has set up a company in Nuneaton, Warwickshire, to offer prescribing support to general medical practitioners and medicines management services to patients. The editor of The Journal (Mr Douglas Simpson) visited Mr Burr recently to find out about his plans

Andrew Burr Primary Care Group Ltd, of which Mr Andrew Burr is the managing director, was officially launched at the British Pharmaceutical Conference in Cardiff. The prescribing support and medicines management services it offers include the following:

Where possible, the services will be carried out through community pharmacies. The idea is that community pharmacists, working with PCGL, will provide the services themselves where they can meet the necessary standards. Where they cannot, the work will be carried out by PCGL. The company will have staff, either full-time or working on a consultancy basis, with the necessary advisory or practical skills. Remuneration is to be apportioned according to the level of responsibility taken by the community pharmacist and the company.
As things stood today, said Mr Burr, not every community pharmacist could provide the level of services that PCGs needed. Working with his company, community pharmacists would be able to offer more than they would be able to achieve by themselves. With his concept, they would all have the capability of offering primary care services.
For the present, Mr Burr's focus is local — on Nuneaton and Warwickshire — but his ambitions are much wider than that. He wants to float his company and to franchise his operation on a national basis. He plans to offer pharmacists the chance to buy 25 per cent of the equity.
The new company is based in a refurbished listed building at 25 Coton Road, Nuneaton. The ground floor has been fitted out as consulting rooms (of which there are three) for pharmacists to carry out medication review and similar services. There is also a laboratory with machinery to carry out near patient diagnostic tests for such parameters as blood lipid levels and for therapeutic drug monitoring, for example, of anticoagulation rates. There is an attractively furnished reception area and access from the street for patients.

Call centre

Call CentreTwo further floors, served by a different entrance, house administrative offices and a call centre equipped with eight work stations. The centre will be used, among other things, to take calls from patients requiring appointments for medication review. There is also a room with hardware for connecting lap-top computers — to be used by the company's consultant pharmacists — into the company's intranet. The intranet is based on a large capacity server. Connection to the outside world is via an ISDN line. Mr Burr says that his company has a number of strategic partners with expertise in telecommunications and information technology.
A distinctive company logo based on a sunflower has been devised and will be used to brand the company's services wherever they are on offer. Primary Care Group Ltd is the overall company. But within that there will be various other titles in use: Primary Care Access (for telecommunications), Primary Care Community (for community based services), Primary Care Consultancy (for, as its name implies, consultancy) and Primary Care Innovations (for IT initiatives).
The prescribing support services being offered by PCGL have been developed against a background of spiralling prescribing costs, the absence of a coherent infrastructure for the support of GPs in this area of activity, and an ageing population. Funding is available, since, according to Mr Burr, 481 primary care groups in England are investing about £50m in prescribing support services this financial year.
The company has already been contracted to provide prescribing support services in Nuneaton and Stratford on Avon.
Formulary work will comprise the first phase of the company's development. The services on offer in this phase have their roots in the Welsh prescribing support project, in which Mr Burr, as pharmaceutical adviser to the West Glamorgan family health services authority, played a prominent part. In that project, pharmacists visited GP practices to facilitate the development of practice formularies and treatment guidelines. It established, according to Mr Burr, that a pharmacist could have a major impact on prescribing costs. It had shown that for every £1 invested in prescribing support £5 could be saved.
Inspiration had also been drawn from a chapter in a book edited by Marshall Marinker ('Controversies in health care policies: challenges to practice', London: BMJ Publishing Group, 1994) in which the term primary care pharmacist had been used and the duties of such a practitioner had been listed as "formulary management, medication review, prescription query, pharmacokinetic assessment, compliance assessment and drug counselling." Primary care pharmacy was, said Mr Burr, an area of great growth and many practitioners were moving into the field.
He favoured, he said, a bottom up approach to formulary development, which meant working with GPs on their preferences, rather than dictating what they should include.
As well as helping to create and update GP formulary systems, PCGL would, at a later stage, offer via its IT systems a monitoring and reporting scheme which would allow non-formulary prescribing to be logged in community pharmacies and reported back by the company to the GP practices concerned. This would be possible as a result of the practices' formularies being held on the PCGL server, allowing participating pharmacies to be warned of non-formulary use in relation to a particular practice. The system would also give community pharmacists notice of the introduction of the various practice formularies so that they could adjust their stock appropriately.
The company, Mr Burr said, would be offering audit of selected patient groups (for example, those taking more than six prescribed drugs) and medication review clinics to review and manage medicines use by particular types of patients. Also on offer would be audit of treatment dosages, for example, whether they were at an appropriate level.

GPs choose

All these services for GPs would be offered in relation to specified disease area modules, such as infection control or cardiovascular disease, and the GPs could choose that any or all of those areas should be covered. Thus, GPs would be able to tailor the service they received to their perceived needs.
Asked which pharmacists would be providing the primary care services involved, Mr Burr said that any pharmacist could provide them provided that they met the necessary standards. The more continuing professional development a pharmacist had undertaken and the more training he or she had undergone, the more services they would be able to provide. There would be many pharmacists capable of formulary development, but he expected that fewer would be capable of running medication review clinics.
In some quarters, Mr Burr acknowledged, it was thought that primary care pharmacy could undermine community pharmacy. But that was not so, he declared. Experience in Wales showed that community pharmacists could successfully perform the primary care pharmacy role. The primary care pharmacist could be a freelance, a hospital pharmacist, work for a multiple or be a local pharmacy contractor. The key was standards. If a pharmacist was able to meet the standards they would be able to do the work. What PCGL specialised in was setting up and delivery processes that worked. Who provided them was secondary.
As the additional management and other duties placed on GPs increased, undue pressure could be placed on their clinical role. Taking over the administration of calls for such things as medication review clinics, queries on medicines or other health matters was one means of easing the load. Mr Burr said that his call centre had the potential to answer the telephone for every GP and pharmacist in Nuneaton as if it were the GP or pharmacist concerned. This could allow practitioners to increase the range and quality of patient services they offered. For example, patients identified as requiring medication changes or review could receive a letter from their GP giving them a telephone number to call for further advice or to book an appointment. The telephone would be answered at the call centre.
PCGL also intends to facilitate the provision of health screening services. It is planning to locate touch-screen computers in places where there is a high public footfall, such as job centres and major stores. It had developed, said Mr Burr, a series of touch-screen programs to enable members of the public to perform a risk assessment for, say, coronary heart disease. The computers provided print-outs based on life style data that the user could take to a pharmacist or doctor. The programs could be adjusted so that particular thresholds of risk could trigger recommendations to seek professional help. These thresholds could be set by local GPs or the health authority. The computers were to be located in special kiosks which were also to be equipped with a telephone. Using the telephone, a patient would be able to contact the call centre and request advice or help. Patients would then be able to discuss their problems with local health professionals or request a call back by a health professional at a time convenient to them. The kiosks could also be located in pharmacies. A suitable environment for them is being designed.

Patient registration

Mr Burr plans, in the second phase of his company's development, that patients should be able to register with PCGL. They would do so through their local pharmacy. PCGL would provide to registered patients such services as medication review clinics or near patient testing that the pharmacy contractor might not be in a position to provide. Since PCGL would be providing the service it would retain the greater part of the fee, giving the balance to the local pharmacy for having registered the patient in the first place. If PCGL trained the contractor to provide the service, the fee position would be reversed.
With such an approach, there was no reason why individual pharmacies should be left behind in the move to offer extended services, Mr Burr said.
Summarising, Mr Burr said that his new company was seeking to develop an outcome based model that would deliver tangible benefits to patients and the National Health Service.