Primary care is changing. NHS Direct, the new nurse-led telephone advice line, is one example of the changing interface between the public and health services. This article outlines recent changes, and considers the implications of this policy shift for community pharmacy
Primary care has undergone enormous changes over the past decade. The introduction of the new general practitioners' contract in 1990 changed GPs' contractual responsibilities, and the subsequent introduction of GP fund-holding represented a further change in primary care provision. GP co-operatives have radically changed the way "out of hours" primary medical care is delivered. The Primary Care Act 1997 created personal medical services pilots, allowing increased local flexibility through local contracts, new providers of primary care and salaried doctors. More recently, NHS Direct was announced in 1997, and walk-in centres were announced last year. All these initiatives represent a shift away from traditional primary care, and a trend towards a more mixed economy of primary care provision. These initiatives have implications for pharmacists working in the community.
The intention to develop a national direct access telephone service, NHS Direct, was announced in the Government's White Paper, "The new NHS - modern, dependable", in 1997.1 It stated: "At home, we will provide easier and faster advice and information through NHS Direct, a new 24-hour telephone advice line staffed by nurses. We will pilot this through three care and advice helplines to begin in March, 1998. The whole country will be covered by 2000."
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NHS Direct raises significant clinical issues, not least the provision of medication advice by nurses |
The role of pharmacists working in the community has traditionally centred on dispensing and providing advice on medicines. However, over the past decade, there has been a shift towards encompassing extended roles, with the report on community pharmaceutical services by the joint working party of the Royal Pharmaceutical Society and the Department of Health in 19923 and, more recently, the Society's Pharmacy in a New Age strategy in 19974 advocating extended roles. The thrust of this shift is to make community pharmacy more integral to the primary health care team, with a positive role in managing minor illness and chronic disease.
Proposed extended roles for pharmacists include the provision of health advice for minor ailments, health education and health promotion, referral to GPs, repeat prescribing, domiciliary visits to the housebound, diagnostic and screening services, and drug monitoring. The provision of advice to nursing homes, and needle exchange facilities are extended roles which are already widespread among community pharmacists.
Some of these extended roles overlap directly with the roles of NHS Direct, particularly the provision of health advice on minor ailments. (Research shows that almost three quarters of the population have asked their pharmacist for advice on minor ailments.5) Other areas of overlap include advice on health education and health promotion, and referral to GPs. In addition, nurses at NHS Direct currently provide advice on drug-related queries, which represents a change from the pharmacist or GP as the traditional source of information about medicines.
There may be many varied implications of NHS Direct for community pharmacy. First, there is the effect of the overlap of roles between NHS Direct and community pharmacy, as outlined above. Linked with this is the effect on the number of people visiting community pharmacies. NHS Direct has the potential to increase business, if self-care and the purchase of over-the-counter medicines and preparations is encouraged. However, if patients circumvent pharmacists by calling NHS Direct for advice instead, then they will no longer be in the pharmacies where they might otherwise have purchased preparations or other goods.
NHS Direct raises significant clinical issues, not least the provision of medication advice by nurses. Although NHS Direct nurses are supported by protocols and have access to databases, including the electronic BNF and specialised sources of advice about drug information and poisoning, they hitherto have lacked the experience of managing complex drug queries. It is important for these, as it is for advice on minor ailments, that there is consistency of advice provided by different sources, especially nurses, GPs and pharmacists.
The issue of continuity of care with respect to medication and prescribing is another area where NHS Direct may have clinical effects. Increasingly, pharmacists hold drug records for patients and are able to foresee and advise on interactions and contraindications. This function may be lost if callers circumvent pharmacists in their search for advice. Also, importantly, clinical responsibility remains ill-defined. If a nurse refers a patient to a pharmacist or a pharmacist advises a patient to contact NHS Direct instead of his or her doctor, where does clinical responsibility lie?
Community pharmacy can contribute to NHS Direct on various levels. At a basic level, NHS Direct sites require information about local pharmacies, in terms of their opening hours and the basic and extended services offered. Also, there is often an out-of-hours pharmacy service available, which NHS Direct could publicise. NHS Direct nurses need to understand how community pharmacies work, and pharmacists can potentially get involved in training or support to the NHS Direct site.
There is the wider question of whether community pharmacists can or should promote access to NHS Direct, either by direct referral, by advertising the service or by having an NHS Direct telephone line on the premises. Should there be a community pharmacist on site at NHS Direct, able to answer medication queries, should there be a local pharmacist available on call, or should there be formal referral mechanisms from NHS Direct to pharmacists? Can some of the proactive work of the extended pharmacist role, including drug monitoring or repeat prescribing, be undertaken through or by NHS Direct? NHS Direct is still evolving; what contribution can pharmacists make to the evaluation of the service and what are outcome measures that would indicate a good service?
The National Pharmaceutical Association and the Essex NHS Direct site will be undertaking a pilot project, to develop specifications for community pharmacy involvement in NHS Direct by December, 2000.6 This will include training of NHS Direct nurses, involvement of community pharmacists in the development of decision support systems, the development and piloting of a "fourth disposition" in the NHS Direct protocols allowing referral to a pharmacist, and piloting and evaluating the "access point" concept of NHS Direct in the pharmacy setting (see p143). In addition, the NHS Direct Pharmacy Support Network supports pharmacists working with NHS Direct sites. This group is producing a training pack for third wave sites.
Access to primary care is changing rapidly. The status quo is unlikely to remain: in the current political climate a shift towards a more mixed economy is likely. The questions for the profession are how can or should pharmacists respond to this shift and what are the implications. In the new world of primary care groups, it is important that PCGs and community pharmacists consider how they can work together on the new policy agenda.
Dr Pearce is a senior registrar in public health medicine in the Primary Care Programme, King's Fund, 11–13 Cavendish Square, London W1M 0AN