This article discusses the implications for primary care pharmacy services of the formation of local health care co-operatives in Scotland, and describes the support structure that was created in Lothian to help pharmacists contribute to LHCCs
The White Paper, "Designed to care - renewing the National Health Service in Scotland", was published by the Scottish Office Department of Health in December, 1997.1 It described the formation of local health care co-operatives (LHCCs) (the equivalents of the primary care groups in England) that would be responsible for managing and delivering integrated services within a defined geographical area and would allow general practitioner practices to provide a wider range of services for their patients.
The White Paper contained little reference to pharmacy. However, formation of LHCCs could have major implications for the development of primary care pharmacy services. This article describes the support structure that was established in Lothian to enable pharmacists to contribute to implementation of the key proposals within "Designed to care".
A network of GP localities had been established in Lothian in 1992 in order to involve GPs in the commissioning of services for their patients. The localities were based on local areas conterminous for health, social work and local government services. Following publication of the White Paper, it was proposed that the localities evolve into eight LHCCs.
It became clear that community pharmacy practitioners needed to organise themselves within the locality structure in order to be able to influence the formation of the LHCCs. The pharmaceutical adviser, through the area pharmaceutical committee (equivalent to the local pharmaceutical committee in England), put forward a proposal to form pharmacy locality groups (PLGs) that were conterminous with the LHCCs. The proposal was supported and funding was identified from Lothian Health to enable the work to be taken forward.
The PLGs were launched at evening meetings held in each locality between May and July, 1998. The meetings were attended by a total of 130 pharmacists, representing 105 pharmacies (60 per cent) and five NHS trusts. The purpose of the PLG structure was discussed through workshops where the initiative was enthusiastically supported. Each PLG elected a co-ordinator to be responsible for co-ordinating all activities and to represent the PLG and its members, for which they would receive an annual fee of £1,000. In addition, to support their work and ensure liaison between localities, one of the co-ordinators was elected to a Lothian-wide post to work one afternoon per week with the pharmaceutical adviser. Secretarial support was also provided by the pharmaceutical adviser's office.
All eight PLG co-ordinators met the pharmaceutical adviser on a quarterly basis. At the first meeting held in September 1998, it was agreed that the PLGs should embrace the challenges for the future as described in the Pharmacy in a New Age document, "Over to you".2 These were:
One of the tasks for each PLG co-ordinator was to establish a communication network. All localities now have a fax/telephone cascade system to allow quick and efficient transfer of information. Information on the PLGs is also disseminated through a Lothian-wide quarterly bulletin sent to all community and hospital pharmacies.
Each PLG meets every two to three months and these meetings have been beneficial and productive for professionals working in isolation. Since the launch meetings, 34 more meetings have been held with an average attendance of 12.
In order to focus the work, the PLGs agreed to work together to complete 12 audits over 12 months. The audits were chosen and developed by the PLG members, with assistance from the clinical audit department, and covered many different issues.
The PLG structure provided the co-ordinators with an opportunity to meet the newly appointed trust chief executives in Lothian. A meeting in January, 1999, included a presentation on the work undertaken during the first six months, highlighting how pharmacists were now working together, sharing information and involved in LHCC planning. The meeting provided the co-ordinators with an opportunity to put forward proposals for the development of primary care pharmacy services.
Plans were put in place to restructure the area pharmaceutical committee to enable the PLGs to be represented and, therefore, have an opportunity to influence strategy at health board level. This has raised the profile of community pharmacy within the health board, resulting in an increase in requests for pharmacy representation on committees. The PLG structure has also helped to promote the pharmacist's wider role in health care.
The audit work has demonstrated in many different ways how pharmacists can contribute to service development. South-East and South-Central Edinburgh PLGs completed an audit that identified the number of quantity inequivalences on multiple item prescriptions. The data were fed back to the GPs with a request to change the quantities to ensure supply was for the same number of day's treatment for all medicines. The audit demonstrated the pharmacist's role in the rational and cost-efficient use of medicines.
South-West Edinburgh PLG audited the pharmacist's role in treatment of minor illness. Data were collected on advice given and sales of over-the-counter products. The audit demonstrated that pharmacists played a significant role in delivering health care in the locality.
North-West Edinburgh PLG audited the number of emergency supply requests being made by patients. The data indicated that repeat prescribing systems were not being used appropriately by patients. Work is now being undertaken by pharmacists and GP practices within the locality to ensure that patients are informed and understand how the system should work.
The formation of the LHCCs has been GP led and the pharmaceutical press has often highlighted that pharmacists are not being included on the management boards. A recent survey has found that 13 pharmacists were on boards as opposed to 962 nurses and 3,367 doctors.3
An important role of the PLG co-ordinators has been liaison with the LHCC clinical director. The PLG structure has helped to secure a place on the management board for three of the co-ordinators with an additional two as members of a prescribing subgroup. Lothian has also appointed primary care pharmacists to each LHCC and the PLG co-ordinators have established good working relationships with them.4
The profession has encouraged pharmacists to start to work together to develop comprehensive primary care pharmacy services.5 This has been difficult to achieve in a profession that practises in isolation and where some competition exists for provision of service. The Pharmacy in a New Age initiative changed the mindset of pharmacists by promoting the philosophy of working in partnership and the Lothian pharmacy locality group structure has facilitated the birth of the New Age pharmacist.
The success of the Lothian PLG structure is demonstrated through the pharmacists' enthusiasm to continue to attend the meetings, generating new ideas to take forward through audit and practice research. The work completed has highlighted to all the primary health care team how pharmacists' skills can be used for the benefit of NHS patients. In conclusion, Lothian pharmacists are making a significant contribution to renewing the NHS as proposed within "Designed to care".
Acknowledgments I acknowledge all the hard of work of the PLG co-ordinators: Harry McQuillan, Carole MacBride, James Allan, Laurence Cameron, Brian Ferguson, Frances Hutchison, Graeme MacBride, Rod Mair, and Ian Menzies. Thanks also to the clinical audit department.
At the time of writing, Dawn MacBrayne was pharmaceutical adviser to Lothian Health. She is now an independent consultant and locum pharmacist. Correspondence to 9 Learmonth Gardens, Edinburgh EH4 1HD (e-mail dawn.macbrayne@rts.ltd.uk)