In June, 1999, the director of the Manchester, Salford and Trafford health action zone (Mrs Edna Robinson) met representatives of the local pharmaceutical committees. This was the culmination of over a year of efforts by the LPCs to become stakeholders in the HAZ. The director had recognised that pharmacists could help the HAZ to achieve its objectives of reducing health inequalities, improving services and securing better value from existing resources, but she needed to be able to discuss these issues with a single body representing the pharmacists from the two LPC areas covered by the zone. Thus "Pharmacy Partnerships" was formed as an umbrella organisation in July, 1999.
The initial steering group for this organisation was drawn from both LPCs and the health authority pharmaceutical advisers, but the membership was soon widened to include pharmacists from secondary care. Two project managers were appointed (the authors) and funded jointly by Manchester health authority and a "Pharmacy in a New Age" development grant from the Royal Pharmaceutical Society. Pharmacy Partnerships is, in effect, a local pharmacy development group, drawing on the skills of pharmacists from different sectors of practice.
The first item on the Pharmacy Partnerships agenda was to identify where pharmaceutical services could reduce health inequalities within the HAZ's target areas of children, young people, active senior citizens, mental health and community capacity building. A joint LPC committee meeting resulted in a visionary brainstorming session for ideas. These ideas were screened by the steering group to ensure that they had the potential to reduce health inequalities, and the result was 13 areas for development (see Panel).
These ideas were then circulated for feedback, via a structured questionnaire, to all contractors within Manchester, Salford and Trafford. Pharmacists were asked to rate each service on the basis of three criteria: patient benefit, professional satisfaction and feasibility. It was important that services for development should score highly on all three criteria; pharmacists would have to be committed to delivering a high quality service in order to gain credibility with the public and the HAZ. Seventy-four contractors returned the questionnaire (a response rate of 33 per cent), including submissions from the head offices of multiples within the area.
The results of the contractors' survey are presented in Table 1. It was expected that smoking cessation and medication review for elderly citizens would be popular with the pharmacists; some work was already under way locally to develop these services. The high rating for the instalment dispensing of psychoactive medicines to individuals who were at risk of harming themselves or others was, however, unexpected.

Areas for development

• Children
  • Dental health
• Young people
  • Smoking cessation and prevention
  • Reducing unwanted pregnancies
  • Supervised methadone dosing
  • Addict general health programmes, eg, nutrition
• Active senior citizens
  • Medication review
  • Pharmaceutical assessment
• Mental health
  • Instalment dispensing
  • Identification of sufferers of mental illness
• Community capacity building
  • Healthy living centres
  • Link workers/multilingual patient information
  • Screening for long-term conditions
  • Minor ailment clinics

Table 1: Key results of contractors' survey ranking exercise (n=70)

Challenging process

A senior medical practitioner and lecturer in Manchester's family planning service (Dr Rosemary Kirkman) was eager to assist in the preparation of the group protocol and training/accreditation of local pharmacists. The group protocol co-ordinator appointed by the Greater Manchester Education and Training Consortia (Mr Peter Jones) gave advice on the adaptation of the existing nurse supply protocols used by family planning centres within the Greater Manchester area. Thus began the challenging process of formulating a workable document that would satisfy stringent legal scrutiny and enable community pharmacists to provide a safe and efficient service from their premises.
A group of health authority doctors and managers signed the group protocol to authorise accredited pharmacists within the HAZ to supply Schering PC4. The pharmacist and the client work through each stage of the protocol, and both parties are required to sign each section of the protocol proforma to ensure that understanding is confirmed. Each consultation should take approximately 10 minutes, and the pharmacist is able either to supply emergency hormonal contraception or refer the client to specialist services where appropriate. Dr Kirkman's team was available to the participating pharmacists for telephone advice.
At this time, a local branch meeting of pharmacists in Manchester, Salford and Trafford provided an opportunity to discuss the expected problems and solutions with providing services to reduce unwanted pregnancies and review medication for the elderly. Examples of problems and solutions surrounding unwanted pregnancy services are given in the Panel above. The group benefited from drawing on the experience and enthusiasm of both primary and secondary care pharmacists. This meeting also highlighted the need for this service to be advertised generally to all age groups of women, not just teenagers, and to include effective contraceptive advice to prevent future need for the service.
The increasing momentum for the inception of this service came from the impending extended holiday period over Christmas and the millennium. Using the results of the survey, and considering the geography of the HAZ area, two pharmacies were chosen from each primary care group in order to provide optimal access for clients. The survey indicated which of the chosen pharmacists would be receptive to providing the proposed service, and these were approached to confirm their willingness to participate. Pharmacists had to commit themselves to completing a Centre for Pharmacy Postgraduate Education contraception distance-learning package and a half-day intensive training session run in conjunction with CPPE and Dr Kirkman. As pharmacists are already experienced in counselling women who receive emergency hormonal contraception on prescription, this training concentrated on the use of the group protocol and role-playing situations with different issues that might complicate consultations with clients. Dr Kirkman accredited all pharmacists who undertook the training and passed the set assessment.
The protocol was also reviewed by the Royal Pharmaceutical Society and letters explaining the service were circulated to local medical committees and the chief pharmacist's office at the Department of Health before the consultations commenced. Publicity for the service was planned through NHS Direct, family planning centres, general practitioners, pharmacies and accident and emergency departments.
The first phase of this service is due to end in June, 2000. A formal evaluation of the scheme is currently being undertaken. Initial feedback indicates that the service has been accessed by a number of women of varying ages and circumstances. The pharmacists have been challenged by their experiences with the clients, but they report great professional satisfaction from this new way of working. There is a waiting list of pharmacists, including regular locums within the first sites, who are due to receive accreditation training very soon.

Conclusion

The process of securing the commitment of all parties to the initiative was rather more complicated than this article might suggest. Resistance was, ironically, most prevalent within the pharmacy profession, although we accept that this was, in part, due to an undisputed need to satisfy legal and ethical concerns. More disappointing has been the reaction of recent Pharmaceutical Journal correspondents: they failed to welcome and encourage initiatives that see pharmacists properly recognised and remunerated for their new contributions to primary care. Pharmacists in Manchester, Salford and Trafford have recognised that the vicious circle of reluctance and pessimism can be broken. Recent statements by the British Medical Association and the Parliamentary All-Party Pharmacy Group (PJ, March 4, p354) confirm that these pharmacists' commitment to provide a new style of pharmaceutical service has been recognised and welcomed.

Examples of perceived problems and possible solutions

Pharmacies are closed at the times when the services may be needed

• Recruit late night pharmacies into the scheme (many pharmacies are open for long hours and give excellent access and convenience)
• Use a separate, mobile clinic
• Raise public awareness of the 72-hour window of effectiveness
• Create a 24-hour advice line that has the names of pharmacies that are open
• Encourage NHS Direct to participate and give appropriate advice and direction

There is a lack of incentives for pharmacists to provide extra services

• Provide remuneration linked to advice, not supply
• Investigate appropriate funding sources
• Promote services as achieving professional satisfaction and respect the pharmacist as a full member of the health and social care team

Teenagers do not know how to access these services

• Market services within youth media and schools
• Train pharmacists and staff to give opportunistic general advice