The 137th British Pharmaceutical Conference took place in Birmingham from September 10 to 13. Its theme was "Medicines: the future horizon". The highlight of the Conference was a keynote speech by Lord Hunt (Parliamentary Under-Secretary of State for Health) setting out the details of how the national plan for the National Health Service in England will apply to pharmacy
Pharmacy can build a better future for itself as a profession, and play a crucial part in delivering the vision of the National Health Service set out in the Government's national plan for the NHS in England, Lord Hunt said in his address to the British Pharmaceutical Conference on September 12.
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Lord Hunt: in a new NHS, pharmacists will spend more time focusing on the clinical needs of individual patients and helping them get the most out of their medicines |
Lord Hunt went on to outline three particular challenges that pharmacy had to face.
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The first was to meet patients' changing needs. This meant three things: first, making sure that people could get medicines or pharmaceutical advice easily and, as far as possible, in a way, at a time and in a place of their choosing; secondly, providing more support in using medicines, with extra help for those who needed it to get the best out of their medicines (help that would mean fewer people being ill because they were not using their medicines properly and would cut the amount of medicines which were simply wasted); and thirdly, giving patients the confidence that they were getting good advice when they consulted a pharmacist.
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The audience at the British Pharmaceutical Conference listens to Christine Glover |
Access to pharmacy had always been one of its greatest strengths, especially in the community, Lord Hunt said. The frontline of health care was in the home and community pharmacists were there supporting the frontline of self-care. The Government intended to encourage people to visit pharmacies as part of its winter planning campaign as it had last year. By 2002, the NHS Direct telephone service would be able to refer callers to visit a community pharmacy, where appropriate, across the whole of England.
However, there was room for improvement, particularly in relation to access to pharmacies outside normal shopping hours. He intended to see that every part of the country reviewed its out-of-hours provision. This did not necessarily mean many more pharmacies opening for longer, but it did mean more flexibility, more imagination and, above all, better information. A single call to NHS Direct should be all that it took to find out where a pharmacy was open.
By 2004, 500 new one-stop primary care centres should have been opened. Lord Hunt said that he wanted to see a community pharmacy in a substantial number of those centres. Co-location was one way, although not the only one, of making it easier for pharmacists to be fully part of the primary care team.
Access was not just about location, Lord Hunt said. It was also about the way services were organised. Pilots had shown that repeat dispensing could be more convenient for patients, as well as cutting waste and giving pharmacists further opportunities for adding value to the dispensing process. Under the NHS plan, repeat dispensing would be in operation throughout the country by 2004. By the same date, electronic prescriptions would be routine in both the community and hospitals and patients would benefit from easier ordering of repeat prescriptions.
Pharmacists would benefit from new opportunities to use information technology to support their practice. There would also be an end to illegible and incomplete prescriptions which wasted everyone's time, as well as being a risk to patient safety.
Lord Hunt said that the Department was now inviting IT companies to bring forward proposals for pilot schemes, demonstrating in everyday practice the electronic transmission of prescription data between general medical practitioners, community pharmacies and the Prescription Pricing Authority. Up to three pilots would start in 2001, running for six months each. A full, independent evaluation would be completed by the end of 2002. These projects would allow the development of NHS-wide standards so that by 2004 electronic prescribing would be routine, and, by 2008 (or earlier), the vast majority of prescriptions would be transferred electronically using the NHSnet.
In time, NHS Direct might have a role to play in allowing people to get their prescriptions conveniently.
"We believe the law permits the distance sale and supply of medicines, but only if the normal safeguards are met. This means, for example, that sales of pharmacy-only medicines by electronic means are acceptable, provided that they are made under the supervision of a registered pharmacist and from a registered pharmacy. Now, if proper safeguards and professional standards are in place, we see no reason, in principle, why medicines should not be sold or dispensed electronically, or by other forms of distance sale or supply, like mail order or home delivery.
"Already e-pharmacy is offering people new ways of dealing with pharmacists. We believe that this new choice should also be available to people with NHS prescriptions. We will, therefore, be reviewing current NHS rules to remove obstacles to pharmacies wanting to offer that kind of service.
"I want to stress to you that this is not a threat to pharmacists' practice, but an opportunity to expand that practice. Those who take up this option must bring to bear the same professionalism that is the hallmark of pharmacists throughout the country. Taken together, the strict controls in the Medicines Act and the pharmacy profession's own Code of Ethics provide considerable reassurance that e-pharmacies will be safe and professional, but no one should be in any doubt that we will be prepared to introduce further controls if they prove to be needed or if e-pharmacies, or indeed e-prescribers, cannot demonstrate their own quality and security of service. Nor should there be any doubt that we will make further changes to medicines legislation that will help us provide a safe service in a better, more efficient way."
Lord Hunt said that this had already started with the recent guidance on patient group directions. However, circumstances still remained in hospitals where pharmacists had to get prescriptions rubber stamped by a doctor just to meet legal requirements rather than to improve patient care. He said that as Parliamentary time allowed, new legislation would extend prescribing rights to new groups, including certain pharmacists. He added that prescribing rights were not a professional status symbol. They were a way of matching the right skills to the tasks to be done. Pharmacists might be the best people to make the prescribing decisions in anticoagulant clinics or for discharge prescriptions
Who prescribed and how they got their medicines mattered less to patients than whether they helped them get better or improved their quality of life. Too many medicines were wasted and far too many people suffered avoidable side effects.
Lord Hunt believed that the NHS had to do two things: first, involve patients more in decisions about their treatments, and, second, provide better services to patients once they had been prescribed their medicines.
The Royal Pharmaceutical Society had already done a huge amount of work to define and promote the concept of concordance, which could be thought of as "a partnership in medicine taking".
The Department would shortly be appointing a new chief pharmaceutical officer and that person would be specifically charged with bringing all the key people together to form a joint task force to implement a national strategy for integrating partnership in medicines and taking it into the way the NHS worked at all levels.
Leading-edge health authorities and primary care trusts had begun to invest in services like medication review and ongoing support for patients with particular medication needs and other kinds of pharmaceutical care. This kind of investment needed to be replicated across the country. By 2004, primary care groups and trusts would have services giving patients access to more help from pharmacists in using their medicines.
An action team would be established within the NHS Modernisation Agency with a remit to promote medicines management. The team would identify a number of health authorities and PCTs with the capacity to deliver good ideas and offer them extra support to do so. This would create a cadre of people with expertise in setting up medicines management services. They would then pass on that expertise to others.
A national pilot trial of medicines management in community pharmacy would be established along the lines promoted by the Pharmaceutical Services Negotiating Committee. Discussions would be held with the PSNC about the details of the pilot with a view to getting it under way next year.
Hospital pharmacy services had come a long way over the past 20 years, Lord Hunt said. Clinical pharmacy had become an established part of hospital health care, but there was much more to be done to improve the use of medicines in hospitals. NHS Executive regional offices would be rolling out a medicines management performance management framework specifically for hospitals later in the year. This would be backed up by new collaborative programmes for spreading best practice.
Education and training for pharmacists had to keep pace with changing expectations of patients and the demands of life-long learning. The Society would be ensuring that undergraduate and preregistration training matched developments in the criteria for other health care professionals. The Centre for Postgraduate Pharmaceutical Education would produce new courses to meet new developments, such as pharmaceutical care and medicines management. Pharmacists in the NHS would also be able to take advantage of the new NHS leadership centre to be established next year.
Lord Hunt said that since pharmacists working for NHS bodies would be receiving support for continuing professional development he felt that other employers who wanted to attract and retain pharmacists would want and need to provide similar support.
Hospital pharmacy was experiencing particular shortages with the increasing demand for pharmacists. NHS employers would need to attract and retain new staff as well as investing in the existing workforce and that was why many more preregistration training places would be offered in NHS hospitals. Over 500 places were planned for 2001-02, at least 50 per cent more than were available 10 years ago.
A new "improving working lives" tool kit would bring together best practices in recruitment and retention of pharmacists and pharmacy support staff.
Lord Hunt said that he wanted to see a debate on how skill mix might develop. Hospital pharmacy had a good record in making use of pharmacy technicians and other pharmacy support staff, but he wanted to see the debate cover all pharmacy services. Taking the debate forward would be a key responsibility for the new chief pharmaceutical officer.
Developments were also needed in pharmacy workforce planning. Predictions suggested a 12 per cent increase in the pharmacy workforce between 1998 and 2003, despite the fallow year. However, more information was needed about demand. Neither the Government nor the Society could do this on their own. Community pharmacy employers needed to work with them to get a good picture of the whole issue.
Clinical governance had been introduced throughout the NHS to deliver quality standards locally. In hospitals, pharmacists were making a significant contribution through, for example, monitoring prescribing and advising on the choice of drugs and preparing medicines ready for use.
There was still work to be done to ensure that community pharmacy was included in every area's clinical governance strategy as fully as it should be. Health authorities would be told that they had a responsibility to ensure that local frameworks for clinical governance encompassed community pharmacy services. Those frameworks had to focus on the totality of services across sectors and to encourage multidisciplinary collaboration. This would be backed up by guidance and resources from the Department. The national terms of service for community pharmacies would be changed if necessary.
The financial and contractual incentives for community pharmacies needed to be looked at as well. Many health authorities had already started to contract locally with community pharmacies to develop and improve services. The core contractual framework needed looking at too.
"A good community pharmacy service is one where the patient comes first; where medicines are available conveniently when patients want them; where pharmacists make themselves available to respond to requests for advice and take the initiative in offering help where appropriate; where patients can discuss personal matters in privacy if they wish and with the absolute confidence that the pharmacist is equipped with up-to-date experience and skills. This is the kind of community service which should be available everywhere, in areas of social exclusion as well as areas of affluence.
"I do not believe that the current system does enough to deliver the service we want and I know that there are many in the community pharmacy world who agree with me."
Lord Hunt said that, when Parliamentary time allowed, a new form of agreement between the NHS, pharmacists and pharmacy owners would be established. Local pharmaceutical services (LPS) contracts would be similar to personal medical services contracts for GPs. They would allow pharmaceutical services to be provided under locally tailored arrangements, free from the restrictions of the rigid national remuneration system and the NHS terms of service.
Proposals would be invited from health authorities for pilot schemes. These would not be limited to dispensing. They could cover medicines management, health promotion and disease prevention, all within a single agreement. Typically, they would be collaborations between health authorities, primary care trusts and existing pharmacy contractors. They could also provide an opportunity to bring in new pharmacy services to meet local needs. It would also be possible for the first time for agreements to be made with individual named pharmacists, as well as pharmacy owners.
Patients would see the benefits, Lord Hunt said, not just in a wider range of services, but in services which had been designed with their needs in mind. Pharmacies would be rewarded according to how well they met these needs, not just for doing what every other pharmacy had to do.
The national contractual framework also had to develop to meet the demands of the new NHS. Discussions would be held with the PSNC to establish minimum standards and to promote and reward high quality services, not just the volume of prescriptions.
"Pharmacies which provide the best service should gain at the expense of those who are only prepared to provide the minimum. No pharmacy, surely, should have the option of standing still while standards are rising elsewhere," Lord Hunt declared.
He went on to warn that if efforts to provide better services for patients were being inhibited by the current control of entry rules then the Government would be prepared to change them. Similarly, in places where the controls could not clearly be justified, in major retail complexes such as Bluewater or Meadowhall, the rules could be changed.
"I am sure that there are very few community pharmacists who really want to be saying to their patients: ‘You cannot have an out-of-hours pharmacy, or you cannot have a pharmacy in your primary care centre, because it does not suit us and we like things the way they are.'"
Changes in the NHS would have to be matched by developments in the profession itself. The Society would be closely involved with the new UK Council of Health Regulators, set up to ensure consistency and co-ordination. The Government was working with the Society to implement its new procedures to deal with and support pharmacists whose performance was impaired by mental or physical ill-health. The new procedures were expected to be in place by the middle of next year. By the end of next year, the Government was planning to consult on new legislation to modernise the Society's disciplinary procedures. At the same time, the Government would be looking to the Society to improve the transparency of its decisions for dealing with complaints.
The Society had set up a working party to review the other aspects of its regulatory role, which the Government supported. The Government wanted to receive proposals from the Society which matched the best practice in modern professional self-regulation and which demonstrated proper accountability to the public and to the NHS. Key among these proposals would be ensuring that continued registration as a pharmacist was linked to continuing and demonstrable competence.
In conclusion, Lord Hunt said that had outlined a vision of how pharmacists as individuals would contribute to implementing the NHS plan. The important thing was not just having a vision, but having a practical programme for getting there.
Substantial new money would be invested in achieving the goal of the better use of medicines. Starting with £5m next year, this would rise to at least £15m by 2003-04. At least £30m would be invested over the next three years. This would encourage and enable local investment in medicines management and pay for the modernisation action team's work, including the national community pharmacy medicines management pilot trial. It included a commitment of £1m towards the joint task force to promote partnership in medicines taking. It also included up to £2m a year specifically to support clinical governance in community pharmacy.
Lord Hunt said that the comments in his speech applied mainly to England. The National Assembly for Wales and the Scottish Executive would be producing their own health strategy documents, which he was sure would also hold a central place for pharmacy.
"The NHS plan sets out a major challenge for all of us. So, too, do the changes taking place in the wider environment. Our task is to move from developing the plans to putting them into action. I have no doubt that together we can unlock the potential of pharmacy, and that together we can give patients an even better service."