By Tony Furber
When asked the secret of success of his hotels, Charles Forte (later Lord Forte)
is reputed to have said, “Location, location and location.” Speaking
to the British Pharmaceutical Conference recently (PJ, September 16, p397),
Lord Hunt (Under-Secretary of State for Health) recognised the importance of
location to National Health Service developments, but also recognised that location
was only one factor governing access to service. Nevertheless, it is an important
factor, both to the public and to pharmacy participation in the 500 “one
stop primary care centres” that the Government intends to have operational
by 2004. Lord Hunt went on to say that co-location was not the only way in which
pharmacy could participate fully in the primary health care team, though I find
it difficult to see such a close relationship developing within a primary care
centre if a pharmacy is not on site.
Equally so, the President of the Royal Pharmaceutical Society (Mrs Christine
Glover) was quite right to point out that management of change is often difficult
and potentially painful and that community pharmacy had invested both skills
and capital in developing the network that it provides today. In this, we must
also recognise that one of the NHS objectives is to become “a good employer”
and ensure that this extends to fairer treatment of contractors than has been
seen by some (non-pharmacy) retail organisations in recent times.
For the primary care centres to be a success, they must be located in places
convenient to the population that they serve, taking account of car parking
and public transport as well as other facilities, such as day-to-day shopping,
post offices and banks (or cash points). This cannot always be said of the pilot
nurse-led “drop in centres” developed over the past couple of years,
some of which are not convenient for access by the general public.
Primary care centres imply a degree of centralisation of general medical practice
services — clearly, there will be fewer centres than doctors’ surgeries
at present, continuing the trend away from the small or “single-handed”
practice towards locations where a wider range of skills and services is available.
Hopefully, this will be matched by improved domiciliary services for those patients
who need it, for this is one of the major strengths of the NHS in Britain and
is inherent in the development of patient care in the community.
Pharmacy has to match the needs of both the patient visiting the surgery and
the patient at home, the “carer” of whom may not easily be able to
leave to get a prescription dispensed, to purchase medicine-
related items or to seek professional advice. At the same time, it has to develop
the potential of the professional links with the rest of the primary care team
and many of the practice-based services now being provided.
It will not be easy. The Pharmaceutical Services Negotiating Committee takes
the view that development should be within existing control of entry regulations
and both it and the National Pharmaceutical Association are keen to avoid any
“direction” of prescriptions, so putting at risk the many valuable
personal patient/community pharmacy relationships that occur at present.
That the distribution of pharmacies must change is inescapable, in the same
way that it is with doctors’ surgeries. That hours of service will change
to match any change in general medical practice opening is also inevitable —
and one of the comments from the public consultation on NHS provision was that
GP surgeries should be open at times more convenient to the public.
Can this be achieved within the existing regulations? I suggest that it can,
but only if the presence of an NHS pharmacy within all primary care centres
is accepted as “necessary or desirable”.
I would like to see local pharmaceutical committees develop a constructive approach,
clearly based on public service but, of course, safeguarding the interests of
current contractors as far as possible. I would also like to think that health
authorities will also seek to include an NHS dispensing facility as a public
service, rather than as a source of commercial income. We should all assume
that a pharmacy is necessary unless there are strong reasons to the contrary.
Perhaps we should also remember the recent statement on access to NHS dental
services, under which health authorities may employ dentists in areas where
contractors will not provide an adequate NHS service. Similar principles could
also be applied to pharmacy.
“E-pharmacy” (and remote dispensing generally) is rightly a matter
of professional concern. An important part of the medicines management process
is the face-to face contact between the pharmacist and patient (or carer in
appropriate cases).
What is the logic of the concerns? Collection and/or delivery already takes
place in respect of patients in residential homes and, I suggest, the delivery
aspect is of particular importance, because it gives the pharmacist the opportunity
to speak to either the patient or an appropriate nurse or carer. With that in
place, does it really matter where the prescription is dispensed? With pharmaceutical
advice on hand or easily accessible, does it really matter where over-the-counter
medicines or other health care supplies originate?
In rural areas, would it not be better medicines management if prescriptions
were dispensed some miles away by a pharmacist in contact with the patient rather
than dispensed and handed over by a person not able to apply the same degree
of patient and product knowledge and appreciation? We should not forget that
there are good examples of medical practices providing an essential dispensing
service to patients in remote areas, but also that pharmacist input is just
as important to the effectiveness of a rural practice team and its patients
as to an urban one, even if an on-site or nearby and accessible pharmacy is
not commercially viable.
This is certainly an area where service is as important as physical location.
I suggest that it is important to look at the issues, priorities and outcomes
before looking at the process. In that, quality is important and I was pleased
to see that clinical governance will be developed for community pharmacy and,
I assume, for any alternative sources of NHS dispensing.
If better medicines management can be achieved through a process involving remote
dispensing and/or e-pharmacy, then we should look seriously at it. If there
is a cost, for example by a visiting pharmacist, then it should be for the Government
to say that it cannot afford it, just as much as it is for the Government to
reject any proposal where improved patient benefit cannot be demonstrated.
In summary, I believe that there should be an NHS dispensing facility in all
one-stop primary care centres, unless there are good reasons to the contrary.
I hope that the profession locally will agree tenancy arrangements to provide
a full pharmacy service while as far as possible protecting existing contractors.
I believe that rural primary care teams and the patients whom they serve also
need medicines management and a pharmacy service. Remote dispensing or e-pharmacy
should be considered if it helps to achieve that effectively.
Tony Furber is an independent pharmaceutical consultant in Sheffield and a former regional pharmaceutical officer for Trent