The author examines the implications for pharmacy practice of the National Health Service pharmacy plan, and calls on the Royal Pharmaceutical Society to act promptly to meet its challenges
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The Government report, “Pharmacy in the future: implementing the NHS plan”
(PJ, September 16, pp384
and 397), sets out
a challenging agenda for pharmacy. While it presents exciting opportunities
for an expanded role and greater potential for professional development, some
elements of the profession who would prefer the status quo may see it as threatening.
The Royal Pharmaceutical Society must embrace the report’s positive aspects
and move towards a more patient-focused service. Failure to do so will lead
to the atrophy of pharmacy as we know it, particularly in the community.
Implementing the changes will require courage, resolution and focus. In particular,
the Society must recognise that it represents all members from all branches
of the profession and not let itself be diverted from the core agenda by vociferous
representation from those who feel the change may threaten their futures.
Despite the document’s radical approach, it also acknowledges a growth
in the number of pharmacists in the coming years. It is not designed to do down
the profession nor to downscale the pharmacist’s role. Rather, it places
emphasis on the individual pharmacist’s role and his or her relationship
with the patient and other health care professionals. The drive toward continuing
professional development must be embraced, and clinical governance must be addressed
rapidly and professionally. Pharmacy cannot afford to be seen as a laggard in
applying the principles of clinical governance.
The pharmacist’s true role within the health service is as an expert in
medicines and their use — hence the recognition of medicines management
as a key part of the expansion of the profession and health services as a whole.
Pharmacists are uniquely positioned here. The learning curve for a pharmacist
to implement changes in medicines usage relating to national service frameworks,
the National Institute for Clinical Excellence and achieving concordance is
much less than for other professions. By contrast, other health care professionals
have more experience in diagnostic skills.
The potential for pharmacist prescribing is a welcome addition that places us
on a par with other professionals. We should not allow the perceived extra status
of being able to write a prescription to colour our views of the pharmacist’s
true role in ensuring the most effective use of medicines by team-working with
other health care professionals.
The key changes can be summarised as follows:
Challenges for pharmacy
The key challenges for pharmacy within the document relate to changes in traditional
roles:
It is clear that improvements in services will be rewarded at the expense of
those who do not improve. Not all community pharmacies will have the resources
or the motivation to equip themselves with, for instance, the facilities for
electronic transmission of prescriptions. There will inevitably be an outcry
from those currently making a reasonable living from the status quo, who have
neither the energy nor the resources to move with the times. It is important
to remember that what may be perceived as a challenge, or indeed a threat, by
community pharmacists, may not be perceived in the same way by patients or other
health care professionals.
We have traditionally aligned ourselves with the idea that a community pharmacist
is the best point of access for advice on medicines and their use. The electronic
age and increasing use of the internet is changing the way people obtain services
and commodities. Medicines will be no exception to this and as the internet-literate
proportion of the community becomes greater so will pressure increase for access
to both advice and the facility to order medicines over the internet.
Electronic transmission of prescriptions can be linked with automated dispensing
and direct mailing of medicines to patients. When the NHS plan says it means
to arrange services around the needs and preferences of patients, not providers,
it is obvious that the current system is not convenient to patients. Although
this will seem extremely threatening to some community pharmacies, this may
not be the case for the patients. Patients may well prefer to get their medicines
at the point at which they have consulted at a one-stop centre, or have their
medicines mailed directly to their own home. It will be futile to resist these
changes. Rather, the profession as a whole should align themselves to these
changes, make sure that the necessary standards and safeguards are in place
and use pharmacists’ skills to enhance and support the delivery of services
that both the public and other health care professionals will value in the future.
Opportunities for pharmacy
The report is full of opportunities for motivated, enthusiastic and capable
pharmacists. It will take strong leadership and firm commitment to move the
whole profession towards this way of thinking. Implementing pilots and ensuring
they are well organised, well managed and well evaluated will demonstrate the
commitment of the Society and the profession to the NHS plan. It will also provide
valuable information on what is, and what is not, practicable in the short,
medium and long term.
The main potential lies in:
In the short to medium term, considerable hurdles must be overcome before we
realise the vision of an electronic, interactive pharmacy service geared towards
the needs of patients and health care professions. However, these can be overcome.
While we struggle to do so we should not lose sight of our long term vision.
In the short term, the key deliverables are the introduction of repeat dispensing
and the opportunities for local pharmaceutical services to test flexible, locally-based
services outside of the national contract and terms of service structures. Both
these activities could start immediately within primary care trusts (PCTs).
The Society should engage with leading PCTs and encourage pharmacists within
them to put forward plans for evaluated pilots to inform the process. Equal
weighting should be given to implementation and evaluation; there is no point
in charging forward with initiatives until we know the benefits and drawbacks.
If pharmacy, and pharmacists, can be seen to be approaching this in a logical,
structured and scientific way, they will be the ones driving the agenda and
pushing forward the debate. If no evaluation is undertaken, the profession becomes
vulnerable to the views and fashions of the political climate and, in the absence
of scientific fact, have little with which to defend themselves should their
roles be challenged.
This is not an exercise in damage limitation: it is an exercise in planning
our future constructively and making sure the pharmacist’s role is embedded
in the future of health care over the next generation. Although electronic transmission
of prescriptions and mail order pharmacy will be seen by some to be a threat,
they also present real opportunities. If such schemes are piloted and evaluated
with the full support and co-operation of the Society as it represents the profession,
the strengths and weaknesses will be transparent, and the pharmacist’s
role in safeguarding the security of the process, the safety of patients and
the advice associated with electronic services, will be obvious and supported
by evidence.
It is easy to portray electronic dispensing and mail order as the end of community
pharmacy and by implication the end of community pharmacists. This need not
be the case; although there will be less need for pharmacists fulfilling the
traditional dispensing function. As medicines become more sophisticated and
as patients become more informed and so more demanding of advice, the need for
advice on medicines and their usage will increase. If pharmacists pick up this
mantle and, for instance, associate the role of information provision and advice
with e-pharmacy services, there will be plenty of opportunity for employment
for pharmacists. The tension here will be between the development of the pharmacist
as a health care professional, possibly in the employ of the PCTs, and the role
of the individual pharmacy contractor. These do not necessarily have to be at
odds. The individual contractor will still have a role, but it may be very different
and independent contractors may reduce in number.
In addition, the pharmacist’s role in medicines management is referred
to frequently throughout the plan. The number of pharmacists providing advice
to general practices and primary care groups has already increased five-fold.
As PCTs evolve and realise their information needs, pharmacists will continue
to carve out a niche in this area. National service frameworks, the NICE and
the culture of evidence-based medicine mean that an increasingly valuable part
of the health care team will be a well educated and informed pharmacist with
the ability to critically appraise the evidence for health care interventions.
One can envisage a future where the general practitioner is primarily a diagnostician
and the pharmacist is primarily a manager of therapy for a particular given
condition, or set of circumstances.
The challenge and the opportunity for the Society is that it represents the
entire profession. Although many members may be independent contractors, it
also has to represent the interests of those who work for large multiples, hospital
pharmacy or those in the pharmaceutical industry. The opportunity for the Society
is to encourage, support and resource community pharmacists to make the change.
Moving the focus of the health service towards provision of services organised
around patients presents a tremendous opportunity for the pharmacist. Pharmacy
has a long tradition of being service based and the work done on patient concordance
places the pharmacist as a natural ally with the patient in moving this particular
part of the medicines agenda forward. The fact that the new chief pharmaceutical
officer post has been advertised and one of the key roles is to move forward
on the concordance agenda is recognition of the pharmacist’s role here.
The fact that the Society has taken the lead in developing concordance is important.
The Society should continue to lead what will now become a multidisciplinary
programme. Like all other aspects of this plan, we need to make sure it is implemented
in a methodical and fully evaluated manner.
Better access
Traditionally, calls for better access to community pharmacies have precipitated
discussion on out-of-hours working, rotas, etc, and payment for services. Although
these remain important at the local level, we should not let them obscure our
view of the long-term vision for enhanced access for patients. In particular,
we should embrace initiatives that include the use of information and digital
technology. If the Society were to take the lead on piloting such initiatives
and tying them in with the work on concordance, it would place pharmacists firmly
at the front of this agenda and not leave them trailing in the wake of other
health care professionals.
It will be interesting to see how the £5m in the first year is to be split
up. If the money for pilots is not available from the Department of Health then
perhaps the Society should consider looking to its own resources or applying
for funding from research councils in association with academic units, in order
to take the lead on this agenda. The time to do this is now. The window of opportunity
is narrow. If the Society does not take a lead, other professional bodies or
individual entrepreneurs who do not have the interests of the pharmacy community
as a whole to consider, may run the agenda for themselves.
Encouraging greater use of pharmacists Lord Hunt’s proposal put the emphasis firmly on the individual pharmacist rather than on premises or organisations. Some of the proposed expansion to services can be made from existing pharmacy premises, some will require improvement to those premises, and some may be delivered away from traditional pharmacy premises. For the profession to move forward, individual pharmacists must be ready to make this change; this will involve a change of both culture and an increase in the knowledge base. If other health care professionals and patients are to want to use the pharmacist more, we need to provide the services they seek. For other health care professionals this is advice and management of medicines, and for patients it is the safe dispensing of medicines, provision of advice and help with concordance. This may necessarily involve the use of the information technology referred to previously — again, this will produce training requirements.
Out-of-hours services This links back to the initiatives on better access — it may be that in order to have a one-to-one consultation out of hours, it may not be necessary to visit a pharmacy but advice could be provided over the phone or via the internet or digital television. Obviously there is some way to go before technology catches up with the concept, but we should be planning towards this in the long term. Other initiatives to be considered could be a bank of pharmacists working for a PCT to cover out-of-hours services, and tying in closely with NHS Direct, so patients can have information about medicines 24 hours a day. We should be encouraging systems to allow medicines to be dispensed readily “out of hours”, or it is probable that this role will be assumed by walk-in centres.
Primary care centres Most of the new primary care centres will
have a community pharmacy included within them. This has implications for surrounding
pharmacies. PCTs may encourage existing contractors to take up a new contract
within the primary care centre.
It is not yet clear on what basis the community pharmacist will work within
the primary care centre. It seems most logical for the pharmacist to be an employee
of the PCT, with specific responsibilities not only for supplying and dispensing
but for medicines management and purchasing.
Repeat dispensing This is the “low hanging fruit” of the proposal, that is, an initiative that can be expanded on almost immediately without major disruption to existing pharmacy services and with considerable benefit and convenience for the patient. Careful thought will need to be given to the pharmacist’s role in checking how the patient is getting on with the medicines and checking whether a repeat is always necessary if in fact the medicines are not needed.
Electronic transmission of prescriptions This section of the
plan is probably the one that would feel most threatening to the average community
pharmacist. Community pharmacists have traditionally believed themselves to
be the most convenient point of access for medicines for patients — they
are based on the high street, they are readily available and they are usually
based in the same communities as their patients. While none of this has changed,
large sections of the community are starting to interact with services and purchase
commodities in different ways.
The predicted large uptake in digital television will broaden access to the
internet even further. As the next generation grows up more computer literate
and familiar with using the internet, this will increasingly be the norm. Pharmacy,
like many other services, will not be able to resist this change.
Distance sale and supply Electronic transmission of medicines
means that the data necessary for the supply of medicines can be transferred
swiftly at any given point. This could mean transmission to an on-site pharmacy
within a one-stop centre, transmission to a local community pharmacy with electronic
connection, or transmission to a central distribution point staffed by a pharmacist
responsible for the mailing of medicines onto patients. The first two options
are implicit to the extent they can be regarded as “givens” within
the NHS plan, the third will inevitably follow, as current pilots in Leeds indicate.
The first organisations to embrace the idea of mail order will probably be those
with infrastructure and overheads to support the set-up costs — the multiples.
These organisations would be able to run pilots and evaluate them commercially
at their cost and to their own agenda. This would give them a business case
for moving from conventional pharmacy services to fully electronic mail order
services. This picture has to be balanced by the views of pharmacists not involved
in multiples, and the Society should seek funding to undertake pilot studies
of distance supply in which independent community pharmacists are involved.
The best environment in which this can happen will be a PCT and a series of
negotiations may be needed with the independent pharmacists within that trust
around terms of service before a pilot commences. The model must be tested and
fully evaluated. At present the assumptions are this is something that would
be wanted by the public and can be delivered through the NHSnet — both
these hypotheses need to be tested.
Extension of prescribing Extension of prescribing is the element of the plan
that will seize the imagination of most pharmacists and excite them about taking
on a new role. The Society will want to encourage pharmacists prescribing as
part of patient group directions in the same way as other health care professionals.
It may be worth remembering Lord Hunt’s salient point about prescribing
not being a “badge of office”, merely undertaking a prescribing activity
will not necessarily enhance our professional status nor secure our role. This
is a small part of a bigger picture and we should be focusing our response on
being the experts in medicines and their management.
Better use of medicines
The implication from Lord Hunt’s speech is that better use of medicines
starts with a clearer prescription which can be dispensed with less chance of
error. This may open the way for skilled technicians to undertake this role,
leaving the final checking to the pharmacist. Indeed, for some medicines and
in some circumstances, there could be the equivalent of patient group directions
for the supply and dispensing of medicines in which technicians take on this
function. This should not erode the role of the pharmacist but should enhance
it by freeing the pharmacist’s time to deal with issues around concordance.
Again, as was highlighted in Lord Hunt’s speech, this requires a professional
environment in which to interact with the patient: perhaps some of the extra
money promised should go into enhancing current premises to provide consulting
rooms.
This should be just one part of the pharmacist/patient interaction. When patients
leave the pharmacy they should be clear about how they to take the medicines,
what the risks and benefits are and how the pharmacist is to support them in
the coming months. So, as well as improved premises, this brings us back full
circle to enhancing the use of digital technology to keep the pharmacist in
touch with the patient and help develop their concordance programme.
Medicines management The plan consistently refers to medicines
management rather than pharmaceutical care. This is because medicines management,
in which pharmacists lead, involves all health care professionals and the patients
in the proper use and management of medicines. The principles of medicines management
can be applied within pharmacies premises or, perhaps more commonly in the future,
pharmacists deeply involved with medicines management will want to practise
in the same centre as other health care professionals. The Society’s response
should cover both these roles. We should not be protective about the “where”
but remain positive and focused on the “how” and the “who”
and make sure we have cohorts of pharmacists ready to take on this challenging
role. This will mean increased clinical knowledge in some cases and help with
communication skills, IT, etc, in many cases. The objective should be to aim
for the highest common factor rather than the lowest common denominator and
to raise standards across the profession as a whole in line with the ideas espoused
in Pharmacy in the New Age.
Leading on the medicines management agenda puts pharmacists at the heart of
implementing the major activities underpinning the changes in the NHS. Issues
such as implementing NICE guidelines, and national service frameworks, performance
improvement on these issues, and forecasting the implications for medicines
budgets will be critical.
The use of medicines should be tied into a cohesive programme of work, where
diagnosis, medicines used and outcomes achieved all become part of the whole
around managed entry and use of drugs. This help us move on to an agenda of
total disease management and care pathways.
Redesigning services
Re-engineering hospital pharmacy The proposals for changes and
improvements to the hospital pharmacy services are overwhelmingly positive.
The roll-out of the medicines management framework will lead to the kind of
performance improvement process that primary care has been going through in
the past few years. This is not a threat but an opportunity for hospital pharmacy
to show the real contribution it makes to the care of patients within hospital.
Pharmacists will have a key role to play at the primary/secondary care interface
and this should become an integral part of this medicines management framework.
Prescribing for discharge makes sense and fits logically into the plans for
electronic prescribing in the hospital environment.
The real issue for hospital pharmacy will be in attracting and retaining quality
staff following the recent considerable haemorrhaging of young mid-career hospital
pharmacists into PCGs and PCTs. This ties into the issues about improving working
lives and ensuring high quality services (see below). If highly trained professionals
are needed to work in a specialised environment, they must be rewarded adequately
both in terms of salary and their professional status, and sadly within a hospital
environment the two are often being seen as synonymous. The Society should work
closely with the new chief pharmaceutical officer and consider some radical
changes to the terms and conditions for hospital pharmacists to allow incentives
for innovative work and due reward for high levels of professional activity.
Ensuring high quality services
The key to high quality services is performance agreed standards and benchmarking
systems to monitor them. There should be incentives for exceptionality and sanctions
for failing to meet the accepted minimum.
The Society has a good track record of policing its own profession and dealing
firmly and justly with those deemed to be below accepted professional standards.
However, its systems need to be more transparent and congruent with those being
applied to other professions. This particularly applies to standards for clinical
governance and working with the Committee for Health Improvement. The Society
should be engaging in dialogue with the CHI, and entering into active discussions
with the newly appointed chief pharmaceutical officer and his or her team with
regard to implementing the principles of clinical governance. Some changes in
terms of service and conditions for pharmacists may be needed, which the Society
should support to increase public confidence in the profession.
Education and training Continuous professional development and
an ongoing commitment to keeping up to date with developments in the profession,
is a prerequisite for maintaining high standards. The important role of the
Centre for Pharmacy Postgraduate Education could be expanded, and the Leadership
Centre for Health will help identify professional leaders for the future. The
Society should encourage pharmacists towards both of these initiatives and emphasise
to organisations in both primary and secondary care pharmacy the importance
of releasing individuals for these developmental roles to move the profession
forward as a whole.
Not all pharmacists will be suitable for all new roles in the profession. It
has often been a mistake in national negotiations that “whatever benefits
are available must be available to all pharmacists.” Realistically, this
can no longer be the case and it should be acceptable for certain individuals,
in community and hospital pharmacy, to negotiate special terms and conditions
in return for acquiring and applying key skills. This may be a contentious point
when the Pharmaceutical Services Negotiating Committee comes to negotiate the
community pharmacy contracts, and it should be the subject of firm, but sensitive,
negotiation between the Society and the PSNC.
Improving working lives Improving working lives is an organisational issue that applies to all NHS staff, and is the equivalent of Investors in People for the Health Service. The principles are that the NHS as an organisation should not only invest in training and development, but be able to prove that this is the case. To pharmacists this will mean ensuring that staff, even those in key posts, have the potential to be released for further professional education and training, and that there are recognised courses of an appropriate standard for them to attend. These courses should not all be of a clinical nature, but should include management and leadership skills, and for those involved in medicines management, influencing and communication skills.
Support staff and skill mix The plan refers to all pharmacy staff, not just pharmacists. This implies an enhanced role for skilled pharmacy technicians. I have already referred to technicians taking increasing responsibility in the prescribing role. One could see it happening, in particular, with electronic mailing and dispensing of medicines. In the hospital environment it may mean specially trained technicians for certain tasks. The Society should encourage this, but should bear in mind the issue of vicarious liability: the pharmacist should still make the final check on safety and appropriateness of medicines.
Clinical governance Pharmacists have a key role in clinical governance, both in helping prescribers implement the principles as they relate to the use of medicines and prescribing activities, and in regulating their own profession. They should be part of a team looking at appropriateness of medicines, using case findings, case retrieving, electronic records, etc, to help general medical practitioners and nurses to review their case mix and establish appropriateness and safety for medicines. In addition clear principles are needed for clinical governance and performance of the traditional pharmacy roles. This should involve not only safety and appropriateness in the supply and dispensing of medicines, but guidelines of best practice and probity in the deliverance of medicines management services.
National contractual framework There is little doubt that the Government intends at some point to change the national contractual framework. This will be a difficult period for the Society and the profession. Pressure will come from traditional sources such as the PSNC, and inevitably there will be tension between those wishing to maintain the status quo — fearing that change may erode the profession’s role, or undermine the ability to make a reasonably living — and those who want to move the profession forward into a new environment. Both sides discussion need to be listened to and their opinions heard. However, we cannot afford to procrastinate for too long. The world is changing and we need to change with it. The best future for pharmacy is to work to its strengths, be the experts in medicines management, and work with the necessary bodies on a national contractual framework that recognises this and provides incentives for excellence.
Stephen Chapman is professor of prescribing studies in the department of medicines management of Keele university