The Pharmaceutical Journal Vol 267 No 7172 p639-640
3 November 2001

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New pharmacy services: what's on offer

Pharmacists can contribute to modernising the National Health Service by providing new services and improving pharmacy premises. Clare Bellingham reports on recent developments

Take your pick: pharmacists can consider introducing a variety of new quality services for patients

Modernisation is one of the Government's favourite buzz-words, especially when it comes to the National Health Service. But how can community pharmacists contribute to modernising the NHS?

The South East Regional Forum of Local Pharmaceutical Committees has set out pharmacy's potential role in a document "Performance, improvement and modernisation in primary care: the role and contribution of community pharmacy" launched this week. And, in Scotland, modernisation of community pharmacy buildings is being targeted by new funding announced on 25 October.

The aim of "Performance, improvement and modernisation in primary care: the role and contribution of community pharmacy" is to summarise the contribution that community pharmacy can make in order to achieve the Government's aims for modernising the NHS. It sets out priorities identified in the first stage of local modernisation reviews and suggests what can be delivered in each area. The document covers a wide agenda and is divided into the following sections where there is room for improvement:

1. Access to care in line with patient needs
2. Care of patients with coronary heart disease and reducing the associated mortality and morbidity
3. Quality of clinical care and insuring a patient-focussed service
4. Care provided for older people
5. Care of patients with mental health problems
6. Public health

Vanessa Taylor, secretary of the South East Regional LPC Forum, and one of the authors of the document, says that she hopes it will be used by LPCs in all parts of the UK to further the involvement of community pharmacy at a local level. Another author, Jenny Webb, the National Pharmaceutical Association's community pharmacy development co-ordinator for the southern region, says: "It would be really good if this document opens up dialogue between LPCs and primary care trusts in order to involve community pharmacists in plans to meet targets via modernisation reviews." It is hoped that the document will be updated as priorities change. Mrs Taylor adds that a similar national document would be useful.

The document describes success stories of services offered by community pharmacists and provides contacts for each, some of which are described below.

Improving access

A key aspect of the NHS modernisation plan is improving patients' access to care. The targets for improving access include making it faster and easier, enabling patients to obtain the right medicines and supporting self care.

One of the targets identified from the NHS Plan is: "Other than in exceptional circircumstances, patients should be able to receive the medication they need at the same time and in the same places as the out-of-hours consultation." In Hillingdon, an out-of-hours pharmaceutical service has been designed to improve access. Michael Levitan, Hillingdon LPC secretary, says that the out-of-hours service provided access to advice and dispensing of urgent prescriptions and oxygen.

The pilot was operated by a rota of 20 community pharmacists based at the NHS Direct call centre who took telephone enquiries about medicines. Data from the service are currently under evaluation (expected to be completed in November). Mr Levitan comments: "It was well received by all concerned, including the managers of the call centre and the call centre nurses."

Over a 12-week period, pharmacists handled approximately 2,000 calls. "The vast majority of queries did not require complex information but rather were the type that community pharmacists deal with in everyday practice," Mr Levitan says. The idea of the project was not to detract from the service that medicines information pharmacists provide but to run in parallel with it. Each pharmacist had worked at the call centre for four days over the 12 weeks. They were based at the call centre between 8pm and midnight and then were on-call at home overnight. There had been a few calls overnight but the majority of enquiries were in the evening or at the weekend, says Mr Levitan.

The service improved access to information, relieved some of the burden on nurses at the call centre, improved access to urgent supply of medicines and oxygen and improved multidisciplinary working.

"The PCT is keen to develop the scheme as a mainstream service," says Mr Levitan. Discussions are under way with neighbouring primary care organisations to roll out the service, because the call centre covers a wider area than just Hillingdon PCT. He hoped that the service would be introduced in April next year but added that, if funding became available, it could be introduced sooner.

A future development of the service is to introduce a pharmacy equivalent of the general practitioner (GP) out-of-hours co-operative, says Mr Levitan. This would involve establishing a pharmacy at the accident and emergency department at the district general hospital, run by a rota of local pharmacists. "It would act a bit like a walk-in centre with a nurse triaging patients and then streamlining them to accident and emergency, a GP, a nurse or the pharmacy," he explains. The pharmacy would be open in the evenings, with the capability of opening overnight and at weekends. The service is expected to be introduced next April.

Another method in which access to care can be improved is to shift the management of minor ailments from the GP to the community pharmacy. A barrier to this has been the cost of paying for over-the-counter (OTC) items for patients who are exempt from paying prescription charges. In Croydon, this has been partly overcome by the introduction of a health authority voucher scheme for minor ailments.

Kathy McGovern, a nurse consultant at Croydon's walk-in centre, explains that patients who are unable to purchase OTC medicines are given a voucher to take to one of a number of pharmacies in the area. The voucher is similar to a prescription for an OTC medicine and includes information such as the dose and amount to be supplied. "I would like the pharmacist to be able to decide what should be supplied. It would be the ideal solution because pharmacists are better-versed in OTC products than other health professionals," she said. This would free time for GPs and walk-in centre staff, and would promote self-care.

Getting the best from medicines

Community pharmacists have a role to play in helping all patients to get the best from their medicines. This role has been highlighted for patients with many illnesses, in particular in the management of long-term conditions, including coronary heart disease.

In Uttlesford, Essex, community pharmacists undertook an audit of whether or not patients prescribed nitrates for ischaemic heart disease also received aspirin.

Judi Davies, chairman of the Uttlesford Community Pharmacy Forum, explains that the audit was conducted in all nine pharmacies in Uttlesford. Any patient presenting a prescription for nitrates was asked if they were taking aspirin. "Pharmacists checked compliance in those taking aspirin, as well as the patient's knowledge about the reasons for taking aspirin therapy and any side effects experienced," she says. In patients not taking aspirin, contraindications were identified and, if none was present, patients were advised to purchase aspirin or were referred to their GP for it to be prescribed. GPs were notified of any patients who started OTC therapy. At the end of every month, GPs were also informed about any patients who were already purchasing aspirin and of any patients identified as not taking aspirin and for whom the drug was contraindicated. All patients were provided with an information leaflet about aspirin. "The audit received positive feedback from customers, particularly about explaining why aspirin therapy was needed," she adds.

The audit was conducted over a four-week period. A total of 125 patients taking nitrates were identified of whom 98 were already taking aspirin. Of the remainder, 12 should have been taking aspirin. The pharmacist initiated treatment in one patient and 11 were referred to their GP. Among all patients, 79 per cent were aware of the benefit of taking aspirin.

Improving quality of care

Clinical governance is a requirement for all health professionals and underpins improvements in the quality of care. In Bexley, Bromley and Greenwich Health Authority, an accreditation scheme for all NHS contracted pharmacies has been introduced.

Tushar Shah, the health authority's pharmacy facilitator, says that pharmacies are assessed annually. Four levels of accreditation exist: access to services, staff training, risk management and continuing professional development. About 40 per cent of pharmacies in the area are now accredited. "The vision is that all pharmacies will be accredited so that there is a uniform standard," Mr Shah comments. Accreditation is important: the health authority rolls out schemes such as supervision of methadone, on the basis that the pharmacy is accredited.

Improving public health

Community pharmacy has an important role to play in improving public health, particularly because of its accessibility. There are a large number of targets in public health, one of which is reducing the rates of teenage pregnancy.

In Rotherham, South Yorkshire, community pharmacists are providing a free pregnancy testing scheme for teenagers. Sue Smith, Rotherham Health Authority, explains that the service is offered by 12 community pharmacies. The service aims to provide counselling and to direct patients to other services, in addition to providing a free pregnancy test. Compared with the approach of pregnancy testing through youth clinics, the service has benefits in its accessibility, particularly when clinics are closed and also because pharmacies offer a local facility, she says. However, a potential drawback is that pharmacies tended to be less private than clinics, she added.

This is a problem that has a solution in sight in Scotland (see below).