The Pharmaceutical Journal Vol 267 No 7178 p863-864 15 December 2001

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Articles

Local pharmaceutical services — what can we learn from doctors and dentists?

By Rebecca Russell, MSc, MRPharmS, and Georgina Craig, MA

Department of Health guidance on local pharmaceutical services (LPS) for the first wave of pilots is keenly awaited. In this article the authors examine the experiences of personal medical and dental services to date, and how the lessons learnt may be helpful to community pharmacy in the development of LPS

The development of personal medical services (PMS) and personal dental services (PDS) contracts was hailed as a major move away from traditional models of service provision. They were designed to, and did enable, general practitioners and dentists to work outside complex national contracts and to enter into a more flexible contract with health authorities.1,2 "Pharmacy in the Future — Implementing the NHS Plan"3 and "Improving Health in Wales"4 announced the piloting of similar contractual arrangements for community pharmacy through local pharmaceutical services (LPS). The primary aim of LPS pilots will be to develop innovative ways of contracting for core NHS pharmacy services, such as dispensing. The drawing board is blank and there are no fixed models. It is the Government's intention that all LPS pharmacies should dispense NHS prescriptions, but pilots should not jeopardise existing medical and pharmaceutical services. Dispensing doctors cannot apply for an LPS contract and one cannot be combined with a PDS or PMS pilot. LPS will be voluntary and will include a right to return to pharmaceutical services. Given that this is a new concept for pharmacy, what can we learn from our colleagues who have already gone down this road? Personal medical services The main drivers for PMS in general practice were problems with recruitment and retention — particularly in deprived areas — and the fact that general medical services (GMS) did not appear to be addressing health inequalities.5 The development of PMS allowed a range of new entrants into what was previously a tightly regulated market. Nurses and "other members of the NHS family" now run PMS, including services such as family planning, care for acute and chronic illnesses and for such groups as refugees and the homeless. PMS facilitated a salaried option for GPs, although this had been available under GMS. Benefits, such as a fixed income and reduced administrative and managerial workload, were seen as attractive propositions for many younger GPs, locums and female GPs wishing to work part-time. PMS pilots have tested: New approaches to nurses' role and skill mix within primary and community care New approaches to addressing the needs of deprived areas and tackling recruitment issues in under-doctored areas Faster, more convenient and accessible services for patients Closer working with social care Whole primary care group/trust approaches At the time of its introduction, many GPs were concerned that PMS might threaten the stability of existing practices. PMS was viewed by many as the thin end of the wedge, leading to a salaried service and loss of independent status. Although some GPs are happier working under PMS than GMS, there remains a great deal of scepticism in the profession. Funding Funding for PMS pilots is allocated from the national GP remuneration pool, and also from additional growth monies set aside by the Government. The funding for GPs opting for PMS is devolved to health authorities as a separate cash-limited budget, which is used to purchase services in line with a locally negotiated contract. The schedule of payments to the PMS pilot can be flexible, for example, in 12 monthly instalments if required. Funding for LPS is likely to be on the same basis, with PCTs funding pharmacists to provide additional services on top of dispensing. Contractual framework for PMS pilots The evaluation of first and second wave PMS pilots informed the development of a core national contract for PMS. Pharmacists who get involved in early waves of LPS are likely to influence the final LPS contract. The PMS national core contract sets standards such as the delivery of national service frameworks and key national clinical governance and public health targets.6 Lessons to be learnt from first wave PMS pilots First wave PMS pilot applicants were thought to be predominantly "leading edge" practitioners. The NHS Executive steered subsequent waves towards deprived or under-doctored areas. The same pattern may follow for LPS pilots. In many deprived areas, pharmaceutical services are underdeveloped. The development of LPS pilots in deprived areas would add particular value since pharmacies help to improve shopping access.7 Most of the GPs who have gone for the salaried PMS option are those who were making below average income from GMS — often because they are in deprived areas, have small list sizes and find it difficult to meet targets for things like immunisation and cytological screening. Most of these GPs are better off financially as a result of the switch to PMS — some by as much as 20 per cent.8 However, their funding comes from the overall global sum for GMS/PMS, which, if unchanged, means an erosion of income for those who do well from traditional GMS. It is likely that contractors who do less well from the current pharmacy contract will be attracted to LPS and a similar situation may develop in pharmacy. Within general practice, there is still no formal negotiating body for PMS doctors and this, along with the erosion of the power base of GMS contractors as they fall in numbers, is causing concern at national level. Local pharmaceutical committees need to find ways of addressing this issue. The Government has suggested that GMS and PMS contracts will eventually converge. The same may be true of LPS. If this is the case, it is important that pharmacy contractors of all types proactively shape LPS. By doing so, pharmacy contractors can ensure that the new national contract meets their needs as well as those of the patients. GMS and PMS contain a significant element of capitation payment that does not exist in pharmacy. This makes the idea of negotiating a similar type of LPS contract much more difficult. Will patient registration become an aspect of LPS pilots? A key issue that must be considered is the arrangements to deal with "casual users" of the pharmacy who are not included in the LPS contract, but who want a prescription dispensed. Those who do well under the traditional system of GMS are GPs with large lists of "well" patients who require little input from their GP. In community pharmacy, by contrast, it could be argued that those who do well from the current system are those with the highest prescription volume. Just as PMS is redressing the balance in general practice, LPS may change the emphasis on prescription volume as a way of generating income in pharmacy. This will have an impact upon the way in which the goodwill value of pharmacies is measured, which in turn may have an impact on future sales of pharmacy businesses. "PMS Plus" pilots enabled GPs to provide services previously funded from hospital and community health services monies. LPS will give pharmacy contractors access to unified budgets within primary care. However, pharmacists do not need to provide LPS to attract funding from these budgets. They can simply negotiate to provide "add-on" services to their current contract. PDS Pilots There are significant differences between the contracts for medical and pharmaceutical services. There are more similarities between dental and pharmaceutical services. Dentists are independent NHS contractors, paid largely on an item of service basis. PDS may offer further clues as to how LPS may develop. The key points about PDS pilots for pharmacy are:9 Dentists contract with health authorities individually or in groups/partnerships for new ways of delivering care Involvement is voluntary PDS is led by local priority setting and pilots are intended to respond to local needs PDS pilots provide either the full range of general dental care services (GDS) or specialist services only Improving access is a key focus for PDS (Later pilots sought to solve access problems by providing emergency drop-in and "phone and go" centres.) There is no national contract, no nationally agreed benefits and no national pattern to pricing and payment mechanisms, but there is a national outline framework for contracts Pilots are funded from existing resources, transferred from the GDS plus existing patient charges (Some growth funding was available for pilots looking to solve access problems and employ additional staff.) As of April 2000, PCTs were able to run PDS pilots commissioned by health authorities Dentists were suspicious of moving to PDS. They have high capital investment and valuable goodwill tied up in their practices. They work in a free market environment, and set up business where there are enough patients to sustain it. However, they were getting less and less remuneration for treating increasing numbers of patients and their fee structure created perverse incentives to intervene — even if treatments were expensive and unnecessary. Young dentists found this way of working mundane and this led to recruitment and retention problems. The Government introduced PDS in areas where the free market had failed to provide adequate access to dental services. Typically, dentists working under PDS receive a part capitation payment (50 per cent) for a threshold of registered patients. If this is crossed, it triggers renegotiation of the PDS contract with extra money. The capitation fee guarantees payment even if there is no need to intervene. Patients pay any charges at the time of treatment. PDS pilots have been running for three years. The system is less bureaucratic and it has resolved problems recruiting dentists because young graduates are more motivated by the move to total care. The parallels with community pharmacy are clear and it may be that such a system could work in areas where there is inadequate provision of pharmaceutical services. Conclusion The introduction of LPS is intended to help community pharmacists to meet the real pharmaceutical needs of patients. There are many lessons to be learnt from PMS, although PDS may be a better model for pharmacy to relate to. Early pilots will shape the national core contract for LPS and possibly the new national contract for pharmaceutical services. Early winners may be those who do less well from the current contract such as those with a low dispensing volume. LPS may help to attract pharmaceutical services to areas with poor provision currently. References 1. Department of Health. The NHS (Primary Care) Act 1997. London: The Stationery Office; 1997. 2. The PMS National Evaluation Team. National Evaluation of first wave NHS personal medical service pilots: integrated interim report from four research projects. Manchester: National Primary Care Research and Development Centre; 2000. 3. Department of Health. Pharmacy in the Future — Implementing the NHS Plan: a programme for pharmacy in the NHS. London: Department of Health; 2000. 4. Health Service Strategy Team. Improving health in Wales. Cardiff: National Assembly for Wales; 2001. 5. Department of Health. Primary Care: The future, choice and opportunity. London: The Stationery Office; 1996. 6. NHS Executive. A contractual framework for Personal Medical Services — third wave pilots. London: NHS Executive; 2000. 7. Policy Action Team: 13. Improving shopping access for people living in deprived neighbourhoods. London: Department of Health; 1999. 8. Income may rise by 20% under PMS. GP September 2000. 9. British Dental Association. BDA Advice Sheet E5, Personal Dental Services. London: BDA; 2000.

Rebecca Russell is publications editor and Georgina Craig is head of professional development at the NPA. Correspondence to Rebecca Russell, National Pharmaceutical Association, Mallinson House, 38–42 St Peters Street, St Albans AL1 3NP

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