The Pharmaceutical Journal Vol 267 No 7179 p892-893
22 December 2001

Keele University Department of medicines management:
Pharmacy, medicines management and the modernisation agenda

Opening the conference, Dr JIM SMITH (Chief Pharmaceutical Officer, Department of Health) explained that medicines management in primary care aimed to improve patient care and reduce waste by better use of medicines. The agenda would be mainly, but not exclusively, delivered or managed by pharmacists and would involve medication reviews, targeted support in national service framework areas, and improved support and advice to patients. Dr Smith said that he would like to see prescribing by pharmacists as "the end point of the medicines management process". Supplementary prescribing would be the first priority and it was hoped that the first prescribing pharmacists would be in place by mid-2003.

More change was on the way in the form of local pharmaceutical services (LPS) which would test innovative ways of contracting and explore mechanisms of providing a wider range of pharmacy services. Guidance will be issued in the spring, and it was hoped that the first pilot sites would be in operation by late 2002. LPS would be agreed by contract with a primary care trust and would not operate alongside the national contract. There would be flexibility around payment mechanisms, but there would still be a need to include dispensing. Most schemes are likely to involve existing contractors, but they could also include NHS trusts, explained Dr Smith.

Making the best use of pharmacy staff will be crucial in order to meet these targets. This will require a critical examination of skill mix and delegation within community and hospital pharmacy. The debate will need to focus on how to provide effective services with the best use of pharmacists and technicians, while ensuring patient safety and maintaining public confidence in the profession. Essentially, the pharmacy programme represented the biggest opportunity, and challenge, for pharmacists for a generation, explained Dr Smith. "There would never be a better opportunity to reshape pharmacy services.

Local implementation

SUDESH BASRA (pharmaceutical adviser, Hillingdon Primary Care Trust) described a novel scheme to improve out-of-hours services, a key part of the modernisation agenda. Hillingdon PCT had piloted an out-of-hours service in order to improve public access to pharmaceutical advice. The scheme is based at the local NHS Direct call centre and operates through a rota of 19 community pharmacists. Over one 12-week period, a total of 742 queries had been received by the pharmacists (approximately nine calls per night, of which 90 per cent occurred between 8pm and midnight). The most common types of query were classified as the use of medicines (52 per cent of calls), advice regarding treatment (17 per cent), interactions (11 per cent), and side effects (10 per cent). The vast majority of queries did not require complex information but were rather the type that community pharmacists deal with in everyday practice, explained Mrs Basra.

Feedback from nurses at the call centre had been positive, highlighting the benefits from improved access to pharmaceutical advice and the urgent supply of medicines.

Mrs Basra said that community pharmacists had also been involved in a prescribing intervention scheme in Hillingdon. Initially, a £5 remuneration fee per intervention had been agreed, which was raised to £10 following discussions with local pharmacists. Over a three-month period, 30 interventions were made by four community pharmacies generating savings of approximately £2,100 on the drug budget. Since April 2001, a total of 120 interventions had been submitted. However, 80 of these were from one pharmacist. There is clearly a barrier to pharmacists' reporting their prescribing interventions, explained Mrs Basra, which is not necessarily related to the remuneration fee.

Other initiatives that had been developed included offering prescribing support to general practices by community pharmacists, operating pharmacist-led medication review clinics in primary care and developing support services for smoking cessation. Looking to the future, there was a need for community pharmacists to adapt to the changing roles and engage more closely with PCTs, Mrs Basra explained. She questioned how long PCTs would continue to drive participation by community pharmacists and argued that there was a need for LPCs to be more proactive. "Is the real threat the new role or the failure to take it on?"

Modernisation agenda

Professor ALISON BLENKINSOPP (professor of the practice of pharmacy, Keele University) outlined the structure and function of the Modernisation Agency. She explained that the national modernisation board and taskforces had been set up in October 2000 to help drive forward the NHS plan and help hold the NHS to account. The Modernisation Agency incorporates the National Patient Access Team (NPAT), the Primary Care Collaborative, the clinical governance support team, other collaboratives, for example, cancer, and a leadership centre. Twelve national taskforces have been set up to take forward specific areas of the NHS plan and these will play a key role in highlighting and spreading good practice. All the taskforces would be mirrored at a local level, explained Professor Blenkinsopp.

Professor Blenkinsopp had been appointed to the national taskforce for access. Priorities for this taskforce included an analysis of access to services (for instance, booking and waiting list systems, capacity and demand modelling, improving access in primary care), ensuring patients get the right medicines at the right time, and also examining models of self-care and the management of minor illnesses. Within local modernisation reviews, key themes that were starting to emerge were issues concerning access, workforce, information technology and mental health.

Within pharmacy, a briefing group had been established to facilitate communication to and from the Modernisation Board and taskforce members, with representation from key pharmacy organisations. In addition, an NHS Plan pharmacy website (www. pharmacyinthefuture.org.uk) was launched in June 2001 to provide a focal point for pharmacists for NHS policy and innovative practice models. It is essential that pharmacists build on successful examples of service redesign, explained Professor Blenkinsopp, but there is also a need to understand the reasons for failures in order to identify future opportunities.

Opportunities and challenges

The Pharmacy Plan offered many opportunities for community pharmacists, but there are a number of threats that could destabilise current work explained SUE SHARPE (chief executive, Pharmaceutical Services Negotiating Committee). Community pharmacy has many strengths to offer both the public and PCTs, including approachability and accessibility, information provision, support for self-care, continuity between primary and secondary care, monitoring of therapies and specific support for certain conditions and patient groups. The accessibility of community pharmacy is a key advantage, but this had not been fully recognised by the NHS. Studies have shown that self-care accounts for approximately 70 per cent of all ill-health episodes and it is important not to ignore the role that pharmacists play in supporting self-care.

Opportunities for community pharmacy to deliver in the immediate future include acting as the "front door" to the NHS and providing effective communication and advice. Medicines management could be delivered through repeat prescribing schemes and the monitoring of patients' responses to therapy by community pharmacists. It is important, however, to ensure that these services are offered as an integrated part of the activities of a PCT, and not in isolation. There are challenges ahead, which include reconfiguring services, reskilling for additional future service provision, developing recognition and integrating into primary care structures. "PCTs are concerned about pharmacists' lack of records and that is something that community pharmacy has got to address," said Mrs Sharpe.

Mrs Sharpe went on to say that she was disappointed to hear reports about PCTs that wanted to drive forward new services with a lack of response from local LPCs. With the new NHS structures, it would be even more essential for pharmacists to engage in local discussions, she argued. She believed that ideas needed to come from community pharmacists, but there must also be a willingness to listen and engage within PCTs. She was also disappointed that more progress had not been made in implementing mandatory lifelong learning, stating that "we have to be able to give a quality assured service across the profession as a whole".

Local pharmaceutical services

The payment system for community pharmacy was introduced many years ago and is now out of date, stated Dr DARRIN BAINES (director, medM Limited). There is a need to develop new systems of paying community pharmacists for their services. LPS will have agreed objectives between purchasers and providers, require the measurement of performance and entail system redesign and skill-mix changes. The system will be discretionary in that no individual will have the right to be an LPS contractor, nor will they be obliged to participate.

Ideally, the systems should be needs-based and use local expertise to create health gain. There are problems, however, when it comes to measuring need. What factors should be considered? Need could not be measured directly and, therefore, proxy measures would be used, explained Dr Baines. Even if what looked like relatively objective measures, such as the number of prescriptions dispensed or the number of local patients, were selected, there are problems with how these should be arrived at, or applied.

Dr Baines suggested that proposals should build on the principles of health improvement, clinical governance, fair access and consumer satisfaction, improved effectiveness and efficiency, appropriate use of pharmacists and better integration. When developing a proposal, there will be a need to define the objectives, targets and quality indicators, measure the quality baseline and agree methods of data collection and reporting. LPS pilots will require new data sources, said Dr Baines, but as yet, few indicators have been developed.

Medicines management

Professor JUDY CANTRILL (professor of medicines usage, evaluation and policy, University of Manchester) discussed the findings from several research projects with which she had been involved. Results were presented from two studies that had focussed on preventable drug-related morbidity (PDRM). In the first study, it was found that approximately 6 per cent of acute medical admissions to a large teaching hospital were the result of drug-related morbidity. Of these, two-thirds were judged to be preventable. The term "community-acquired PDRM" described these cases, said Professor Cantrill.

The second study involved a retrospective analysis of patient records in one general practice. The results were highly dependent on the level and quality of data recording. In the preceding two years, it was found that 25 per cent of patients receiving ACE inhibitors had not had their potassium value recorded, and a further 25 per cent had not had creatinine levels documented. Other problems included limited access to the results of anticoagulant monitoring. Professor Cantrill stated that many errors relating to medicines are the result of inadequate systems of monitoring therapy.

She also explained that the management of patients who visit general practitioners with minor ailments is a widespread concern for their workload. She presented results from the "Care at the Chemist" scheme. Over a 26-week period, all patients seeking appointments or telephone prescriptions for 12 minor ailments at one general practice were offered a consultation with a community pharmacist at one of eight community pharmacies serving that practice. The pharmacists were allowed to prescribe treatments from a limited formulary, and any patients exempt from NHS prescription charges received medicines free of charge.

The study found that 38 per cent of patients wishing to consult with a minor ailment transferred the workload to the community pharmacy. Of the 576 transfers, only 21 (3.6 per cent) were referred back to the practice. Of the patients who chose to consult a GP, almost half were prescribed a drug listed in the over-the-counter formulary. Reconsultation rates did not differ significantly between general practice care and those who consulted a pharmacist.

The management of some self-limiting conditions by community pharmacists is acceptable to patients and removing the financial disincentive improves access to treatment for self-limited illness, explained Professor Cantrill. The scheme has recently been extended to the whole PCT.