The Pharmaceutical Journal
Vol 268 No 7204 p931-932
29 June 2002

Radical overhaul planned for pharmacy in Scotland

The way in which the strategy for pharmaceutical care in Scotland would radically overhaul pharmacy practice was described to the Royal Pharmaceutical Society's Council in an address by the Scottish Executive's chief pharmaceutical officer, Bill Scott, on 12 June

Mr Scott said that "The right medicine: a strategy for pharmaceutical care in Scotland" had been produced not by civil servants but by the pharmacists of Scotland, through a series of workshops over two years. Everything in the plan was what Scotland's pharmacists had asked for. More than that, everything in the plan had been tested somewhere in the United Kingdom.

The strategy was to change the way in which the National Health Service in Scotland used community pharmacists in delivering public health, in clinical care of patients with chronic diseases, in care of common ailments and in social care. It was not a plan for medicines management — those words were not in it — but a plan for providing care. This included such things as disability aids — and a chunky knife and fork could not possibly be described as a medicine.

The strategy's origins were in the White Paper "Our national health: a plan for action, a plan for change". The priorities for Scotland were a national effort to improve health, to achieve better access to services, to make the best use of skills and resources — and a strategy for pharmaceutical care.

Challenges

What were the challenges for Scotland? Scottish people were top of the league for heart disease and for cancer. Scotland had rural and isolated communities. It had a growing elderly population that was not matched by increasing birth rate. The demands on the health service were constantly increasing. The challenge was to keep people healthy and to do so within the budget.

All reports on the NHS had a clear message. There had to be change. Pharmacy was part of that change process. But because of manpower shortages they could not take the matter head on. There had to be innovative uses of NHS staff.

The greatest opportunity for Scotland was a devolved parliament. England, Wales, Northern Ireland and Scotland had the same NHS, but they did not have to deliver health care in the same way, and they could use pharmacists in different ways. For the first time, the Government had realised that health was not stand-alone, that the causes of ill-health were multifactorial — environment, social circumstances, housing and education. They were all linked and the Government was trying to work across those boundaries.

The greatest thing was that Scottish ministers really believed in pharmaceutical care. They could see that using pharmacists properly could improve the health of their nation. How would they do that? First, they wanted to look at public health, where community pharmacists were the ground troops. Pharmacies were healthy living centres — places where people could go without an appointment to get information and help.

"Retailing" public health

Because of pressure from other retailers, pharmacists' traditional retailing activities were of reduced interest and the "front shop" should be used for "retailing" good health, with the pharmacist paid for the use of the premises. The Government had to pump-prime that by giving the housing agencies and social care agencies money to invest in that.

But public health was more than that. It had to infiltrate all aspects of the health service. Therefore they had consultants in public health working at health board level. In any planning of health services, pharmacy needed to be represented, to say how it could help deliver the government's agenda.

Another issue was the care of chronic illness. In one current pilot the patient received a prescription for a year and the condition was managed by the community pharmacist over the course of the year. Did that not change the perception of how pharmacists benefited patients?

It also changed the remuneration system. There was a need to get away from concepts such as "dispensing fee" and "trainee". Pharmacists had some of the best education in the world, and young minds were being wasted. The strategy was about how to use those young minds for the benefit of the people of Scotland. They would monitor therapy and review medication. They would use supplementary prescribing to alter the medication or introduce new medication. That was not pie in the sky; it was actually happening. What was needed was to make it happen everywhere in Scotland.

In the clinical care of common ailments, community pharmacy should be a portal into the NHS. That was being delivered in trials in Scotland, where a person exempt from prescription charges could consult a community pharmacist, who would prescribe a medicine, paid for by the NHS.

When that system was first mooted, people had said that pharmacists and patients would abuse it. But an evaluation by Manchester University had shown that they did not. The system cost less than the general practice system, patients thought it was wonderful, and the GPs had seen a decrease in their workload. The system needed to be rolled out across Scotland.

An important aspect was that pharmacists were independent prescribers. They were prescribing now, and they had to be independent. Ministers said that they had to be independent.

Pharmacists would have the budget for treating common ailments, and they would have to live within that budget. They would probably make a better job of it then any other clinician. Because of the complexities of dealing with common ailments the patients would register with the pharmacy. That had not caused any problems in the trials.

Instead of reinventing the wheel, pharmacies would be Scotland's walk-in centres. On a visit to a London walk-in centre, he had found a nurse giving out emergency hormonal contraception freely and a pharmacist selling it. Scotland did not want such a mixed message. Pharmacists would provide walk-in centres as part of the social care programme. Money had been invested in two pharmacies to create a new type of pharmacy, with pharmacists working alongside people from housing, the benefits agency and social services. That was not needed in every pharmacy but it was needed in deprived areas where the nearest housing or social services department was a bus ride away.

Hospital pharmacy

The strategy did not leave hospital pharmacy unscathed. Hospital pharmacies were a distraction for the profession. Hospital pharmacy could not progress unless it got rid of all the box filling and distribution. With hospital pharmacy, as soon as two members of the team were off, pharmacists were hauled back from the wards to the dispensary. That was nonsense. It suggested that they were not needed on the wards in the first place.

If patients brought their own medicine into the hospital with them there would be no need for pharmacy stores. Dispensing and distribution could be centralised off-site and pharmacists and technicians could be located at ward level, working generically. Pharmacists could — and did — run clinics, as part of a bigger team. Pharmacists became generic health care workers with a specialism in medicines. Most importantly, hospital and community had to be as one.

The pharmacist of the future in Scotland was an independent health care practitioner, integrated into the clinical team, with generic health-care skills and a major interest in pharmacotherapy.

By 2006, by delivering the strategy for pharmaceutical care, repeat prescriptions and care would be provided through the community pharmacy. Common ailments would be treated through the pharmacy. On hospital admission, patients would take in their own medicines. Problems with medicines would be picked up by a pharmacy technician or a nurse who would be able to address the problems. On leaving the hospital, the patient would not be given unnecessary medicines, and wastage would be reduced.

How was that vision to be achieved? There was already commitment from partners and from stakeholders. Patient groups had written to Mr Scott to ask why such a sensible approach had not been in place before. The chief medical officer fully supported the strategy. Other colleagues saw it as helping to deliver their own plans to improve health. The GPs saw it as a mixed blessing. The nursing profession had been the most negative.

It was not rocket science. But it was the little things that made an enormous difference to someone's lifestyle. One did not have to be a brain surgeon to make a great impact on the health of the nation.

One major step in implementing the strategy would be repeat dispensing. New funding streams had to be found to make it work. That probably meant taking it from someone else's budget. If pharmacy was looking after most chronic illness and most common ailments, someone else's budget was getting freed up.

Mr Scott suggested that pharmacists, whether working in GP surgeries, hospitals or community pharmacy, needed to come together in pharmacy locality groups, which would hold the budget for pharmacy.

The biggest disadvantage ever given to the profession was the employment of pharmacists in GP surgeries. For pharmacists to work in surgeries was a waste of the profession. What they did in the surgery could be done in the pharmacy. Community pharmacists saw patients every day. Pharmacists in a GP surgery did not. They had to be part of the same team.

Pharmacists isolated in surgeries saved money only for GPs. None of the savings were invested in pharmaceutical care. That wholly disadvantaged community pharmacy. Pharmacy was using its own people to undermine pharmaceutical care.

Community pharmacy needed a new remuneration model. It was not right to pay on volume of prescriptions, using a system that had hardly changed since its concoction in 1948. Community pharmacists should be paid not for their bodies but for their brains. They were educated for five years, clinically as good as anyone else, and yet the greatest industrial injury from which they suffered was repetitive strain injury from cutting up packs. That had to change.

Of course, pharmacy had to harness technology. There were still millions of prescriptions to be dispensed, but it was not pharmacists who should be doing it. They had to get the skill mix right. They also had to have premises fit for the 21st century. And the sooner continuing professional development was compulsorily, the better.

The Society

Pharmacists in Scotland also had to find new ways of working with the Society. The issue for the Council was to realise that they lived in a devolved nation. Because most pharmacists worked in the NHS, either as contractors or directly employed, then most pharmacists in Scotland worked for a devolved administration. They worked for the Scottish Parliament and had to have systems and structures in place that recognised that.

There was a need for a fundamental review of the Society's Scottish Executive and the way which pharmacy was structured. The Council had to trust the executive to make policy itself within the NHS in Scotland, while still being part of a British Society. If dialogue between the Scottish ministers and the pharmaceutical profession was to continue, it had to be a dialogue with pharmacists in Scotland, not in London.

Pharmacy in Scotland wanted to see technician registration now, not next year. There was a need to look at supervision, which in its current interpretation was not a solution but a problem. There had to be flexibility in the way policy was made in Scotland. There had to be diversity.

If pharmacy did not implement the strategy, the problems would remain, and Mr Scott's political masters would ask him to address those problems. Therefore it was in his interest and that of the profession to address the strategy as a significant contribution to improving health.

Pharmacy did not sit under the table of policy-making. It was at the table as an equal player making a real impact to the health of the nation. That would lead to better and fairer, access using community pharmacy fully. There was a commitment that everyone in Scotland would see a health care professional within 48 hours. A key health care professional in meeting that commitment was the community pharmacist. There would be better planning of services and, most of all, the best use of skills and resources.

All pharmacists had entered the profession to engage with people to make their lives better and provide health care, not to be a dispensing factory. Scotland was going to deliver and give all who entered the profession an opportunity to use their intellect to improve the care of the population.