Pharmacy in the Future — implementing the NHS Plan states: "Whilst most people find it easy to get medicines during normal shopping hours, this is far less true out of hours. Health authorities will be required to review local arrangements in partnership with NHS Direct, primary care trusts, local pharmacies and patient representatives so that:

• There is more easily available and more reliable information for patients on the opening hours of local pharmacies

• Wherever possible patients who need to start taking common medicines out of hours are able to obtain them at the same time as the consultation

•l Arrangements for dispensing other drugs urgently out of hours are well co-ordinated and reliable and readily accessible by those who need them."

With regard to the first requirement, the Southampton and South West Hampshire Health Authority has already produced a laminated sheet, which provides details of all pharmacies that are routinely open after 6pm on weekdays and Saturdays or open on Sundays (including both official rotas and "voluntary" opening). These are displayed in pharmacies and surgeries and have significantly improved the availability of information to the public. In addition, the health authority has updated the NHS website, www.nhs.uk, with details of pharmacy opening hours.

With regard to the second requirement, a number of initiatives are taking place within local out-of-hours co-operatives to try to tackle this issue.

In considering the final requirement, the health authority recognised that the current arrangements for accessing a community pharmacist out of hours could not be considered either reliable or readily accessible to patients and this was therefore highlighted as an area that needed review.

Current service

Like many others, the health authority has traditionally maintained a list of pharmacists who are willing to be contacted in the event that an urgent prescription requires dispensing. The system requires the patient to access a pharmacist via a police station (which is supplied with details of these "volunteer pharmacists"). The health authority had previously agreed with the local pharmaceutical committee (LPC) that a payment should be made to these pharmacists in recognition of their commitment. In addition, there is provision within the Drug Tariff for an enhanced dispensing fee for urgent prescriptions dispensed out of hours.

It was recognised that the main weakness of this system was the requirement for the patient to contact a police station in the first instance. Given the small number of requests, the police were often unaware of the procedure. In addition, although it was unlikely that all of the pharmacists on the list (currently 15) would be unavailable, it was recognised that the system did not guarantee the availability of a pharmacist out of hours.

An analysis of urgent prescriptions dispensed before the pilot suggested that, on average, one urgent prescription was dispensed each week. However, feedback from patients, nurses and prescribers suggested that a number of patients failed to navigate this system successfully and either did not make contact with a pharmacist or went back to the prescriber or to the local accident and emergency department.

The proposal

Discussions took place with the LPC, Hampshire & Isle of Wight NHS Direct and local general practitioners and out-of-hours providers. A paper setting out the following options was discussed at the health community wide access and capacity group.

• Option 1 — maintain current situation

• Option 2 — maintain the current voluntary on-call service, using NHS Direct in place of the police

• Option 3 — arrange for a community pharmacy to be open overnight

• Option 4 — establish a community pharmacist on-call service/P>

Option 1 was considered untenable because the current system was considered to provide neither easy nor guaranteed access to a pharmacist.

Option 2 was discussed with NHS Direct, but it felt unable to take on the role of co-ordinator in identifying a volunteer pharmacist willing to dispense an urgent prescription.

Option 3 was considered both prohibitively expensive and a poor use of scarce pharmacist time.

The final option, to establish a community pharmacist on-call service, was therefore supported and a working group established to develop this proposal further.

It became clear that a service would ideally continue to use the current volunteer pharmacists because they provided a useful geographical spread across the district. A model was therefore developed whereby a single pharmacist would act as "on-call co-ordinator" (on call for a period of one week) and be contactable via a mobile telephone, the number of which would be made available to GPs, deputising services and NHS Direct. On being contacted by one of these services, the co-ordinator would either provide advice to the prescriber or patient, arrange with a pharmacist on the voluntary list to supply the required medicines, or arrange to supply the medicines him- or herself. To be able to act as a co-ordinator it therefore followed that the pharmacist needed access to a community pharmacy out of hours.

In addition, it was agreed that the existing hospital on-call service based at Southampton General Hospital would act as a back up to this service.

The service would operate from 8pm to 8am on weekdays and Saturdays and from 5pm to 8am on Sundays and public holidays, recognising that there was good availability of community pharmacies open at other times.

A briefing paper on the proposed pilot, including a series of questions and answers, was prepared and circulated to those pharmacists on the voluntary list with a request that they consider participating. A payment of £250 per week on call was agreed with the LPC, as well as a commitment to continue paying the previously agreed annual fee to those pharmacists on the voluntary list.

Starting the pilot

Ten pharmacists agreed to participate in the pilot and each pharmacist was provided with an on-call pack, which included information on pharmacy opening times, contact details for GP out-of-hours providers, a list of the volunteer pharmacists and details of the hospital on-call service. The pilot started in November 2001 and local GPs, NHS Direct and out-of-hours providers were informed of the details both by letter and through a special edition of the prescribing newsletter.

Funding

The total annual cost of the pilot was estimated as £26,000; £14,000 for payment of on-call co-ordinators, £11,000 for annual payment to pharmacists on the volunteer list, and £1,000 for mobile telephone rental and miscellaneous costs.

The health authority was in a position to fund the pilot from the local pharmacy budget. This was due in part to a rationalisation of the existing pharmacy rotas and also because of a reduction in the uptake of the "pharmaceutical advice to residential care and nursing home" service.

Progress

A review meeting of the on-call co-ordinators was held in March 2002. All participating pharmacists agreed that the service was worthwhile and that they were happy to continue in the role. In addition, the pharmacists had received positive feedback from patients, on-call prescribers and NHS Direct. There were three main benefits of the scheme compared with the previous arrangements:

1. It was a simpler process for patients and prescribers (recognising that NHS Direct was the obvious first port of call for patients out of hours)

2. Direct contact by NHS Direct or the on-call prescriber with the pharmacist enabled individual cases to be discussed and agreement reached on what action was necessary (NHS Direct in particular seemed to value the availability of a community pharmacist out of hours to discuss whether an urgent prescription was actually required.)

3. Use of the volunteer pharmacists continued, which meant that the co-ordinator could often arrange for a pharmacist in the same locality as the patient to dispense the urgent prescription

The following problems were highlighted:

• A number of the volunteer pharmacists were still receiving calls direct from police stations via the old system

• Requests were being received from NHS Direct for patients living outside the Southampton and South West Hampshire area, including calls from other NHS Direct centres that thought the service was nationwide

• Requests were being received for out-of-hours provision of oxygen (A number of the volunteer pharmacists provided oxygen, but it was noted that the urgent dispensing fees within the Drug Tariff did not include payment for oxygen dispensed out of hours; it was therefore agreed that an equivalent fee would be paid locally.)

• There were security concerns from pharmacists attending their pharmacy out of hours and a need was identified to request a police officer attend should the pharmacist feel at risk.

Analysis of calls

An analysis of calls to date shows that, on average, the co-ordinator receives one to two calls per week (range zero to four). The calls are evenly split between NHS Direct and the local commercial deputising service, with 60 per cent of calls requiring an urgent prescription to be dispensed — either by the co-ordinator or one of the volunteer pharmacists.

Next steps

With the dissolution of the Southampton and South West Hampshire Health Authority, discussions have taken place with the three PCTs that the pilot covers. There is a consensus that the pilot has proved valuable and that the service should continue.

Discussions have also taken place with the LPC and other PCTs within Hampshire and the Isle of Wight about the possibility of rolling out the service more widely. There is a view that the current geographical area is an appropriate size for one co-ordinator and that local knowledge is an important element of the co-ordinator's role.

Conclusions

The pilot has demonstrated one way of achieving the requirement to have a reliable and readily accessible system for contacting a community pharmacist out of hours. The previous system (which many health authorities still rely on) was inconvenient and not easily understood by patients, for whom the obvious first port of call should they need an urgent prescription dispensing would now be NHS Direct.

The ability for an on-call doctor to contact a pharmacist out of hours easily allows a discussion to take place on possible options, which is clearly preferable simply to issuing an "urgent" prescription and expecting the patient to access a pharmacy.

By using the existing "volunteer pharmacists" the pilot has minimised the number of pharmacists formally on call at any one time while providing a reasonable geographical coverage of pharmacists that can be called upon. Co-ordinators have not found being on call for a one-week period too onerous.

During discussions with other PCTs a number have questioned the value for money of the pilot, given the low number of calls. The temptation is to divide the cost of the service by the number of calls and derive a "dispensing fee". We consider that the key objective of the service is around guaranteeing access to a community pharmacist out of hours for urgent issues (both advice and dispensing) and that it is inappropriate to measure its usefulness by the number of calls. However, it is important to ensure that the service is only accessed for truly urgent situations when the prescription cannot wait until the next day.

Acknowledgements I am most grateful to the 10 on-call co-ordinators and the other volunteer pharmacists for all their assistance, and their willingness and enthusiasm to participate in this pilot.