The Pharmaceutical Journal
Vol 270 No 7235 p198-199
8 February 2003

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One year on: has it been the right medicine for Scotland? summary

Tayside direct supply project moves towards full regional roll-out

An increasing number of pharmacists in Tayside are now prescribing under the "DirectCare at the Chemist" scheme. In Arbroath and Montrose, the scheme is already well established. More urban areas will adopt the scheme this year

Tayside's "DirectCare at the Chemist scheme is doing more than just allowing community pharmacists to write prescriptions, it is establishing a new model of how pharmaceutical services can be provided and remunerated, John Hamley, chief pharmacist at Tayside Primary Care Trust, believes.

Under the scheme, patients who are exempt from paying prescription charges can register with a community pharmacy and be prescribed non-prescription medicines by pharmacists on the National Health Service. Pharmacies are paid a capitation fee and are reimbursed by the Prescription Pricing Division in the normal way for the medicines supplied. Thus, Mr Hamley and his colleagues point out, it has established the principles of patient registration, capitation fees and pharmacist prescribing. Information technology links and the use of a single common patient identifier are also important parts of the scheme.

Ken Penman, project co-ordinator for the scheme, explains that the scheme started in November 2000 with baseline data on general practitioner consultations and prescribing being gathered. In April 2001, the first pilot phase of the scheme started in the Arbroath area, involving five GP practices and six pharmacies (both independents and multiples).

Mr Penman explains that the aim of the scheme is to avoid patients who are exempt from paying prescription charges making appointments with their GP just to get a prescription so that they can get an over-the-counter medicine without having to pay for it themselves.

"The scheme improves access to health care for patients, GPs make more use of their skills because they see a more appropriate range of patients, community pharmacists make more use of their skills, and it encourages joint working between pharmacists and GPs," he says.

Registered patients can receive a range of non-prescription medicines used to treat common minor ailments (see Panel below). In addition, patient group directions are used to allow some medicines, particularly those for hay fever, to be supplied in quantities larger than the pharmacy medicine pack sizes. Patients can also be given appropriate advice (with or without a medicine) or referred to their GP. CP1 prescription forms are used to record the medicines supplied, allowing reimbursement, and each consultation is noted in the pharmacy patient medication record (PMR) system with the pharmacist as the prescriber.

Mr Penman says that since the start of the scheme in Arbroath, over 2,000 patients have been registered. Of these, around half have consulted a pharmacist with 92 per cent subsequently receiving a medicine, 3 per cent being given advice only, 2 per cent making an over-the-counter purchase and 3 per cent being referred to their GP for a routine appointment. Only a few consultations have required an urgent appointment with a GP.

The most common complaints treated have been head lice infestation, pain in children, coughs, indigestion, nasal congestion and hay fever. Both patients and pharmacists have been happy with the scheme and are keen to see it continue.

Roll out the barrel

Where the DirectCare scheme differs from other similar and successful pilots in England is that it is progressively being extended across the whole of Tayside. In November 2002, it was extended to Angus Local Health Care Co-operative, a rural area of 110,000 people with five population centres and a further 16 community pharmacies. By April it will cover Perth and Kinross LHCC and 133,000 people in an area which is largely rural but also includes the city of Perth. If this is successful then it will be rolled out to Dundee, the main urban area in Tayside, it is hoped by the end of the year. The rest of Scotland would then be covered, region by region, next year.

Mr Hamley explains that one reason why Tayside was selected as one of the direct supply pilot sites (the other is at Patna, Ayrshire, see PJ, 4 January, p26) is the widespread use of the community health index (CHI) number. This is a unique patient identity number, encoding the patient's date of birth and sex, which is now used on all patient records in both primary and secondary care in Tayside. Using the CHI number on the pharmacist prescriptions allows them to be linked to all the other health records, and for the appropriate GP budgets to be cross-charged. The CHI number will also become important when the scheme is extended to Dundee and there is a greater use of IT.

One of the reasons why the direct supply scheme is now forging ahead is the appointment of Mr Penman as its project manager. Jean Wallace, now one of Tayside's 35 practice pharmacists, was involved with the first phase of the pilot as manager of the Lloydspharmacy branch in Arbroath. "Before Ken arrived, we were going nowhere," she says. "There was lots of heated discussions but no agreement. Ken brought the GPs and pharmacists together and took away our fears."

One of Mr Penman's tasks has been to visit all the GP practices and pharmacies ahead of the scheme's roll-out in Angus. Each pharmacy was allowed to choose its own start date. Local publicity for DirectCare starts this month. The procedure for enrolling patients has also been simplified, with the main difficulty being obtaining patients' CHI numbers. Mr Penman ran well-attended training evenings for pharmacy staff.

As the roll-out goes regional, and then national, a number of corporate governance issues need to be addressed, Mr Hamley says. These cover fraud prevention, ongoing funding and payments, data protection and confidentiality and the possible need for a separate pharmacy prescribing budget. "It is these corporate issues we need to address if we are not to be in big trouble later," he says. The Association of Scottish Trust Chief Pharmacists is trying to draw up a template for these issues.

Prescribing in action

In Arbroath and Montrose, pharmacists and their green CP1 prescription forms have become part of the health care scene. At Boots The Chemists in Arbroath, pharmacists Angus McNicoll and Margaret Hagan say that direct supply has been well received by customers. Apart from some initial confusion between pharmacist prescribing and repeat dispensing, patients have found the scheme useful. One common scenario is where a mother is told about a head lice problem when collecting her children from school. With the DirectCare scheme she can come straight to the pharmacy and receive the necessary treatments without needing either a doctor's appointment or any money.

At Steeple Pharmacy, Montrose, pharmacist owner Diane Manzi says that supplying non-prescription medicines is something pharmacists have always done. "Now, with DirectCare, we can supply those exempt patients who would previously have had to wait two or three days to get a prescription." At Steeple Pharmacy, a recently installed consultation area, part-funded by Tayside NHS Board, allows the pharmacist to access the PMR system while counselling patients. Consultations before a direct supply are made here.

Mrs Manzi says that the formulary against which pharmacists can prescribe is limited at present. She hopes it will be extended when it is reviewed later this year. "For example, I could see patients wanting nicotine replacement therapy coming in every couple of weeks. Using our Smokalyzer [carbon monoxide breath analyser] we could demonstrate to them the benefits of giving up smoking while prescribing the next instalment."

So far, the DirectCare pharmacist prescribing scheme is proving a success. Extending it to cover Dundee will be challenging, because a more mobile population is likely to use more than one pharmacy at different times, but if the scheme can be made to work there then there should be less difficulty in extending it to the rest of Scotland. There will then be the opportunity to widen the range of conditions treated and the variety of medicines which can be prescribed, perhaps with prescription only medicines being included