The Pharmaceutical Journal
Vol 270 No 7240 p361-362
15 March 2003

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LPS — a one-year progress report

Bids for projects to be provided under local pharmaceutical services contracts were first invited by the Department of Health in March 2002. These pilot schemes are now just starting. A second wave was approved last month. Fawz Farhan reports

Local pharmaceutical services have now become a reality. Last week, Northumberland Care Trust became the first to go live with its LPS pilots offering a truly innovative approach to care provision (see Panel below).

LPS has aroused much interest and debate since it was first unveiled last April. It was initially met with suspicion by contractors who considered it a ploy by the Department of Health to undermine pharmacy and erode funding. However, this attitude has largely changed, judging by the overwhelming response by contractors to PCTs' recruitment of LPS providers.

David Lammy, Parliamentary Under-Secretary of State for Health, speaking at the Pharmaceutical Services Negotiating Committee dinner earlier this month, said he is in no doubt that LPS will encourage innovation, provide flexibility and help pharmacists make better use of their skills. "I am enthusiastic about LPS as it could, and should, liberate the National Health Service and pharmacists to provide services where they are most needed," he said.

However, LPS is not for everyone as some services are best provided under the current contract. LPS can provide unique, add-on services to meet specific needs or to specific patients groups, such as drug misusers, the mentally ill and people from ethnic minorities. Some of the successful LPS pilots have also used the contracts to increase access to health care, promote different skills and services that are not linked to prescription volume, and integrate pharmacy with other health care providers, prescribers and local authorities. A total of 18 LPS pilots have now been approved by the Department of Health, seven of which are preliminary approvals where PCTs have yet to identify suitable providers.

PCTs with full approval are expected to start pilots in April, while PCTs with preliminary approval will be given longer to complete the process. This will have to include a consultation period of 30 days, the recruitment and training of LPS providers, and, in some cases, refitting of premises.

Department of Health LPS implementation manager Theresa Prendergast says pilots should ideally start within three months of approval (with an additional four-to-six weeks for preliminary approvals) so that they do not become outdated, as any changes to the original proposal would need to be resubmitted. "Six months is (now) quite a long time, and in that time proposals become irrelevant, run out of steam or are taken over by something else in the PCT," she says.

The Department has commissioned a national evaluation of LPS pilots led by Professor Peter Noyce at the school of pharmacy, University of Manchester. The evaluation is intended to shed light on the effective use of LPS in modernising health services provision. An evaluation report will be presented to the Department in 2005–06. National rather than local evaluation has been chosen because the Department was conscious of the further burden on resources this would put on PCTs. However, it is looking for co-operation from all pilots and PCTs and has promised there will be minimal documentation and extra work required of them.

Lessons learnt

The Department of Health insists that LPS has been a learning curve for all those involved, with plenty of opportunity to learn from mistakes and fine-tune the process for the future. PCTs themselves admit underestimating the complexity of LPS and the amount of work involved.

Some of the common themes that have emerged during the preparation and processing of bids are outlined below.

Organisation One of the main barriers to LPS has been the creation of PCTs in the first place. PCTs are at different stages of development and even established ones are finding their roles continuously evolving. This has meant the infrastructure for pursuing LPS has not always there. When more PCTs mature, the number of LPS bids is expected to increase. PCTs involved with LPS have recognised this and some have suggested that primary care development managers work alongside PCT and pharmaceutical advisers.

Understanding Both the Department and PCTs recognise that having a clear understanding of what LPS entails is crucial. Understanding the correct process and the expectations of the Department is another consideration. Tony Carson, community pharmacy development manager at Lambeth, Lewisham and Southwark PCTs, says: "It is such a new process. Everyone is getting their heads around it and trying to understand it and it has been difficult. There is little that people can use as there is no template."

Workload The stark warning from PCTs and pharmaceutical advisers is never to underestimate how long it takes to submit an LPS bid. Many who have embarked on LPS have had to neglect other responsibilities to concentrate on LPS full time. Some PCTs thought a project manager was necessary to ensure proper planning and preparation of LPS. Jane Moffat, head of medicines management at Brighton and Hove PCT, says: "LPS is complicated and is one of many roles that I am doing at the moment. I have to try to juggle it with the others. I needed external support because I did not always have the time."

Clarity The aim is to keep the review process for LPS pilot bids to a six-week period between the submission deadline and the announcement of successful bids. The tight schedule means bids need to be clear, relevant and succinct, says Ms Prendergast. They also need to be clearly written and presented because the evaluation panels will be scrutinising several bids in a short time. Some bids have failed in the past simply because they have not been communicated clearly. Mr Carson says: "The Department has stressed the need for clarity in LPS bids. We used consultants who provided expertise that helped to structure the information in the bids, ensuring that they were clear, concise and coherent and met the requirements." Proper planning and preparation is essential when it comes to LPS bids. Rushing a bid through to meet the deadline is a waste of time and effort, and it is better to wait for the next time. Ms Prendergast says that although deadlines for LPS bids are currently once a year, this may be raised if it becomes apparent that more bids need to be brought through.

Consultation and collaboration Collaboration with stakeholders is essential to ensure the success of pilots and patient involvement. Some PCTs gained support and collaboration through open discussion at meetings. Meeting were held with GPs, pharmacy development groups and patient support groups and local authorities. Greater emphasis is being placed on impact assessments. PCTs need to consider various standpoints, including that of community pharmacists. PCTs thought contractors were initially distrusting of the Government and PCT agenda behind LPS and agree that openness and transparency is essential.

Funding issues Some PCTs have had to look at a variety of sources to fund LPS. Some have simply diverted money from other health professions, while others have had to look more broadly and use funds from other sources, such as those for national service frameworks and medicines management. Set-up costs have included training and payment of pharmacists for their time and solicitors' fees for contracts. Funds for premises were sometimes required. In future, where LPS and existing pharmacy contracts co-exist, probity arrangements will have to address how the PCT checks which prescription forms are sent to the Prescription Pricing Authority as part of the LPS and at whose cost.

The contractors' view

Contractors have responded enthusiastically to LPS. Lambeth, Lewisham and Southwark PCTs received 50 expressions of interest for five LPS sites; North, Central and South Manchester PCTs received 54 for 12 sites; and Brighton and Hove City PCT, received 30 for three sites.

LPS offers contractors a more secure and longer-term way of offering services than current ad hoc funding arrangements. Many have had their fingers burnt in the past, with successful projects ceasing abruptly because of lack of funds. Pharmacists were then left with the dilemma of whether to continue offering the service at their expense, or withdrawing a much needed service from deserving patients.

Paul Benson, an LPS provider in Manchester, is strongly in favour of LPS because it allows him to be more clinically involved and gives him the opportunity to make an impact on medicines management. LPS can even lead to involvement in other services such as management of minor ailments and prescribing. Mr Benson believes LPS is also financially rewarding because payment is based on service not prescription volume. He is allowed to run the LPS contract alongside his old contract for dispensing and can even opt out of LPS if he finds that it does not suit him.

Tim O'Donoghue of Greenlight Pharmacy in Camden was already providing specialist services to the local Bangladeshi community and believed these would be best delivered through an LPS contract. He demonstrated this to Camden PCT through qualitative work and was selected as an LPS provider. Under LPS, Mr O'Donoghue will be targeting Bangladeshi patients by providing language translation and advocacy in the pharmacy and pharmaceutical monitoring of up to 300 registered patients with coronary heart disease and diabetes.

He believes LPS is an ideal model for delivering purchased services. The secure funding also ensures continuity of service and therefore raises the profile of pharmacy among patients and GPs. LPS is also better suited for qualitative services.

Nicola Roe, professional services manager at Rowlands Pharmacy, has been working with Salford PCT on increasing access to medicines and managing patients on long-term medication for chronic illness. She believes LPS crystallises the debate about money and gets innovative ideas in front of key PCT people.

Way forward

Following the announcement of the second wave of pilots, the Department has decided to revise the LPS guidance notes and proposal forms. The revised documents, expected this month, take into account deficiencies that became apparent in the first and second wave of bids.

The consultation process now has to allow 30 days for people to respond. It was thought unsatisfactory that some bids had allowed only five days for consultation. Impact assessments will also be more clearly defined under new headings. PCTs will have to produce a draft assessment stating their views on the matter and any negative impact of LPS on existing primary care services will need to be justified.

Despite a seemingly slow start, LPS is now getting under way in England. A third wave of bids has been invited by the Department with a submission deadline for these of 1 September.

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