The Pharmaceutical Journal
Vol 270 No 7246 p568
26 April 2003

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Developing new out-of-hours services

Demand for out-of-hours services is increasing. Debbie Andalo finds out the different ways that pharmacists are expanding their out-of-hours roles

Community pharmacists are developing different solutions to increase out-of-hours services as they strive to meet the Government's modernisation agenda to improve patient access to services around the clock. Schemes that are being put to the test are boosting the profession's status with patients as well as making pharmacists fully part of the primary health care team. Pharmacists are seeking to expand their traditional out-of-hours role at a time when general practitioners are expected to take up the option offered in their new contract to opt out of their out-of-hours responsibility — leaving the way clear for pharmacists and other health professionals to fill the gap.

Pharmacists in Lancashire are involved in an out-of-hours initiative which GP leaders at the British Medical Association are keen to see become the model for the future. From May pharmacists will be paid £25 an hour to offer consultations for minor illness alongside nurse practitioners and GPs working in the out-of-hours primary care centre run by the GP co-operative Fylde Coast Medical Services (FCMS). Pharmacists will also offer medicines advice to other health and social care professionals out of hours. A limited out-of-hours dispensary has been established at the centre in Blackpool and it will operate during pharmacist sessions on weekdays from 7pm to 10pm and on weekends and bank holidays from 9am to 10pm.

The project has the backing of the local pharmaceutical committee and 20 of the 163 local community pharmacists have volunteered to work at the centre. Central Lancashire LPC chairman Andy Lipshaw says pharmacists have been keen to get more involved with the out-of-hours service for years and admits that the pharmacists' voluntary out-of-hours rota has been fragile. He says: "In the past the rota has been dependent on pharmacists' goodwill. Although we have never refused to come out when called, it does mean we will now have something more firmly in place." He believes that the out-of-hours demand on GPs has helped push the scheme through. "This wouldn't have happened five years ago — now the GPs cannot get enough of us. We have been pushing at their door for a long time and it seems they have now pulled it open."

There was support from LPC members for the limited opening dispensary even though it will be open during the day when other pharmacies are operating. Mr Lipshaw says: "We will only take prescriptions from the GP practices using the centre. We did consult the pharmacists in the locality and nobody felt strongly about it although there was some concern that it might develop into a full-blown pharmacy, which was never the intention. It is only intended to be a limited pharmacy to dispense the items which are needed at the centre." If patients prefer prescriptions to be filled by their local pharmacist, they will be faxed there instead for dispensing, he confirms. Mr Lipshaw says the initiative, which is being developed under a Local Pharmaceutical Services contract, helps boost the status of the pharmacy team. "The role of pharmacy is increasing and there are many areas where we are working more closely with GPs, such as supplementary prescribing. In a couple of years it may well be possible that pharmacists will become the first port of call for patients in a whole host of areas."

The BMA is watching the development closely because it expects that, particularly in England, most GPs will take up the new contract option to opt out of their out-of-hours responsibility. Chairman of the BMA's prescribing subcommittee Dr Peter Fellows says: "This pilot is just the kind of scheme we are trying to promote and it may become the model for the future."

Joint working

Community pharmacists in Middlesex have also been trying to improve the out-of- hours service they deliver. They had hoped to establish an out-of-hours dispensary — which would also sell over-the-counter medicines — as part of a multimillion pound out-of-hours scheme based at Northwick Park Hospital. The initiative would have involved pharmacists, nurses, accident and emergency doctors and GPs working across primary and secondary care. The project was drawn up as part of an exemplar scheme to meet the out-of-hours recommendations of the Carson report ("Raising standards for patients — new partnerships in out of hours care"), a GP-led review of out-of-hours services published three years ago, which concluded that medicines should be available to the patient at the same time and place as the out-of-hours consultation. The first phase of the project — where the GP co-operative Harmoni and nurse practitioners provide the core out-of-hours services — has already got off the ground. But the second phase, which involves pharmacists, dentists and the mental health crisis team, is still being worked out. Michael Levitan, secretary of Middlesex LPC, says: "So far the visionary part of the bid, which includes pharmacists, hasn't been funded but negotiations are still continuing."

In the meantime community pharmacists have reached agreement that from April, as part of another Department of Health pilot, they will provide out-of-hours palliative care drugs and oxygen to patients across Harrow and Hillingdon. Twenty community pharmacists have signed up to the scheme under the umbrella of the West London Cancer Network. They are paid a retainer and a £50 call-out fee to provide medicines from their own pharmacies within an hour of the request from the GP co-operative. Mr Levitan says: "This is significantly different from the former voluntary scheme."

Both the Middlesex and the FCMS schemes have flourished on the back of well-established GP out-of-hours co-operatives, which have historically been at the forefront of innovation. What they illustrate is that there is no single model for expanding pharmacy services out of hours.

The National Pharmaceutical Association says pharmacists should design a system which reflects local need and should work on establishing new partnerships with other health professionals as well as improving links with each other. Head of NHS service development at the NPA Georgina Craig says: "I think the FCMS model illustrates how services are going to develop. In that instance it is the out-of-hours GP providers who are providing the service while what we would ideally like is for pharmacists to be contracted to do the work."

She would like to see a network of community pharmacists contracted to work out of hours that is similar to the way that GPs have organised themselves into out-of-hours co-operatives. "If pharmacists can provide the out-of-hours input as a group they will become more used to working with each other co-operatively and will be able to develop pharmacy services at a local level."

The NPA in conjunction with the Pharmaceutical Services Negotiating Committee has developed a community pharmacist resource pack to help them meet the new out-of-hours challenges. The pack will be available once the Department of Health guidance on out-of-hours medication services — which will include an out-of-hours formulary — has been published. The guidance is in its final draft and expected to be published soon.

In the meantime the NPA has this advice for community pharmacists: "You need to talk to your PCT about this. The PCTs are looking for solutions and there is the opportunity here for pharmacists to become part of the network of out-of-hours providers, beyond dispensing."

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