Primary care: Tensions visible between community and primary care pharmacy
This year, the British Pharmaceutical Conference
practice programme featured a day aimed at pharmacists working
in primary care settings. Sessions — chaired by Clive Jackson,
chief executive, National Prescribing Centre — included
a discussion on attitudes involving primary care pharmacists, straw polls,
question time with a panel from the
Royal Pharmaceutical Society and a debate. Lin-Nam Wang (on the staff
of The Journal) draws out the main themes
Straw polls using a cordless response system were conducted throughout
the day at the sessions |
Several recurring issues emerged during the primary care pharmacy sessions,
but underlying all of them was the question of what a primary care pharmacist
(PCP) is. A variety of names are often used synonymously, including PCP,
pharmaceutical adviser, prescribing support pharmacist and community
services pharmacist, said David Morgan, consultant in pharmaceutical
public health, Velindre NHS Trust, Cardiff, and he asked other Conference
participants for their definitions of a PCP.
Clive Jackson, chief executive, National Prescribing Centre, offered: “Pharmacists
employed within National Health Service organisations delivering primary
care services”. Mr Jackson said that when the NPC had looked at
competencies for PCPs, it had looked to pharmacists working in general
practitioner surgeries and primary care trusts. In contrast, Sally Greensmith,
a member of the Royal Pharmaceutical Society’s Council and a primary
care pharmacist, gave a far wider definition: “The Society and
PCTs need to recognise that community pharmacists are as much PCPs as
those directly employed by PCTs.”
Tension
Whatever the definition of a PCP, it is clear that in practice, there
is a gap between community pharmacists and PCT pharmacists. Alison
Tennant, specialist in pharmaceutical public health, Dudley Beacon
and Castle PCT, spoke of a tension, in some areas, between contractor
pharmacists and PCT pharmacists. “Agendas do not match. Community
pharmacists are trying to ensure a consistent and reasonable funding
stream and PCT pharmacists are trying to deliver services that are
seen to be quality driven and value for money. What community pharmacists
and PCPs see as being needed locally can be very different,” she
explained.
According to Mrs Tennant, one cause of this tension is the way in which
community pharmacy is paid, but it is hoped that this will be tackled
by the new community pharmacy contract. A more difficult hurdle is the
attitudes of community pharmacists and pharmaceutical advisers. “Trying
to build bridges and facilitate discussion with both groups can be difficult.
There are some areas where views are becoming more and more entrenched
and the PCT is moving on and leaving community pharmacy contractors behind,” Mrs
Tennant warned. Furthermore, there is the difficulty of getting community
pharmacists to attend communication workshops.
Ann Lewis, Secretary and Registrar, Royal Pharmaceutical Society, agreed
that communication is a real problem and said that every opportunity,
including continuing professional development and local branch meetings
need to be used to talk things through.
Clive Jackson said that a system to cascade information to people who
are busy is needed and that perhaps pharmacy development groups could
do this.
In a vote, 76 per cent of participants thought that there is a distinction
between community pharmacists and primary care pharmacists and 47 per
cent said that they believe that PCPs do not understand the potential
of community pharmacy in delivering the new NHS agenda.
Segregation
However, Sally Greensmith told the audience that some PCTs are beginning
to realise the potential of community pharmacy to help them reach their
targets and deliver the services necessary to achieve Commission for
Healthcare Audit and Inspection (CHAI) ratings. However, in some areas,
only selected pharmacies are being allowed to deliver services that
all pharmacies should be allowed to deliver.
Dr Angela Alexander, speaking as a local pharmaceutical committee secretary,
told the session that one PCT in Berkshire has introduced an accreditation
scheme for community pharmacies and is refusing to allow pharmacies that
are normally managed by locums or part-time pharmacists to take part
in the scheme and, therefore, to take part in primary care service developments. “This
is further ‘ghettoising’ the pharmacies that are managed
on a part-time or locum basis and those are the pharmacies we need to
put more, not less, input into,” Dr Alexander said.
A solution needs to be found by which all pharmacies provide the same
services, commented Andrew Burr, a member of the Society’s Council.
And perhaps pharmacists would not provide the services themselves, but
allow others to deliver services from the premises. Excluding people
and not taking them forward would be counter-productive further down
the line, Mr Burr said, and he urged PCTs to think again. “If you
start to exclude service sites, you are diminishing access,” he
warned.
In response to an invitation to a panel of the Society’s Council
and senior staff to state its views on accreditation, especially in areas
with a large locum population, Professor Bob Michell, a Privy Council
nominee member of the Society’s Council, said that most members
of the public would become extremely confused over who was accredited
and who was not: “[The public] assume that if someone is wearing
a white coat, in the right department, then that person is a pharmacist
and they will receive advice without being critical as to the level of
training of the person giving the advice.” In addition, Professor
Michell asked if accreditation would apply to professional excellence
as the profession sees it or to things that mean a lot to service users.
According to Sally Greensmith, this unequal treatment could also affect
basic clinical governance. “PCTs and community pharmacists have
a joint responsibility to work together to make sure that locums are
up to speed and understand what is going on in the PCT. I feel strongly
that resource has to be made from the PCTs to facilitate this process
so we do not get this ‘ghettoising’. Everybody needs to be
on the same level — not just for an accreditation scheme,” Mrs
Greensmith said.
Alision Ewing, the Society’s Vice-President, suggested that the
use of standard operating procedures could help locums.
However, Philip Green, deputy secretary and registrar of the Society,
said that although the locum issue is important, it “should not
be a show stopper”. Mr Green accepted that service provision is
easier if there is continuity of care, but said it really ought to be
possible, as it is in the hospital service, for a consistently good service
to be provided even with different people working on different days. “Problems
in community pharmacy are slightly different, but not insurmountable.
In fact, there is not continuity of care in any part of the health service
as it is a 24-hour-a-day, 365-days-a-year operation,” he said.
When polled, only 13 per cent of the session participants said that they
believed that PCT support for locum pharmacists is improving.
Work force and skill mix
Graham Hill, professional development pharmacist, East Riding and Hull
LPC, expressed his concern that even if equal treatment for all community
pharmacies is achieved, the lack of pharmacists in some areas could
make it difficult to “introduce extended services at the coalface”.
Ann Lewis said that although there has been a steady increase in pharmacists
in recent years, because of new and extended roles and longer opening
hours, skill mix issues and preregistration places need to be looked
at.
In addition, in the afternoon debate Wally Dove, a member the Society’s
Council, argued that some of the best pharmacists with clinical skills
have been “siphoned off to become PCPs and to perform what is really
a fiscal function” (see Panel below).
On the other hand, the restructuring of the NHS has resulted in many
more PCTs than there were health authorities, said Sally Greensmith,
and during the restructuring, key, experienced pharmaceutical advisers
had moved on to other roles, leaving many PCTs without pharmacy expertise.
Clive Jackson added that he had seen an increase in the number of technicians
being taken on to PCTs. Alison Ewing said that hospitals had lost huge
numbers of pharmacists and technicians to primary care, and this forced
a skill mix review. This meant retraining support staff. “We’ve
noticed the skill gap at the moment is higher up,” she said.
Regarding preregistration trainees, Ms Ewing described difficulties in
having four or five students and those who split their year between community
and hospital, because of the shortage of pharmacists able to spend the
time to train them. “Novel ways of using pharmacy staff are needed,” she
said.
The role of the Society
Peter Johnstone, head of medicines management, North Liverpool PCT, said
that he saw pharmacy as a hub-and-spoke model, with NHS bodies as spokes,
but believed that the hub that brings good practices together is missing.
Mr Johnstone asked whether the Society sees itself as an obvious candidate
for the hub. In response, Ann Lewis said that because many organisations
are not directly connected to the Society, perhaps the Society could
better support primary care by acting as a facilitator. She saw the
model as a Venn diagram where organisations overlap.
Dr Gill Hawksworth, the Society’s president, reassured participants
that PCPs are “absolutely crucial to developing the NHS agenda” and
said that the Society will be seeking assurances from Government for
support of the PCP role.
In a final vote, 66 per cent did not think that the Society understands
the roles or responsibility and influence on health care of PCPs, but
53 per cent thought that the Society is starting to listen.
For debate: are primary care pharmacists
leading or leaving the profession?
With the population of primary care pharmacists
increasing to over 1,300, a debate entitled “Primary care pharmacists: leading
or leaving the profession” was held during the session. Proposing
that PCPs are leading the profession were Joe Asghar, regional pharmaceutical
adviser, regional directorate of health and social care (north),
and Professor Tom Walley, department of pharmacology and therapeutics,
University of Liverpool. The opposition, proposing that PCPs are
leaving the profession were Wally Dove, a member of the Society’s
Council, and Professor Liz Kay, head of pharmacy services, Leeds
Teaching Hospitals NHS Trust.
Some of the key statements made by the debators included:
 Joe Asghar: PCPs are effective professional leaders
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Joe Asghar “Primary care pharmacists have
demonstrated the qualities to be considered effective professional
and political leaders
and have assisted in delivering the vision for a modern health service.
“Community pharmacy has changed relatively little in 30 years. The
new contract will be interesting and challenging and may give community
pharmacists the chance to show their worth, but at present, we cannot
call them leaders of the profession.”
Tom Walley “The term primary care pharmacist covers a whole
range of roles. Primary care pharmacists are out there, actively
becoming part of multidisciplinary teams and helping to develop a
changing profession.”
 Wally
Dove: PCPs have not delivered original promise
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Wally Dove: “I do not believe that [primary care pharmacists]
have delivered what was originally promised — in the main they
have not facilitated the development of community pharmacy.
“ Instead, they have become part-time accountants, hell bent on reducing
the drugs bill for their masters. Their main activity is tinkering
with formularies and nagging doctors to rein in their prescribing habits. They
are a side show — a distraction from the real
task, which is caring for patients in and from community pharmacy.”
Liz Kay “Primary care pharmacists should
be finding means to increase the prescribing of new drugs and patient
access to improve
public health as independent professionals and not on saving money.
Primary care pharmacists are doing little to improve the quality
of prescribing, reduce dispensing errors and establish safe systems.” |
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