The Pharmaceutical Journal
Vol 272 No 7281 p19-20
3/10 January 2004

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By talking to everyone, one pharmacist has developed patient-centred care

By Harriet Adcock

Vision for pharmacy series

Seamless health care, centred round the patient, is what Riaz Esmail, a community pharmacist in Harrow, Middlesex, likes to offer his patients. But his vision does not end with the people who come through the doors of his pharmacy. He wants everyone to benefit from a more patient-focused pharmacy service.

When the Government report “Pharmacy in the future” was published in September 2000, Mr Esmail, proprietor of Fairview Pharmacy, asked himself if he wanted to be part of it. He saw it as an opportunity to change how he delivered pharmacy services to his local community. And while he realised that changing the way in which one pharmacy operates would have minimal impact on the health of society in general, he also recognised that change must start somewhere.

One of the things that most frustrated Mr Esmail in 2000 was that he was tied into a volume-led contract. During our interview he was contacted by a pharmacist colleague to discuss a patient’s prescription about which he had concerns. His colleague agreed with his concerns, with the outcome that the patient’s GP would be contacted with a suggestion to cancel the prescription. “With my clinical input the patient is helped and the prescription rejected.” As community pharmacists are only too aware, this sort of intervention, while improving patient care and providing professional satisfaction, is not rewarded financially. Mr Esmail believes strongly that pharmacy should move away from a volume-led system, with payment reflecting clinical input and improved patient care.

Be proactive, create right environment

So, with this in mind, Mr Esmail set about changing the way in which his pharmacy provided its services. “We wanted to be pro-active and lead the change, so my staff and I put on our thinking caps, consulted our patients to see which aspects of the services we currently provided they most valued and, using the framework, planned where our skills would be best used,” he says. This involved focusing on two main areas: self-care and a prescription and dispensing service, which would be enhanced by a medication review service.

There is, of course, nothing extraordinary about this but Mr Esmail saw that with a little restructuring and innovation he could provide a much more patient-oriented service that would attract funding based on quality rather than quantity.

The first priority for Mr Esmail was to create the right environment for delivery of the Fairview vision. The changes made at the pharmacy were simple but effective.

Medicines on general sale are now easy to see and handle by customers. A pharmacist work station next to the medicines counter and a private consultation room provide areas for patient-pharmacist interaction. NHS branding is used to promote NHS services and two computer terminals provide free internet access for patients wanting to source health information.

In addition to the two terminals provided for use by patients, Fairview pharmacy is kitted out with four other computers linked via a network. This allows pharmacy staff to access patient records wherever they are in the pharmacy — in the dispensary, in the private consultation area or while handing over prescriptions to patients.

Mr Esmail believes patients should be encouraged to seek out information about their medicines. However, he realises that the web is not the answer for everyone so Fairview also provides a small library, including reference books, CD-ROMs, videos and cassettes. “We want to develop the concept of the expert patient. While patients are waiting for their prescription, they can look at the BNF or Merck Manual. We hope this will generate questions. And if a patient challenges their therapy, this can improve care,” Mr Esmail says.

Getting patients talking is one thing, but Mr Esmail believes there should also be more talk among pharmacists. From the start, he has been keen to communicate his ideas and to encourage sharing of best practice. To facilitate interaction with other pharmacists in Harrow, he set up an e-group called “seamless pharmacy”. Pharmacists can subscribe to the group, which is used to share information, for example, protocols and standard operating procedures. “Pharmacists need to develop a corporate mentality. Whether you are a PCT pharmacist, a hospital pharmacist or a community pharmacist, we are all working towards health improvement and need to work together,” he says.

Target PCT priorities

In his planning, Mr Esmail looked at the key priorities for his local primary care trust. He recognised that the conventional primary health care team would not be able to achieve the targets set by the National Service Framework for Older People for medication review. “It was essential that the PCT thought laterally and considered the input that community pharmacists could make,” he says.

So, together with the pharmacy team at the PCT and external consultants, Mr Esmail developed a bid for a local pharmaceutical services (LPS) medication review pilot and put it to the PCT. Mr Esmail recognised that simply providing a medication review service would not be enough. To be sustainable, pharmacists must offer GPs a complete service — from reviewing the patient’s medicines, to making recommendations and to managing any changes.

The system Mr Esmail is choosing to pursue for the medication review service is web-based and has been set up by commercial programmers specialising in pharmacy services. The web-based approach was chosen because Harrow PCT uses a number of environments for its medication reviews. For instance it manages four older people wards within the local acute trust. “Medication reviews are done in a variety of settings. It is logical that the information is put on the web so it can be shared.”

The reviews are conducted by a second pharmacist, Russell Foulsham, but Mr Esmail is confident that the set up can be run by a single practitioner with trained dispensers.

Spreading innovation

Customers of Fairview pharmacy are starting to benefit from the LPS pilot. However, one isolated pharmacy providing extended services to the general population is not the solution. “We need to build capacity by making these and other related services available across the PCT. To be a valid piece of work, we need to be able to share it. It may not be right for everyone but if it is right for a critical mass, it becomes enough.”

To reflect this, part of Mr Esmail’s bid for an LPS contract involved training other pharmacists. “We will deliver 50 sessions of pharmacist training annually.” Mr Esmail’s aim is to establish a learning centre at Fairview to provide support to local pharmacists wishing to provide extended services in primary care.

“ We want other community pharmacists to sit in on the medication reviews. They can then decide if they want to pursue the provision of such a service and, if they do, Fairview will mentor them.” After conducting medication reviews at Fairview, in a supportive environment, pharmacists can then go back to their own pharmacies and make the necessary changes. This sharing of expertise and provision of training is a move away from what can be seen as the competitive business environment of community pharmacy. If pharmacists work in isolation they may be able to protect their competitive edge. But Mr Esmail’s view is that if services are to be delivered differently, pharmacists cannot afford to continue to work in that way.

Mr Esmail acknowledges that by doing things differently, pharmacists will not necessarily make more money. “But we will be paid for our clinical input,” he says.

“Pharmacists were a bit wary and we had to convince them that we were looking for their participation.” Most are watchfully waiting and Mr Esmail is keen to get the training aspect of the LPS pilot off the ground.

Fairview has also applied for funding from the West London Research Network in order to help other pharmacies in Harrow provide similar services. “If successful, we will put it to the PCT that the services are required and should be included in its planning cycle.”

Challenge of change

Mr Esmail faced a steep learning curve both in understanding policy and procedures and gaining new skills.

He has also had to invest in IT, in redesigning his pharmacy and in upskilling his staff. But he does not think the process has been too onerous. “Pharmacies all have one computer — that’s a start,” he says.

With the Government so serious about re-engineering health services around patients, Riaz Esmail and his staff at Fairview are contributing to this goal. The challenge for pharmacists everywhere is to show that using pharmacy as a service provider does not necessarily mean more investment but disinvestment in services that do not work. That is the discussion community pharmacists have to have with their PCTs.

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