The Pharmaceutical Journal
Vol 272 No 7284 p122
31 January 2004

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Integrating pharmaceutical services into out-of-hours primary care

By John Jolley

Agenda series

The new general medical services contract provides the mechanism to allow GPs and practices greater flexibility to determine the range of services they wish to provide. This has resulted in a high proportion of practices indicating their intention to opt out of providing out-of-hours care.

To ensure that patient access to these services is not compromised primary care organisations are to be made responsible for finding suitable providers. The Department of Health stated in its document “Pharmacy in the future” that pharmaceutical services should be integrated into all primary care services. It has issued three guidelines that include provision of pharmaceutical services out of hours:

• The vision for pharmacy outlines systems for developing pharmaceutical services in the NHS

• The framework for a new community pharmacy contract recommends the standards of service provision and the timetable for implementation of these new services

• The Carson report (see later) defines standards for out-of-hours care and makes proposals for the availability of medicines out of hours

These provide new opportunities for pharmacists, but the issues of implementation and reimbursement remain key factors. This article will review new developments that may help pharmacists to realise some of these opportunities.

Opportunities

Surveys of GP practices estimate that at least 80 per cent will opt out of out-of-hours care, either partially or totally, thus requiring PCOs to secure alternative primary care providers. By the end of 2004, all PCOs should have taken over responsibility for out-of-hours care, and will need to develop contracts with suitable providers and professions such as NHS Direct and NHS 24, and commercial primary care services. Pharmacists are ideally placed to provide pharmaceutical services as part of the primary care team, providing they are prepared to adapt to the needs of the out-of-hours patients.

Vision for pharmacy

The “Vision for pharmacy in the new NHS” is built on two documents published in 2000: “The NHS plan”, a vision of a service shaped around providing a fast, convenient, high quality service, and “Pharmacy in the future — implementing the NHS plan”, the programme for developing pharmacy services on the principles set out in the NHS plan.

Two such developments in improving patient access are defined:

• NHS Direct and similar organisations should refer people to their local pharmacy

• Out-of-hours access to medicines should be improved

Three years on, little progress has been made with either objective. The new local pharmaceutical services scheme talks of improved access to medicines and advice out of hours through integration of pharmaceutical services with other out-of-hours services but, as yet, financing such activities is proving a major obstacle.

Framework for a new contract

The new framework provides for service categorisation into essential, enhanced and local additional services:

• Essential services include distribution of medicines, promotion of self-medication for minor ailments and referral of patients to other health care providers

• Enhanced services are those services that require accreditation of dispensed medicines or medicine use

• Additional services are those that may be commissioned locally by a primary care trust and may include a range of services, some of which are defined in the framework

Out-of-hours services are not mentioned in these lists, but pilot schemes improving access to medicines and advice out of hours have been included in selected LPS schemes. However, the main problem is the method of financing, since all additional services will have to be funded out of reductions in pharmaceutical professional fees made effective from 1 April 2004 or from additional money made available from the PCTs.

Carson report

In October 2000 the DoH published a set of standards for all those involved in providing out-of-hours care, known as the Carson report. This report makes a number of recommendations. Those relevant to pharmaceutical services are:

• That patients should be able to receive the medicines they need at the same time and in the place as the out-of-hours consultation, except in exceptional circumstances

• Those existing remuneration arrangements for out-of-hours providers and pharmaceutical services should be revised and, where appropriate, modified to allow for the provision of all appropriate medicines

Implementation of these standards is due from April 2004, but to date there seems to be little preparation to provide pharmaceutical services as part of an integrated primary care service.

Making pharmacists part of the service

Pharmacists can play at least one of two roles in the out-of-hours service:

• Members of clinical triage teams: Primecare (a commercial out-of-hours provider) receives, on average, 60,000 calls per week between 6pm and midnight, 4 per cent of which relate to queries regarding medicines

• Trainers: there are large numbers of health care professionals and semi-skilled workers who require training on responding to enquiries relating to the availability of medicines — pharmacists are well placed to do this

Payment of pharmacists for supplementary activities has always been a problem since many of these activities are not included in their NHS service contracts. Work on out-of-hours care through commercial organisations can be paid at locum rates for all participating professionals. The technology available will enable clinical triaging to take place across the country so that local manpower shortages can be overcome. In time it will be possible for members of the triage team to take calls from their own homes.

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