Decide want you want from new contract
A different approach to the new community pharmacy contract was presented
by Musa Dhalla, director of Webstar Health, when he spoke about the changes
it offers and the impact it will have on pharmacists. He said that pharmacists
faced a number of options and that they need to ask themselves what they
wanted to do — or to be — in the future.
The new contract, with its multi-tiers, will no longer be volume driven
but outcome driven. Despite this change in emphasis, dispensing would remain
the gateway to the future — it would simply be costed under a different
formula, Mr Dhalla explained.
To be able to provide advanced services — incidentally the first
clinical service for which pharmacists are to be paid under a national
contract — means that the pharmacist must be able to sit down with
the patient, not be overheard and remain undisturbed. This middle tier
of the new contract — involving face-to-face review of a patient’s
prescription — will only be possible when these elements have been
accredited. Moreover, the premises and pharmacist will have to be further
accredited before the pharmacist is in a position to provide the top tier
of services in the contract — enhanced services. Mr Dhalla pointed
out that questions remain over who will actually do the accreditation but
it seems likely that it will fall to the primary care trust to do the initial
accreditation and then monitor it on an ongoing basis.
Pharmacists have to be aware that gross profits will flow in a different
way under the new contract and that the income from dispensing will be
lower but clinical services will be remunerated. What is important, suggested
Mr Dhalla, is to focus on the sort of service you provide: “Is it
largely a dispensing service or do you see yourself as a pharmacy with
a public health focus or a chronic disease focus?”
Mr Dhalla warned that pharmacists should be aware that the traditional
idea — if you double your dispensing activity you will double your
income — will not hold. “The effort you put into chasing purchasing
margin will be dissipated,” he said. Nevertheless, pharmacists who
do process a lot of prescriptions should think how to maximise their profits
through automation and the use of support staff.
Pharmacists should consider why patients come to their premises. “Is
it the location, the service you provide, the relationship with local GPs,
your facilities or your particular mix of prescriptions?” If, for
example, the pharmacy is situated in a high street it may process many
prescriptions but they take up a small part of the business (say about
50 per cent) and the pharmacy has no particular relationship with GPs it
will tend to depend on passing trade. “This would give you the basis
for giving your pharmacy a public health focus,” Mr Dhalla suggested.
If, on the other hand, prescriptions tend to come from one or two GP practices,
and the pharmacy is situated close to a health centre, and there are strong
relationships with the GPs the pharmacist could build on those relationships
and develop chronic disease management services, he thought.
Mr Dhalla emphasised that these were only examples, and that most pharmacies
were a mixture of dispensing, public health and chronic disease management
services, but pharmacists should analyse where they are currently. Because
of the change in service provision and the fact that profits will flow
in different ways pharmacists need to re-evaluate the infrastructure of
their business, their skills and those of their staff and their buildings.
Pharmacists need to start planning and give some thoughts to the focus
they want to have.
POM to P switches to focus on long-term conditions in future
One of the first major POM to P switches took place about 20 years ago,
according to John Blenkinsopp, independent consultant to the pharmaceutical
industry, when ibuprofen became available without a prescription.
Since then, there has been a steady trickle of other products, nearly
all for specific indications. And since the legal procedure for making
switches
was made more streamline two years ago many more switches will be in the
offing.
Dr Blenkinsopp explained that switches will need to be accompanied by much
improved patient information and next year there will be “user testing” to
make sure customers understand what the products are and how they are to
be used. Britain, he said, is leading Europe in the idea that “health
care starts with self-care” and that with the UK taking over the
EU presidency next year this is something that is likely to be high on
the political agenda.
Dr Blenkinsopp also pointed out that the emphasis on POM to P switches
would change from those for acute conditions to chronic conditions (following
the recent lead of simvastatin). Between now and the end of the year the
Medicines and Healthcare products Regulatory
Agency will start consulting
on five new switches. It is expected that 10 per year would follow.
He also expressed the opinion that with these additional medicines more
easily available pharmacists could become much more involved in patient
care. He cited the example of heartburn, for which GPs gain no points for
treating under their new contract. “GPs do not want to see patients
with heartburn” so there is an opportunity for pharmacists.
But he emphasised that this would lead to changes in working practices
for pharmacists. Among the most important challenges, he suggested, is
the provision of consultation areas that are “signposted, seated
and secret” and the burden of keeping records. However, by developing
relationships with primary care trusts and GPs there is a great opportunity
for pharmacists to take over the management of various chronic conditions
and share their care with local GPs.
Opportunities for pharmacists in the provision of chronic disease management
in primary care
As yet there are few examples of community pharmacists providing chronic
disease management services in a community setting — they mainly
take place in GP settings, said Alison Blenkinsopp, from the department
of medicines management, Keele University. However, she suggested in her
talk, that the Government has plans that would change that and give pharmacists
more opportunities to become integrated members of the primary care team.
Professor Blenkinsopp started by defining what is a good way of describing
chronic disease management (CDM) and she said that in the US the phrase “anticipatory
care” is often used. “In other words, minimising and preventing
future problems,” she explained.
At its best CDM improves patient outcomes, reduces health inequalities
and lessens hospital use.
Professor Blenkinsopp described the pyramid of care that has been developed
to illustrate the needs of people who are chronically ill and require
health care. Most patients are at the base of the pyramid. They are able
to function
with basic care or “usual care with support”. Patients in the
middle tier require “assisted care”. These are patients at
high risk of developing problems if they are not treated properly, explained
Professor Blenkinsopp. At the top of the pyramid is the group who need “intensive
case management”. In other words, these are the complex cases (such
as patients with chronic obstructive pulmonary disease and heart failure)
that require a great deal of medical input and absorb most resources.
Furthermore, research indicates, she said, that between 25 and 30 per
cent of patients with chronic illnesses want to be more involved in their
care
and can be taught how to change their dosages and how to respond to different
clinical signs (the expert patient).
Health resources, therefore, can be better targeted to slow down the
progression of disease and provide most support for the really ill.
Professor Blenkinsopp spoke about the two pilots schemes that are running
in the UK based on US managed care models: Kaiser
Permanente and Evercare (PJ, 15 May, p601). Currently 2 per cent of high risk patients drive
30 per cent of hospital admissions. The concept of Evercare is that by
the
employment of case managers, patients can be kept out of hospital, their
use of medicines is reduced and there is greater satisfaction for families.
She also described the scheme for strategic health authorities to ensure
that “community matrons” are employed all across England by
April 2005 and the further Government plan for 3,000 advanced primary care
nurses (30 per primary care trust area) be in post by 2008 caring for 250,000
patients.
Professor Blenkinsopp spoke about the focus of the new general medical
services contract on chronic conditions and how much of the Government
thinking is along the lines of self-care of longer-term conditions. Illness
needs to be caught early and prevented from deteriorating. The move to
increase the number of POM to P switches is all part of this Government
strategy.
Within this thinking there should be many opportunities for pharmacists.
They could provide practice-based clinics with or without supplementary
prescribing skills, they can provide medication review on a simple monitoring
and support basis (the base of the chronic disease pyramid) or provide
surveillance and risk reduction for the use of high-risk medicines. They
can also offer support for self-management.
Professor Blenkinsopp recognised there are barriers to overcome to achieve
this. Pharmacists need access to patient records and providing CDM demands
a high standard of record-keeping. Ultimately, across the whole primary
care team, the question will need to be asked, who provides what care
and where? And whoever provides care should give patients the same message.
Make sure that local
GPs are on side
Richard King, director of Pharmacy Consulting Ltd, gave his experiences
of implementing medicines management projects. He spoke in general about
how medicines management schemes could fit in with the new contract. He
also described the benefits of involving the pharmaceutical industry in
establishing medicines management programmes in providing training, for
example, and other resources.
It is important when offering a service to make sure local GPs are on side,
so that when pharmacists make recommendations for product or dosage changes,
for example, they accept the benefits. It is also important to ensure that
patients are not alarmed by the process, that they accept that the exchanges
with the pharmacist will be confidential.
One of the unintended consequences of medicines management is that once
patients have gained trust in the system, pharmacists often find they want
to stay chatting for a long time. It will be a challenge for pharmacists
to learn how to end consultations firmly but politely and make sure patients
leave.
Who will accredit pharmacists and their premises for providing advanced
services?
Musa Dhalla: accreditation likely to be undertaken by primary care
trusts |
Will it be possible for a pharmacist to continue a service that would
be classified as enhanced before they are even accredited for providing
advanced
services, and who will be doing the accrediting of the pharmacist and
his or her premises for providing advanced services? These were some
of the
challenging questions asked at the conference. Some of these questions
remain to be resolved, but Musa Dhalla believed that the accrediting
will be undertaken by primary care trusts — whether they want to
or not. This is despite the fact that advanced services are to be funded
nationally
through the global sum and PCTs would not benefit from the provision
of advanced services per se, he said. The speakers were in agreement
that
PCTs would have to do the initial accreditation and then monitor the
situation annually. However, when it comes to enhanced services, the
PCT would have
to be more involved. If a PCT wants a particular service and commissions
it from a pharmacist, the PCTs will have the responsibility to provide
training if any were necessary.
Garry Myers, a Numark member and a member of the Pharmaceutical Services
Negotiating Committee, advised delegates to become involves with their
local pharmaceutical committee. “LPCs should be in dialogue with
the PCT on implementation of the contract. Moreover, LPCs, as statutory
bodies, represent all pharmacists, not just the multiples, and this
is the way for the individual pharmacist to become involved.” |
The
Pharmaceutical Journal
David Wood, chief executive of Numark plc, opened the autumn conference
by saying that pharmacists have just one opportunity with the new contract
to change the way that they provide services: “And if you do not
grasp those opportunities, others will step in,” he emphasised.