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1 April presented challenges for primary care organisations in terms of implementing the new contract
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Leeds pharmaceutical needs assessment
Leeds Primary Care Trust has published its
pharmaceutical needs assessment online (click on “freedom
of information”).
Mohammed Hussain, community pharmacy adviser, says the PCT wants
to share it with other PCTs and pharmacists in order to spread
best practice and also to receive feedback. |
Community pharmacists in England and Wales may feel that their lives
have been dominated by the new pharmacy contract in recent months. They
are not the only ones: implementing the new contract has presented some
major challenges at a primary care organisation level, too.
PCOs in England and Wales are essential to the new contract. They have
roles in its implementation and its ongoing monitoring, and in the commissioning
of services in the contract’s third tier.
In the past, relationships between community pharmacy and PCOs have varied.
While in some locations, good communication has led to close working
and flourishing services, in others, pharmacy never quite made it onto
the PCO agenda. The new pharmacy contract means that has had to change.
So what should PCOs have done, or be doing, to implement the new contract?
One of the initial jobs is to conduct a pharmaceutical needs assessment
and, from that, develop a plan for service development. PCOs also need
to assess how prepared contractors are to deliver the new contract, although
it will not be until October that formal monitoring will begin. In addition,
PCOs should be maintaining a list of those pharmacists and pharmacies
that have completed the assessment for providing advanced services.
On top of these roles, PCOs need to agree with local pharmaceutical committees
which topics will be included in the public health essential service,
provide guidance to contractors about which groups of patients should
be targeted for medicines use reviews, and agree when to move to repeat
dispensing. Then there are clinical governance issues and, of course,
commissioning enhanced services. It is clear that the agenda for PCOs
is enormous.
A local approach
Every PCO is tackling the implementation of the new contract differently
and, because of these differences, it is important for pharmacists
to find out what is happening in their area.
In Adur, Arun and Worthing Teaching Primary Care Trust, Sue Carter,
head of prescribing and pharmacy, is the overall strategic lead for
the new
contract but implementation takes a team approach. “I work closely
with the pharmaceutical advisers and we are hoping to appoint a community
pharmacy facilitator as soon as possible to do the organisational and
operational roles. At the moment, this job is being shared between us
all,” she says.
Meanwhile, Waveney PCT has appointed a lead for the new contract from
outside pharmacy. “He is approaching it from a business management
perspective and I advise him on the professional side,” explains
Brian Jolley, professional executive committee pharmacist at the PCT.
Together, they report to a steering group set up last autumn to oversee
the new contract. The steering group is chaired by the director of public
health and its members include the trust’s chief executive.
Mr Jolley says that having the business expertise is useful: “A
lot of the management of the new contract is based on non-pharmacy systems.
Some PCTs are getting hung up on professional issues therefore missing
the ‘easy-fix’ things that can be put in place quickly.” To
illustrate this, Mr Jolley gives the example of the signposting essential
service. The PCT already had a health information telephone line so it
decided to co-ordinate the pharmacy service through this existing mechanism.
All pharmacies have been supplied with cards that provide this telephone
number, the number for NHS Direct and the smoking cessation helpline.
Mr Jolley says that this is much easier than providing pharmacies with
a big volume of contacts that is difficult to keep up to date.
Beyond essential services
In East Kent, the smoking cessation scheme
that has been in place for the past three years looks set to
be one of the first enhanced
services in the new community pharmacy contract. It involves
pharmacists providing an advisory role and using a patient group
direction
to provide nicotine replacement therapy. Furthermore, it has
been decided that there will be just one enhanced service for smoking
cessation that can be offered by both pharmacists and also GPs
under their new contract. Smoking cessation lead, Rachel Spencer,
explains: “We envisage having one enhanced service specification
that any pharmacist, GP, nurse or other member of the GP practice
could use. This would not just be better from an administrative
point of view, but it would also mean that everyone offering
the service would be working to the same standards for the same
amount
of money.”
Wandsworth PCT has also been developing local enhanced services.
Mr Rajah comments: “Although we do not have the tariffs yet,
we can set them up on the basis of local needs and adjust the fees
later. So we have looked at the PCT strategy and developed services
from there.” One of the resulting enhanced services is a minor
ailments scheme linked to the NHS walk-in centre in Tooting. “It
is a voucher-based scheme in which the nurse at the walk-in centre
identifies patients with minor ailments and provides them with a
voucher to take to a local community pharmacist. There are a number
of parallels between walk-in centres and community pharmacies and
this service helps to build relationships between the nurses and
pharmacists,” he explains.
The potential for these services has had to be recorded in the
local delivery plan — set out at the beginning of the year — so
that funding can be made available later in the year. “It could
be a problem if PCTs have not put enhanced services in their local
delivery plan this year,” comments Mr Jolley.
In terms of advanced services, Ashford PCT expects that the first
contractors in its area will be ready to begin advanced services
in four to six weeks. “We are asking them to target medicines
use reviews in the area of pain management because of the recent
developments with cyclo-oxygenase-2 inhibitors and
co-proxamol. As soon as pharmacists tell us that they have been
accredited, we will be offering training to them in this specific
area,” says
Sylvia Bonnett, joint head of medicines management at the PCT. |
Ashford
PCT has taken a similar approach, with a primary care manager leading
the implementation of the new contract and Sylvia Bonnett, joint
head of medicines management at the PCT, providing support from a professional
point of view.
Wandsworth PCT has opted for a high-level steering group. “We started
by setting up the steering group to look at the mechanics of the contract,
including the baseline assessments and pharmaceutical needs assessment.
The group is made up of LPC and PCT representatives and meets once a
month,” explains David Tamby Rajah, community pharmacy lead at
the PCT. “Over the past 12 months, we have held a number of training
events for pharmacists and have produced a new contract toolkit for pharmacists.
We will soon by holding another training day that will look specifically
at the essential services.”
Communication is a common theme and it is clear that successful implementation
of the new contract requires good communication between PCOs and pharmacists.
In Waveney, a pharmacy development group —called a pharmacy liaison
group — has provided community pharmacists and the LPC with an
opportunity to communicate with the PCT for several years. “For
example, we put a proposal to the group of the public health topics we
wanted to target this year,” says Mr Jolley.
Adur, Arun and Worthing PCT has gone one step further in setting up a
multidisciplinary stakeholder group involving not only the LPC and PCT
representatives but also patients, members of the public and GPs. And,
in Ashford, PCT representatives are visiting contractors. “We have
nearly finished visiting each pharmacy to find out how contractors are
feeling about the new contract. Before the visits, we sent out questionnaires
that helped to get a baseline,” Ms Bonnett explains. Breaking the contract down
Control of entry
The changes to control of entry are highlighted
as a challenge for primary care trusts by specialist pharmacy
lawyer David Reissner
of Charles Russell solicitors. He says that not only are the
new
regulations more complex than the old ones, but they also place
new burdens on PCTs.
“For example, whenever a new application
is made, they will have to take up references and carry out checks
on the applicant’s fitness to practise, decide what to
do about information they receive, and make decisions within
a limited
time frame.”
He says that the problem lies in the Department
of Health’s inability to change the primary legislation
that contained the “necessary or desirable” test.
Instead, it opted to publish guidance to PCTs.
“The guidance
says a lot about ‘competition and choice’, but the
word ‘competition’ does
not feature in the regulations. Since the ‘necessary or
desirable’ test
is deliberately restrictive, it would be hard to make sense of
regulations which include the word ‘competition’,” Mr
Reissner says. |
In terms of implementation, one approach taken by Ms Carter was to
break the contract down into chunks such as control of entry, workforce
planning,
clinical governance, the different services and skill mix. From this
she developed a work plan outlining what needed to be done and when. “We
came to do our pharmaceutical needs assessment quite late. But now
that we can see the finer details of the new contract, it has enabled
us to undertake a robust and up-to-date assessment which should be
finished in a month’s time,” she says.
Waveney PCT carried out a baseline pharmaceutical needs assessment
12 months ago and developed a pharmacy-specific strategy that fits
into
the PCT-wide integrated approach. It has not formally assessed how prepared
contractors are. “There was a fear among contractors that we would
start the monitoring process early so we took a different approach: we
gave the contractors guidance about what we wanted them to be doing and
offered support to help them achieve this,” says Mr Jolley.
Community pharmacists in Adur, Arun and Worthing are already used to
monitoring because post-payment verification visits were introduced there
six years ago. “Every pharmacy providing NHS services is visited
every three years. This enables the pharmacist to see which areas need
improvement but it also has other benefits, for example, many pharmacists
don’t claim all the fees they could. So it is a win-win situation
all round,” says Ms Carter. “We intend to evolve this system
so that it meets the needs of the new contract. In the meantime, we will
be making informal support visits to pharmacies over the next six months
before beginning formal assessments in October.”
Ms Carter stresses that contractors have not got anything to fear from
PCT monitoring: “We know that the standards will be something of
a shock for some pharmacists but we will offer constructive support to
help them reach the required level,” she explains. And Mr Jolley
adds: “I don’t think community pharmacists have realised
the importance of monitoring yet. They are not fully prepared for it
because they haven’t been performance-managed before.” In
particular, he thinks monitoring will present problems for multiple pharmacies. “My
experience is that multiples do not realise that they will have to take
a different approach with each PCT rather than a unified one across all
their branches.”
This point is echoed by Ms Bonnett who explains that the difficulty appears
to be that, in general, pharmacists working for multiple chains do not
have the same ownership of the new contract as their independent colleagues.
Instead, they wait for directives to be given by their head office who
tend to take a national rather than local approach.
In addition, she comments: “One of the things our visits to pharmacies
highlighted was that a number of community pharmacists are not making
full use of the information that is available, for example, some still
had not read the service specifications.” Mr Jolley adds that the
recently published National Pharmaceutical Association guide to the new
contract for PCTs (PJ, 26 March, p354) is essential reading for contractors
since it will help them to understand what PCOs have to do. Ms Carter
is also concerned about the apparent lack of readiness for the new contract
among some pharmacists. “While some are very clued up, there are
others that are sitting on the sidelines,” she says. “I am
also concerned about pharmacies that operate solely on locums. This seems
almost untenable with the new contract. Although some locums have got
accredited to provide extended services, many do not want to do more
than core dispensing. On top of this, having stability in the workforce
in each pharmacy will become crucial if a pharmacy is to build up a successful
relationship with local GPs and the PCT.” Challenges for PCOs
PCOs have faced huge changes in recent years so it is hardly surprising
that some perceive the new pharmacy contract to be yet another addition
to an ever-increasing workload. Ms Carter concedes that workload is
an issue but says: “The challenge is to do the new contract justice
on top of everything else we are doing. I am confident we will get
there, it is just that is will not be overnight.” She adds: “There
will be a period of instability at both pharmacy and PCT level while
it all shakes down but the light at the end of the tunnel is that the
new contract provides fantastic opportunities for pharmacy.”
The Department of Health has also been the source of other problems,
namely, according to Mr Jolley, not providing enough information about
the new contract. PCTs were still waiting for essential information at
the end of March, which was not ideal considering the new contract went
live on 1 April. Ms Carter comments that there has been a general lack
of information and support. “PCTs have just had to get on with
it; most of my support has come from neighbouring PCTs,” she says.
As a result, it is likely that the new contract will be implemented differently
in different areas, and that is why contractors — independents
and multiples — must forge successful relationships with their
PCT. |
The
Pharmaceutical Journal