The Pharmaceutical Journal
Vol 274 No 7351 p654-655
28 May 2005

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AAH Convention

Have doctors snaffled all the money?

Pharmacists regard the new pharmacy contract with a mixture of fear and anticipation, according to research commissioned by AAH Pharmaceuticals. Some of the small independents are sceptical that they can meet the new agenda and tend to fear the new contract whereas larger groups that see the revenue opportunities and the potential of pharmacists beyond basic dispensing tend to feel anticipation, said Steve Dunn, group managing director, AAH Pharmaceuticals. In addition, some pharmacists lack confidence in going back to their clinical roots. “A minority of pharmacists have been deskilled [by the old contract incentives] and are fearful of returning to clinical practice and leaving the safety of the dispensary,” Mr Dunn said.

There are concerns about the workability of the new contract in England, including the view that pharmacists can only progress towards enhanced services if primary care trusts begin to commission more clinical services. However, resources for such services may have already been used on the general medical services contract overspends. “Doctors can earn 40 per cent more than they did before GMS. Have doctors snaffled all the money? Will there be any left for pharmacy services paid for locally,” Mr Dunn asked. If not, this would result in an unviable model for pharmacy because “the reduced revenue for dispensing would threaten livelihoods”, he warned. Funding the necessary IT was another concern.

However, Mr Dunn said that he was not suggesting any sensible alternative to the new contract, given the Government’s clear intentions. “[Pharmacists’] future remuneration now depends on Government’s willingness to enhance [their] potential through commissioning services rather than [their] skills at buying better,” he explained. Mr Dunn predicted challenges in the coming months, in terms of more pressure on the drugs and pharmacy budget as Government looks for ways of releasing more money to fund projects, such as the agenda set by the National Institute for health and Clinical Excellence, national service frameworks and new therapies. Another challenge is the potential conflict between health care professionals, driven by the pursuit of available funding.

The survey respondents were also concerned about getting heard in consultations with PCTs. Small independents could suffer at the hands of multiples that can invest in the process, Mr Dunn said, and he called for professional bodies for pharmacy to change their orientation to support those without a collective voice. “The [Royal Pharmaceutical] Society is boxing itself into a regulatory role, the equivalent of the General Medical Council, but who is going to speak for pharmacy the same way that the British Medical Association speaks for doctors,” Mr Dunn asked. “Pharmacists are much less likely to be heard if they are not represented and other professionals who are not seen as outsiders in the NHS may well hoover up all the money before pharmacy gets to it,” he warned.

“[Pharmacists] need the confidence to deliver, designed care packages, training support, IT resources, resources in premises, Government commitment and collective representation,” Mr Dunn concluded.

MURS: building competence and confidence

Three major areas need to be addressed in order for pharmacists to perform new contract roles, according to Geraldine Mynors, head of projects, Medicines Partnership. First, pharmacists must have technical and clinical knowledge “Unless [pharmacists] have the basic foundations, the rest does not matter much,” Ms Mynors said. Second, pharmacists must have organisation and team working skills so that pharmacists’ time can be freed to take on new roles. Project management skills are needed to put new systems in place and, down the line, pharmacists will need to convince GPs that medication use reviews are a good idea and to work with others in the primary care team. Third, pharmacists need consulting and decision making skills in order to be able to engage with patients.

Consultation skills are key to exploring issues and teasing out what it is that is making it difficult for patients to take their medicines. The best way to improve consultation and shared decision-making skills is to try them out. Ms Mynors suggested pharmacists perform role plays before putting skills into practise. One contractor, for example, told The Journal that he would aim to do four MURs a week, making appointments for quiet periods. To build confidence, he will begin with his most friendly customers.

Another useful tip for performing MURs is to “prime the patient”, Ms Mynors said, by making patient guides, such as “Focus on your medicines” available. “Patients going into a review will get more out of it if they know what they can expect,” she explained. The Primary Care Pharmacists Association is producing medicines review cards and another useful resource is the Centre for Pharmacy Postgraduate Education concordance module.

The new contract involves more engagement with patients and community pharmacists are in an ideal position — they are approachable and trusted and, increasingly, equipped with consultation areas — to be at the forefront of this culture shift, Ms Mynors added.

Where opportunities for pharmacists might lie

If pharmacists are going to maximise their opportunities, they have to think outside the old box, Clive Jackson, chief executive of the National Prescribing Centre, said. Mr Jackson picked out areas in which “opportunities abound”: management of long term conditions, signposting and delivering support to patients across health and social care environments, new prescribing responsibilities, public health, specialisation within pharmacy, skill mixing, and new commissioning and contractual frameworks. He also highlighted factors that could determine pharmacy’s success or failure. “Anything pharmacists do has to improve quality and equity of patient care delivery and one of the big benefits that pharmacy has is convenience and choice in patient care,” Mr Jackson said. Other determinants of success will be improving cost effectiveness and reducing waste.

Management of long-term conditions, which encompasses self care and disease management, has become one of the Government’s top priorities. About 17 million people in the UK have a long-term condition. The style of health care delivery will change and Mr Jackson called for pharmacists to be part of the change. For example, the management of long-term conditions includes “complex case patients”, for whom the Government intends to appoint 3,000 “community matrons” by 2008 (according to the NHS Improvement Plan), to provide seamless and personalised care. However, Mr Jackson wondered whether there are 3,000 nurses available who have the skills to slot in. “If not, where are these skills going to come from and who will provide the pharmaceutical care,” he asked.

There could be more non-medical prescribers than medical prescribers in the next decade. New prescribing opportunities will also increase pharmacists’ potential, particularly with the likelihood of independent prescribing (which Mr Jackson described as “a really big opportunity”) in the near future. In addition, the opportunity to counter prescribe products that have been moved from POM to P and under minor ailments schemes has the potential to open up new business.

Public health includes not only giving lifestyle advice and support. Mr Jackson said that he thought another public health area in which pharmacists might get involved is the reporting of adverse drug reactions. In addition, future developments in genomics will revolutionise pharmacy. “The question is who will be doing that sort of genetic profiling,” he said.

Mr Jackson predicted that tiers will develop within pharmacy and that in the next 12 to 18 months there will be more pharmacists with special interests. This phenomenon may not be restricted to the hospital sector and could include new roles for community pharmacists. “We have to decide carefully how we are going to maximise the use of pharmacists — how best to use pharmacists’ time. We may even have to drop some roles,” he declared.

Skill mix is about optimising the scarce use of professional resources. “If you can show better use of the pharmacist pool in your area, you will push the right buttons,” Mr Jackson said. Potential also exists between professions, with out-of-hours services presenting a major opportunity.

However, all the above may be a waste of time unless pharmacists can influence the people who do the commissioning, Mr Jackson warned. PCTs are huge players in deciding who will provide services and pharmacists need to ask what makes them tick. There may also be opportunities in new areas. For example, there is the potential to move services, such as diagnostics and follow-up care, from hospitals into primary care. The question is whom PCTs will decide is best to perform these services.

The pharmacy contract is not the only route by which services can be delivered. “With the election out of the way, I think we will see a move to include alternative provider medical services (APMS)-type services,” Mr Jackson said. Under APMS, PCTs can contract with commercial and voluntary sector providers (among others) for primary care medical services. These contracts are designed to allow PCTs extensive flexibility and discretion so that they can shape services to the needs of the community.

Another area that deserves consideration is GP commissioning. Once commissioning is devolved to GP practices it will have significance for pharmacy so this will need to be talked about. Pharmacists will need to ask who will be leading on GP commissioning. This could be a number of practices. “Pharmacists will need, at this stage, to keep an ear to the ground for who will be the key player,” Mr Jackson advised.

Essential to success is for pharmacists to put themselves in the position of the commissioner and this involves answering the following key questions:

· What does the commissioner want or need?
· What do patients want or need?
· What do other professionals think?
· What do carers think?
· Where is pharmacists’ time and expertise best used?

“This could be pharmacy’s golden age,” Mr Jackson concluded. “There are opportunities for pharmacists. Ultimately it is all about professional optimism and spirit, and community pharmacists have that,” he added.

Manpower issues need more solutions

The new contract means that workforce and skill mix issues need attention. Although work force shortages might be alleviated, to some extent, by the increased pharmacy student intake, this is a long-term solution, said Karen Hassell, lecturer, Manchester University. There is also the issue of whether or not there will be enough preregistration places available. Dr Hassell suggested other solutions include using technicians and trying to improve workforce satisfaction, for example, by allowing flexible working hours.

Dipan Shah, St John’s Pharmacy, Weymouth, told The Journal that he is ready for the new contract and intends to train his staff to become checking technicians. However, another delegate at the convention expressed reservations about investing in training only to lose staff to other employers (typically hospitals and GP surgeries) who can offer better pay and more flexible working hours. Pharmacists are thinking about other ways of tackling the workforce issues presented by the new contract. Steven Lo, proprietor of Lo’s Pharmacy, South Yorkshire, told The Journal that he might consider employing a pharmacist solely to perform medication use reviews in his chain of pharmacies as an alternative to his current pharmacy managers undertaking this duty.

Another issue on the horizon is that new maternity rights will allow staff up to a year off work — particularly significant to pharmacy’s largely female workforce. “Some of the independent multiples will have a major workforce problem trying to cover this right, because most pharmacies rely on a few well-trained dispensing technicians and medicine counter staff,” Satnam Butter, superintendent pharmacist, LPC Pharmaceuticals Ltd, Weedon, told The Journal.

NICE seeks wider communication

The National Institute for Health and Clinical Excellence is to look at ways of getting its guidance direct to pharmacists in primary care, perhaps through pharmacy IT systems, Fraser Woodward, communications manager, NICE said

Mr Woodward acknowledged that it was not for pharmacists to police GPs in terms of following NICE guidance, but suggested pharmacists could make patients aware of NICE guidance so that they could challenge their GPs themselves.

More talks about new IT needed

“If your supplier is not talking to you about the new contract and new IT applications, you must ask them why,” said Geoff Mackay, customer technology controller, AAH Pharmaceuticals. The move from a product-based economy to a service-based economy means automation is essential for speeding up dispensing processes and creating the headroom that pharmacy needs to deliver new services, he said.