James Murray connects to the pharmacy’s IT system, which will
soon be linked to those at GPs’ surgeries |
Knowing that the new general medical services contract would affect
out-of-hours service provision, Warrington Primary Care Trust took the
opportunity to redesign its out-of-hours service provision. James Murray,
professional development pharmacist at United Co-op (and one of the pharmacists
who provides out-of-hours care for the PCT), explains what that has involved.
“The out-of-hours and unscheduled care service needed an overhaul
in any case and so Warrington PCT looked at how they could use pharmacists
to
help fulfil the out-of-hours recommendations of the Carson report [“Raising
standards for patients — new partnerships in out of hours care”],
he says.
The PCT put out a tender for a three-year local pharmaceutical services
out-of-hours contract. It asked what pharmacists could provide and how
the bidders thought that their service could be made to work.
Mr Murray believes that United Co-op won the contract because the service
it described was closest to how the PCT had envisaged the service running
and, importantly, it involved other contractors.
But, given that other LPS contracts might be offered elsewhere, Mr Murray
knew that the team would be under pressure. “It was important for
the company that the project worked,” he says, “but we also
needed to make sure that the out-of-hours pharmacy service stands up
on its own — this has never been seen as a loss-leading enterprise.”
Out-of-hours provisions
Pharmacy involvement in the out-of-hours and unscheduled care service
consists of two parts: the out-of-hours pharmacy service itself (an
evening service from 7pm to 10.30pm Monday to Friday and a weekend
and bank holiday service from 9am to 10.30pm) and the supply of drugs
for GP bags and a GP drugs cabinet which the pharmacists ensure are
fully stocked with in-date patient-pack stock. This can take a GP two
to three hours, Mr Murray explains — an important consideration
for the PCT as this time can be redeployed to patient care.
Patients access the service by telephoning a dedicated number. A receptionist
confirms that the patient does not require an ambulance and then passes
the patient on to a triage nurse, who takes a brief medical history.
The patient is then transferred to either a GP or a pharmacist. The pharmacist
can deal with any drug-related queries and provide services, such a emergency
hormonal contraception, under patient group directions.
The triage nurse is able to filter patients who can wait until the morning
for treatment and those who are trying to obtain an out-of-hours appointment,
but should be going to their GPs in the daytime. After 11pm, the dedicated
telephone number transfers to NHS Direct.
Since the same number is transferred to wherever the appropriate service
is, patients simply need to have one number to hand when they need out-of-hours
care. Having a single telephone number has also made promoting the service
easier — the PCT is keen for patients to know about the service
and has recently promoted it through the local newspapers and distributed
leaflets to surrounding pharmacies. Pharmacists’ involvement
The pharmacy is staffed by a dozen pharmacists from United Co-op’s
community pharmacies in the area, who are paid for their time at the
upper end of the standard range.
“Pharmacists are involved to different degrees, depending on how
they are able to fit the cover in around work and family commitments,” Mr
Murray explains. “Some come one or two nights a week, some just
cover the weekends. I do, on average, a shift a fortnight.”
The pharmacists only dispense out-of- hours prescriptions, but are able
to do so both for prescriptions written by the GP at the centre and for
patients who come in with out-of-hours prescriptions.
The pharmacy also stocks a selected range of over-the-counter products
to cover most minor ailments, which also helps to take pressure off GPs.
And patients are always given a full course of treatment, rather than
only enough to last them until they can see their GPs. This avoids the
patients taking up GPs’ time to obtain medicines they could have
been given at the out-of-hours centre in the first place.
If the service is as busy for the next six months as it has been since
it started last November, 18,000 patients will have used the pharmacy
in the course of the year. “The vast majority of the prescriptions
are for antibiotics for children with bad infections — we sometimes
have 40 of those in a day on a Saturday,” says Su Jamieson, a United
Co-op pharmacy manager and one of the other pharmacists who provides
cover for the service. “The service is different every night — we
can do anything from four to 27 prescriptions in a night,” she
adds. Developing the service
The service is also always evolving, Mr Murray explains. “We have
quarterly meetings with the PCT’s unscheduled care manager and
medicines management team, discussing operational changes, such as how
the drug bags are being used and what they need to contain, as well as
changes to the out-of-hours formulary,” he adds.
At the moment the pharmacists are only able to dispense prescriptions
for items in the out-of-hours formulary. This leads to a few problems,
Ms Jamieson says, as every now and then a GP will prescribe a particular
antibiotic that is not listed. However, the pharmacist on duty can telephone
the doctor and raise the problem and, almost always, the GP will re-write
the prescription for a forumulary item.
A forced-choice system is also planned so that GPs cannot write a prescription
for an item not in the formulary. Quarterly reviews of the formulary
allow any problems that arise frequently to be resolved and to ensure
that drugs are not being unnecessarily added to the formulary, since,
Mr Murray explains, the service is designed to be used for genuine
emergencies.
Another development Mr Murray is keen to see is the pharmacy’s
IT system being connected to the GPs’ practices. “The new
patient medicine record system will be going live in the next few months,” he
says. “It will allow pharmacists to use the out-of-hours computer
system in the same way a GP or nurse can. Any information entered onto
the system updates the patient’s own record at the GP’s surgery
by 8am the following day. This allows the GP to see what’s happened
the night before, ensuring continuity of care.”
Mr Murray is also keen to see the pharmacists providing other prescription-only
medicines through PGDs, such as trimethoprim for urinary tract infections
and flucloxacillin for impetigo, further easing pressure on other providers
of out-of-hours care. |
The
Pharmaceutical Journal