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Pharmacists in England and Wales are now providing the first advanced
level service under the new community pharmacy contract. They are helping
their patients
gain a better understanding of their medicines through structured and
recorded
medicine use reviews (MURs) or prescription interventions.
What the rules say
In England, the rules governing advanced and enhanced services
are set out in directions from the Secretary of State for Health
to
primary care trusts. Similar rules apply in Wales. For medicines
use review services, these say that the pharmacist:
· Must have an MUR certificate from a relevant higher education
institute
· Must send a copy of the certificate to
appropriate PCT(s)
And that the pharmacy from which the MURs are to be performed
must have a consultation area that:
· Is clearly designated and distinct from the general area of
the pharmacy
· Allows the pharmacist and the customer to sit down together
· Is somewhere that they can talk at normal volumes without being
overheard by other staff or customers
In addition, the pharmacist has to comply with relevant parts
of the clinical governance requirements under the new contract. |
Consultation area specifications are designed loosely in order to
allow contractors to work flexibly within the physical limitations
of their community pharmacies |
Under the rules
of the new contract, MURs and prescription interventions must be provided
by accredited pharmacists from consultation areas that
meet the required specification (see Panel: “What the rules say”).
Although the specification for accrediting pharmacists is rather tight,
the specification for consultation areas has been left deliberately loose.
This is designed to allow contractors to work flexibly within the physical
limitations of their individual pharmacies.
So, for example, there is no minimum or maximum size for a consultation
area. But other considerations, including the need for at least two people
to be able to sit down, will influence the minimum useful size. And at
the same time, the requirements of the Disability Discrimination Act
1995 (DDA) must also be taken into account.
In a similar way, there is no prescribed form of wording for the signs
identifying the consultation area, only the need for the area’s
function to be clearly marked.
Why consultation areas?
For many years the biggest complaint levelled against community pharmacy
premises by customers and patient groups has been that there is no
privacy in them. Some customers are happy to talk openly to the pharmacist
or the staff about their health issues; many others are reluctant
to do so.
In general, pharmacy has been deaf to these complaints for too long.
However, over the years, the trend in pharmacy design has been to install
some form of consultation area during a refit. These have ranged from
simple, end-of-counter areas, possibly with some form of partitioning
for partial privacy, through to fully fitted consultation or treatment
rooms.
When drawing up the specification for the MUR advanced service, the
Pharmaceutical Services Negotiating Committee took the view that training
and accreditation
of pharmacists was not enough to make this service successful. If it
was to gain the support of pharmacy customers and other health care
professionals, especially GPs, then it would need to be done from private
consultation
areas in order to forestall any criticism. Good consultation areas
The best consultation areas will be those where there has been forethought
in planning. The key issues are:
· Providing adequate space from the beginning
· Meeting the needs of pharmacists and customers
· Future-proofing for new services or technology
· Compensating for any lost retail sales space At Alliance Pharmacy, we are currently on our fourth standard design
of consultation area. These have progressed from partially enclosed areas
with saloon doors, through stand-alone booths, to fully enclosed rooms.
Before the specification for the consultation area was finalised, around
200 Alliance Pharmacy branches had some form of pharmacist intervention
area, many of which, it was realised, would not meet the new
standard.
Trials of the early designs examined issues such as whether the consultation
area should be at the front of the pharmacy (in the retail area) or at
the back (closer to the counter and dispensary). In general, customers
prefer the consultation area to be close to the front of the store. This
location also tends to be the one that has the smallest impact on retail
sales space.
However, pharmacy staff do not like the area to be away from the medicines
counter or the dispensary, which are seen as the more professional end
of the pharmacy. In addition, especially in smaller pharmacies, putting
consultation areas near to the front windows reduces the natural light
entering the store. But the busiest part of any pharmacy is normally
between the medicines counter and the dispensary, with most staff passing
through this area frequently. Anything that restricts the flow of people
at this point will cause
problems.
Initially, Alliance Pharmacy looked at a consultation area booth with
curved walls. These were unsuccessful for several reasons. The curved
walls looked good and customers thought that they were less “clinical” but
they were inefficient in terms of space. The curved walls did not allow
standard retail fixtures to be hung on the outside and meant that the
fittings on the inside had to be custom-made, which was more expensive.
They also tended to leave awkward areas of wasted space, again restricting
retail sales area.
It is also worth taking a good look around existing pharmacy space. Is
there a storeroom or staff area that could be converted (preferably without
requiring access via the dispensary)? It is also time to take long hard
look at stock levels and ranges. Slow-moving or less profitable lines
should be the ones making way for the new area.
A private conversation
The consultation area specification states that those inside should
be able to converse normally “without being overheard”. It
is important to note that this does not mean that the sound of their
voices cannot be discerned at all, merely that those on the outside
cannot make out the details of conversations that they should not be
hearing — in dictionary terms, it is the difference between “heard” and “overheard”.
(As an aside, this definition also means that it is possible for carers
or trainees to sit in on a medicines use review, with the customer’s
consent, because they then hear the conversation direct rather than overhearing
it inadvertently.)
Conversations can be masked by increasing insulation on or inside walls — although
it should be noted that sound can travel through the supports of even
well insulated rooms — or by increasing background noise. The instore
radio broadcasts used by Lloydspharmacy are an example of how ambient
noise can be selectively increased.
The walls on our initial style of consultation area did not go all the
way up to the ceiling. As a result, sound was reflecting off the ceiling,
reducing the privacy of conversations. This was changed in subsequent
designs. Future-proofing
Future-proofed consultation areas will have computer points, storage
and access to hot and cold water |
In reality, little equipment is needed to perform the current advanced
service of MURs: recording forms, some reference materials and, perhaps,
some information leaflets. This does not mean that consultation rooms
should be designed with only this basic specification in mind. Future
advanced or enhanced services may well require much more, including:
· Computers to access local or national patient records (and printers)
· Storage for point-of-care testing equipment and consumables
· Safe disposal of clinical waste
· Access to hot and cold water (and waste disposal)
· Electric power points
Failing to design these in from the beginning could be a false economy.
It may lead to expensive refurbishment being required in future. The
requirements of the DDA must also be borne in mind. For example, even
if a wheelchair can fit into the consultation area, can it easily be
turned around and got out again? Avoid any kind of step or trip hazard
around the entrance.
Our latest designs of consultation area now take all of these aspects
into consideration. Straight floor-to-ceiling walls allow retail fixtures
to be attached to the outside. A high level of internal equipment prepares
the way for providing a much larger range of services in future. Double-glazing
with internal blinds allows visual privacy if needed (balanced against
issues of pharmacist and customer safety).
There are several sources that contractors can turn to for advice on
consultation area design. The National Pharmaceutical Association has
produced a catalogue of design consultants, including the major wholesalers
(www.npa.co.uk).
Installation
Even once an acceptable design for a consultation area has been agreed,
do not underestimate the practical difficulties that can arise during
installation. Putting areas into one or two pharmacies should not
be too difficult. Beyond this, it may be necessary to consider having
a project manager or team to keep on top of the process.
Alliance Pharmacy has aimed to minimise the impact on branch teams
by arranging external contractors to install consultation areas outside
normal trading hours (normally at weekends).
Following surveys, necessary materials are produced off-site, ready
for assembly. A typical installation involves clearing the area of
old stock
and fittings, erecting the walls, laying floor coverings, plumbing,
fitting lighting and computer cabling, and remerchandising. This
involves having
a series of different people coming in to undertake different tasks.
At Alliance Pharmacy, installation of consultation areas is taking
place alongside our rebranding exercise. A significant number of
branches are
also receiving full refits, above and beyond consultation area installation
and rebranding. Do I need one?
Consultation areas are not currently needed for contractors who are
only aiming to provide the essential services tier of the new pharmacy
contract
in England and Wales. However, the way the contract is structured
together with expected developments in future mean that a consultation
area
will soon become a necessity. More services are likely to be added
to the advanced level and many enhanced services may also require
the use of a private area. Without one, the future looks bleak for contractors
as money begins to follow services, not simply prescription volume.
Consultation areas in Scotland
Community pharmacies in Scotland can take
advantage of funds made available by the Scottish Executive Health
Department to health
boards specifically for improving pharmacy premises. These funds
have been provided as part of the implementation plan for “The
right medicine”, the Scottish pharmaceutical care strategy.
In 2005–06, health boards have been given £500,000
in total for this purpose.
Medicines use reviews are not part of the new pharmacy contract
in Scotland. Thus no national standards have yet been set in
Scotland
for consultation areas, as they have been in England and Wales.
It is expected that reviews of some kind will be included in
the pharmaceutical
care model schemes and the chronic medication service, scheduled
to be introduced in April 2007. Standards for premises may be introduced
as part of this process.
SEHD guidance suggests that funds for private advice areas in pharmacies “should
normally be for partitioned area(s) and not necessarily enclosed
rooms, unless there are specific reasons which dictate otherwise”.
However, Alliance Pharmacy’s experience with installing consultation
areas in England and Wales suggests that partitioned areas are
unlikely to be suitable for all the additional and enhanced services
envisaged
for future phases of the new contracts. Thus all Alliance Pharmacy
branches in Scotland are receiving fully enclosed consultation
rooms to the same specification as in England and Wales. |
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The
Pharmaceutical Journal