Pharmacy Management
Practice-based commissioning: the jury is still out on many issues
Sandy Briddon: engagement with practice-based commissioning patchy |
The jury is out on whether primary care trusts are truly making progress
towards achieving universal coverage of practice-based commissioning,
according to Sandy Briddon, project director for what was the Thames
Valley primary care trusts. The Department of Health has specified that
universal coverage will be achieved when all PCTs are providing practices
with information on clinical and financial activity, indicative budgets
and incentive payments, and governance arrangements are in place.
Although Department of Health figures showed that by August 2006, 69
per cent of PCTs had arrangements in place and 74 per cent of practices
were receiving incentive payments, Ms Briddon says that in reality there
are wide variations nationally in the level of engagement by PCTs and
GPs.
In a number of areas PCTs are not providing GPs with indicative budgets
or hospital activity information.
“How can practices participate … without having that type of
information,” she
asked. Ms Briddon told participants that a lot of PCTs are in financial
deficit and are therefore setting lower budgets for their practices,
which is a huge challenge for these new
commissioners.
The few governance arrangements that are in place are being challenged
by PBC consortia and lawyers working with groups of practices, said Ms
Briddon. There is also little involvement of nurses, pharmacists and
social care in PBC.
“If we do not start to gel this together then PBC will not meet
the aims the [department] hoped it would,” she said. She questioned
why GPs are working in large consortia. “Is it the fear factor
that if they do not now work together somebody in the private sector
may come
and do this for them? Or do they genuinely want to improve care locally?
I think the jury, again, is out on that,” she added.
In summary, she concluded that PBC is the tool for delivering service
reform. The message from the Government is that there is no more big
money for the NHS so we need to improve access and quality of care within
the resources that we have, she told participants.
Joint management of pharmacy across the interface
Although most of the medicines-related savings under PBC will be made
in primary care, secondary care needs to be involved, said Ian Bourns,
director of medicines management and pharmacy at East Sussex Hospitals
NHS Trust, in his presentation on joined-up thinking between hospitals
and PCTs in the drug budgets.
Mr Bourns explained that, because the influence of secondary care is
significant, it needs to be involved in PBC otherwise large savings will
not be made and less money will be available to commission services from
secondary care. He mentioned several areas in which hospital pharmacists
could be involved, such as improved communication across the interface.
Mr Bourns then presented some of his own thoughts about future scenarios
in terms of funding of the NHS. He said that joint drug budgets are often
mooted as a way of addressing interface funding issues. But, he said,
while there are multiple organisations he cannot see that working. However,
he added: “Where we have got care pathways coming along, we may
be able to identify the expenditure for given diseases and, if we can,
there is a lot of opportunity for changing how we work.”
Mr Bourns also floated the idea of joint management of pharmacy services
across primary and secondary care. He believes that it is possible but
pointed out that strategic advice would still be needed to individual
organisations, which might have slightly different aims.
“I suspect we will see greater integration in the majority of health economies
between primary and secondary care, a lot of which will be focused around
care pathways. But in some areas we will see a joint management approach
to pharmacy,” he said.
Finally, he argued that to address the NHS financial problems radical
changes are needed and these changes will affect pharmacy. Pharmacy staff
across boundaries will need to share information and develop joint information
sources. They will also need to resist internal pressures from their
organisations to be protective and parochial.
Jonathan Cooke, director of research and development, and clinical director
of pharmacy and medicines management at South Manchester University Hospitals
NHS Trust, told participants about a medicines management outreach project
in South Manchester, where hospital pharmacists were funded to work with
GP practices to support effective prescribing in line with the PCT and
trust medicines management strategy. The project actively improved communications
on medicines issues across the primary/secondary care interface.
Professor Cooke explained that a number of budding consultant pharmacists
in the areas of respiratory medicine, cardiology, palliative care, psychiatry,
surgery, pain control and oncology were involved. A three-month review
of the project, which spanned five GP practices, demonstrated that it
was financially viable and the interventions made were similar to those
made by hospital pharmacists in admissions wards. This type of service
might help to reduce admissions to hospital as well as improving pharmaceutical
care to patients.
Professor Cooke also raised the possibility of vertical integration of
the pharmacy workforce. “Why do we not look at rotating our pharmacy
staff through the different sectors to get the confidence, knowledge
and skills to deliver some of [the new contract] quality initiatives,” he
said.
Groups of pharmacists could take over GP practices
Some practice-based commissioning consortia may be predatory and be
looking to take over both provision of pharmaceutical advice and community
pharmacy services, said Peter James, one of the founding and lead GPs
in the East Berkshire GP Consortia. But, equally, he said, he could
not see why groups of pharmacists cannot be predatory and start to
take over some of the underperforming GP practices.
Dr James’s advice to pharmacists is not to wait for PCTs or GP
consortia to involve them in PBC. “Given that PCTs were not very
effective as commissioners, I am a little bit wary about whether they
are going to involve you very quickly and very efficiently and effectively
in the near future.” Pharmacists need to be proactive in coming
forward and telling PCTs what they can contribute, he added. They should
also market their benefits to consortia, he suggested.
He believes that pharmacists can play both a strategic and operational
role in PBC. “The consortia need people to work with all practices
but also with individual practices within the consortia that are perhaps
not working in the same way or to the same level as other practices,” said
Dr James. He also mentioned increasing access, chronic disease monitoring,
medicines compliance and wastage, and uptake of immunisations as areas
in which pharmacists could help practices.
Dr James highlighted that PBC consortia will be using peer pressure to
target overspending GPs. “This is better at achieving compliance
with the norm than anything else you can do, including prescribing incentive
schemes,” he said. He recommended that prescribing advisers who
benchmark GPs should hand that information over to PBC consortia, which
will then challenge their colleagues about their prescribing habits.
Pharmaceutical advisers and commissioners share many skills
Jonathan Mason: new contract will be of interest to commissioning
consortia |
A lot of prescribing advisers in PCTs are taking on practice-based
commissioning roles since many of the skills that they have developed
in their advisory
roles are transferable to commissioning, said Jonathan Mason, head
of prescribing and pharmacy at City and Hackney PCT.
For example, prescribing advisers have developed influencing and negotiating
skills, which can be used to help change GPs’ referral behaviour.
They are also accomplished at gathering a plethora of data together and
presenting it in a useable format, which will be a valuable skill for
PBC consortia in terms of analysing referral and activity data, said
Mr Mason. Pharmacists have an appreciation of where medicines and pharmaceutical
care is needed in care pathways, and are able to integrate PBC data and
messages into their routine prescribing visits and practice support activities,
he added.
An important part of Mr Mason’s role is liaising between commissioners
and contractors around what sort of services consortia want to commission.
He believes that there are a number of areas in the new community pharmacy
contract that will be important for practice-based commissioners. The
essential services provided by pharmacists, for example, will ultimately
improve the population’s health and reduce the impact they have
on other local health care services. The same applies to advanced services;
the benefits of medicines use reviews, such as improved concordance and
savings from unwanted medicines, are a good argument for investing in
pharmacy services, said Mr Mason. “Talk to the PBC consortia and
practices and ask them who you should be targeting for MURs — it
will not cost the consortia anything and it is really good public relations,” he
advised.
Mr Mason acknowledged that enhanced services is where the real impact
will be for both patients and consortia. Services such as minor ailments
schemes, smoking cessation, obesity management, substance misuse, immunisation
and emergency hormonal contraception will all ultimately lead to improved
access for patients and reduce accident and emergency and walk-in centre
attendances, he said.
Mr Mason’s presentation also addressed the opportunities that PBC
presents for hospital pharmacists. “If you can get proper [discharge]
planning to make sure that patients are not readmitted, that is a good
bargaining tool with PBC consortia.” Hospital pharmacists can also
conduct medication reviews during inpatient stays, get involved with
care pathway design and shared care issues and look at supplementary
prescribing and where that fits in with management of long-term conditions,
he suggested.
Prescribing budgets need to be embedded in care pathways
Shailen Rao, head of medicines management and diabetes lead at Hillingdon
PCT and chairman of the Primary Care Pharmacists’ Association,
told participants that in his area there are three localities with
one PBC board led by GPs. The clusters are currently developing their
commissioning intentions but have not yet taken on any budgets.
At the moment, says Mr Rao, many GPs see PBC as being about the services
they can provide not about taking on the prescribing budget. He has been
trying to convince commissioners that the prescribing budget is an area
where savings can be made quickly. This is because lots of data are available
on prescribing, it is a large budget that is mostly managed by the GPs
themselves, and it does not require any workforce development.
He believes that PBC has the potential to turn the tables in terms of
the prescribing budget since it will incentivise GPs in much more effective
ways than prescribing incentive schemes did. He believes that, instead
of pharmacists wondering how they can get GPs to do what they want them
to do, GPs will be asking how can they get help to do what they want
to do.
Mr Rao said that much of the work that pharmacists have done around guidelines
is a precursor to care pathways and what has been missing is the environment
within which those guidelines can flourish. “I think that, particularly
around chronic disease management, PBC will give us that opportunity,” he
said. However, he warned that in all this change and positive enthusiasm
to create care pathways, prescribing budgets should not be forgotten. “Prescribing
budgets need to be part of the whole commissioning process.”
A key issue is raising this with commissioning groups. Medicines management
teams are already well placed and experienced to provide the momentum
to get prescribing budgets embedded in care pathways, he said. |
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Pharmaceutical Journal