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Toni Orr is a community pharmacist manager in Kilmarnock,
Ayrshire
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Currently, funding for social care is under the control of each individual local authority social services department. The framework that exists to govern both the NHS and the local authority bodies states that it is “not normally reasonable” to use NHS funds on community care services but some GPs have started to interpret this rule imaginatively
by making use of the statement in the 1990 Act, that it can be done where “the
provision of such services is necessary to meet a health need” or
where there is a formal partnership and pooling of funds between a primary
care trust and local authority. However, under new proposals announced
on 6 March by Health Secretary Patricia Hewitt, the funding will be rearranged
by shifting the money between the NHS and the local authority budgets
to facilitate more seamless care for society as a whole.
The proposals represent the biggest shake-up of the rules that govern
the commissioning of health and social services since the NHS was founded.
Local authority leaders must be feeling concerned about this because
it takes total budgetary control for their services out of their hands.
Ms Hewitt has set out the Government’s consultative proposals for
a commissioning framework for health and well-being, which has been drawn
up jointly with communities and the local government secretary Ruth Kelly.
Basically, it means that there are now proposals being discussed for
GPs to prescribe support for those people in each community who need
assistance, eg, home helps, respite breaks for carers, exercise for patients
who are overweight, supply of self-monitoring equipment and making available
social work, counselling and occupational therapy services.
Something had to be done and someone had to make the first move because
this
current system is flawed. It worked once but no longer does because of
the demands that are put upon it by a growing and ageing
population.
There are three important issues here that are of interest to pharmacy.
First, if GPs are going to be allowed to prescribe social care in the
UK then it should follow that all independent prescribers would be involved
in this process too, including independent pharmacist prescribers. Any
pharmacist who has undertaken domiciliary visits and found a clear requirement
for MDS support has been frustrated by the red tape that must be dealt
with to ensure that they are paid for the service.
Our contract states that we will provide pharmaceutical services as an
independent contractor for the NHS and yet, day after day, we are failing
patients.
GPs, social workers and carers constantly approach us to provide domiciliary
support for medication for clients or family members and we are under
huge pressure to provide an MDS.
Not many people outside the pharmacy profession realises how labour-intensive
this service is. To them it is just “a wee box of pills”,
but to those providing the service the amount of technical input required
is massive.
We have to replicate these boxes accurately week after week, update the
records, organise and order (in some cases) the prescriptions, seamlessly
change the medicines if someone has been in hospital — and that
is often difficult when there are no formal discharge communications
to community pharmacy. The numbers of patients requiring this service
is high and this section of our population is vulnerable and growing
in number. We look after these patients in a way that nobody wants to
quantify or recognise.
Expectation
Domiciliary MDS systems started as a free service provided by pharmacists
because we recognised the gap in service. But it is groaning under
the weight of expectation. People expect us to fill a box or blister
for one tablet a day but this is not necessary for health reasons.
There has been research that shows that an MDS is only necessary when
there are four or more medicines a day but people still ask for them.
The reasons for extra support are diverse, and many are valid, but
they are not necessarily health needs. Social need is another matter.
The second issue arising from the Government’s statement is that
it is different in Scotland, where I work. Because funding streams in
Scotland are changing, I wish to highlight a difference across the border.
The community health partnerships (CHPs) in Scotland have been developed
over the past few years to address these problems and to bridge the divide
between health and social care.
In Ayrshire we are trying to tap into funding streams for payment for
domiciliary MDS. Our lead pharmacists have raised the issue at the CHP
executives’ meetings and the Ayrshire and Arran community pharmacy
development team is trying to develop a proposal — but the process
is tortuously slow.
One local authority has developed a medication policy that says any more
than one medicine should be in a blister. Pharmacy was consulted but
to protect the local authority “home helps” they chose to
make their own policy, which causes difficulties in the locality as they
have created a demand which pharmacists, as suppliers of this demand,
cannot meet. You can see their point but they then complain when contractors
refuse to service the numbers of patients for whom they have requested
support.
In Scotland, we are paid £98 per contract (pharmacy) per month
under the interim contract arrangements to provide not only these MDS
systems but also another significantly under-funded service called the
chronic medication service. And there are no fee payments for instalment
dispensing. Unfortunately, locally, there are often contractors who do
not understand the Scottish contract or local developments and who want
to increase prescription volume — so they take on new MDS patients
for no extra payment while we are trying to develop a properly funded
service. This highlights my third point: MDS provision should be a core
service. It is an issue that affects the nation as a whole. This is a
gap in the service that should not be dealt with on a local level and
GPs, pharmacists and nurses should all be able to instigate requests
for MDS support.
Mrs Hewitt said her department had evidence that every pound spent on
social care saved the NHS 30p. Some research suggested that the savings
to the NHS were as much as 80p per social-care pound. Imagine the savings
that could result, over and above this, if wastage of medicines, by patients
who cannot cope with their medicines and order too much, were avoided.
I visited a patient recently for a domiciliary review which had been
requested by a social worker. The patient was deaf and did not have a
particular health need for an MDS. Then I saw her medicines cabinet:
it must have contained about 1,000 co-codamol tablets. It was every pharmacist’s
nightmare and her social worker had grave concerns, so I decided to support
her and provide an MDS for everyone’s peace of mind. Of course
this is a personal story, but many pharmacists will have seen similar
situations during their careers.
I concede that pharmacy leaders in Scotland are developing new service
specifications but, hopefully, a properly funded service will be organised.
Please, will someone listen and understand that pharmacists and members
of society are crying out for domiciliary monitored dosage systems everywhere.
Changes to the funding streams are crucial to pharmacy and society’s
future. |
The
Pharmaceutical Journal