The Pharmaceutical Journal
Vol 278 No 7449 p502-503
28 April 2007

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Community pharmacy practitioner champions

Community pharmacy prepares for next stage of new contract in Scotland

This year will see the start of the next core service in the new community pharmacy contract in Scotland: the acute medication service (AMS).

Derek McAllister, a member of the ePharmacy delivery team, said that of the five GP computer systems in Scotland, four are currently beta-testing the electronic AMS system (eAMS) and the other is due to start beta-testing this week. “The software will start to be rolled out to GPs this month, and this is due to be completed by June,” he said.

Pharmacy computer system suppliers will then start beta-testing in July, with some starting to roll-out eAMS software in July and August. “The mainstream roll-out will be from September,” he said. “Bar-coded eAMS paper prescriptions can still be processed manually until the pharmacy becomes eAMS-enabled. So there will not be a big bang start for AMS.”

Mr McAllister explained how eAMS will work. Its basis is the electronic transfer of prescriptions and, in summary, it will involve six stages:

1. GP prints a GP10 prescription that contains a barcode and simultaneously sends an electronic prescription message to a central ePharmacy message store

2. Patient presents the GP10 prescription in a pharmacy

3. Pharmacist (or pharmacy staff) scans the barcode, which retrieves the electronic prescription details from the message store

4. Prescription is dispensed

5. Electronic message is then sent to the ePharmacy message store

6. Remuneration and reimbursement are supported through ePay

“The process at the GP practice is largely unchanged, as is the process for patients,” said Mr McAllister. “But the process at the pharmacy will change because the dispensing process is electronically supported.” He pointed out that all pharmacy system suppliers have been given a minimum specification for eAMS (as described here) but that there is huge potential for individual suppliers to offer extra functionality.

It will only be possible to retrieve electronic prescriptions from the ePharmacy message store by scanning the paper prescription. “The paper prescription is the patient’s permission, or token, to pull down the electronic prescription,” Mr McAllister said. He predicted that it will take one to two seconds for each prescription to be retrieved from the message store. “Pharmacists might want to think about who scans the prescriptions,” he suggested. “It isn’t necessary to scan the form, then immediately process it the whole way through. Instead, it can be done in stages.” So if a pharmacy receives a batch of 200 prescriptions from a surgery, these could be scanned by a pharmacy assistant. This would pull down the electronic prescriptions, so they are waiting on the pharmacy’s computer system for dispensing.

Once the electronic prescription is on the pharmacy’s computer, the community health index (CHI) number will be used to match the prescription to a patient’s record. The computer will then use a dm+d code (Dictionary of Medicines and Devices code, contained in the electronic message) to display the drug the prescription is calling for, or a short-list if there is no exact match. “The pharmacist can over-ride suggestions but, in a lot of cases, the system will recognise that the exact item has been dispensed for the patient before and so will suggest that item,” he explained. “If an item does not have a dm+d code, then the drug will have to be identified using text [as now]. Well over 80 per cent of all items have a code, and this equates to more than 90 per cent of what is prescribed.” The remaining items are unusual or new drugs.

Another new function is that all pharmacy systems will have to endorse prescriptions electronically. Endorsing can be delayed to be completed in a batch rather than during dispensing. An electronic claim for payment will be submitted once all the information has been completed and the medicine has been issued to the patient. Patients’ exemption status needs to be captured on the computer, which is something that may be done in advance.

“If there is no electronic message, then the paper prescription is still legal and can be processed manually,” Mr McAllister commented. In addition, some prescriptions will initially fall outside eAMS so will remain paper-based, these include hand-written GP10s (eg, from home visits), prescriptions without a CHI number and prescriptions written by non-medical prescribers.

The new electronic payment process, or ePay, will still require paper prescriptions to be sent to Practitioner Services Division. “The paper form triggers the use of the electronic data. The barcode is scanned and this retrieves the electronic dispensed message,” he explained. “The important point is that the electronic message takes priority over the paper form, so if a mistake is made then the electronic message must be resubmitted rather than amending the paper form.”

Pharmacy champions raised a number of issues around implementation of AMS. These included the need for support materials in advance of AMS starting, guidance on new standard operating procedures for dispensing and patient information leaflets.

How the chronic medication service will be shaped

The chronic medication service (CMS) is the jewel in the crown of the new contract, according to Bill Scott, chief pharmaceutical officer, Scottish Executive. “We have got 2,500 clinical practitioners working in the high street in Scotland but we treat them like driving a Ferrari in first gear. We need to put something in place to utilise the knowledge and skills of the pharmacists in our community. That’s why this contract is about clinical practice and quality of service, not about volume and dispensing, although these are important,” he said.

The need for CMS was demonstrated by the pharmaceutical care model schemes programme, which showed, for example, that 30 per cent of people with asthma do not know how to use their inhalers properly.

A clinical specification for CMS has now been drawn up, and it will take a two-phase structure (PJ, 21 April, p447).

The first phase will involve the pharmacist helping patients to get the most from long-term medicines without the need to refer to the prescriber.

Although these are things that pharmacists do already, the important points are that this role will be recognised in the contract and that it will formalised through a systematic approach to ensure all issues are identified, Mr Scott explained. One possibility being looked at is decision support material to ensure a standardised service.

The second phase will involve pharmacists managing a patient — including serial dispensing — for up to 12 months. “Everything the pharmacist does must be based on national evidence-based guidelines,” he said. “The GP, patient and pharmacist will have to be satisfied that there is a system in place to ensure the patient gets the best out of their medicines and that if there is a change in clinical circumstances that requires referral back to the GP that this happens.”

The details of how CMS will work are still being discussed but an approach being considered is a central electronic repository of standard guidance on how each long-term condition should be managed. On registering a patient, the pharmacist could then download the relevant guidance in order to provide a management plan.

Mr Scott stressed that an electronic system must be introduced to support CMS. “It is also important to ensure that GPs are fully engaged with CMS and the information going back to them,” he said. “We need to learn from the experience of MURs in England and Wales, and avoid the problems encountered there.” In the first instance, CMS will only be available for people who live in their own homes. “We want to customise the service for patients not living in their own home,” he said.

Mr Scott concluded: “The pharmacies we work in today will be totally different from those we will work in in 10 years’ time. They will enable us to deliver better pharmaceutical care services for the people of Scotland.”

Positive progress with minor ailment service

Latest figures show that almost 700,000 people have registered for the minor ailment service (MAS). “That is about 25 per cent of the potential population who can register,” said Bill Scott, chief pharmaceutical officer, Scottish Executive. The figures also reveal that around 50,000 people receive an MAS consultation every month, which results in prescriptions to the value of 0.15 per cent of the gross ingredient cost in primary care. “This is low and shows pharmacists are not running away with the drugs bill,” Mr Scott said.

But despite the fact that 50,000 consultations a month are provided, the monthly figure for consultations resulting in referral or advice is just 200. “This is a gross under-reporting,” Mr Scott said. He suggested the reason was bureaucracy: advice provision or referral consultations are only recorded if the pharmacist prints a form and the patient signs it. This rarely happens because of the time it takes. “We need to find a better way of recording these consultations,” he said. One possibility is removing the link between payments and these consultations (because they currently activate reregistration) so there would be no need for a patient signature.

Mr Scott discussed various issues that had been raised about MAS. First was the concept of supply versus consultation. “MAS is not a supply service. It is about a patient going for a minor ailment consultation at the pharmacy, like they would consult a GP, not about going for a bottle of paracetamol,” he said. This also explained why MAS consultations could not be offered by pharmacy assistants. “If we are saying to people, go to the pharmacy not the GP, then they should expect a consultation with a pharmacist.”

Feedback from practitioner champions included a need to define the difference between a minor illness and a chronic condition (eg, hay fever over the summer), to increase the indications that can be treated (eg, urinary tract infections under patient group directions), and to get pharmacy computer system suppliers to improve eMAS software.

A lack of knowledge about MAS among the public and primary care practitioners was raised. Some pharmacy champions reported GPs sending patients to a pharmacy to get a product using MAS, rather than prescribing it themselves. But the public’s lack of knowledge about MAS was the biggest concern. Mr Scott commented: “What we now need is a significant public relations campaign.” The reason this had not been done yet was to give time for the service to get established before a PR campaign resulted in more demand.

Registrations still presented some problems. Pharmacy champions highlighted a need for temporary registrations (particularly for out-of-hours and rota times), and suggested patients could register online. Another issue is how to register homeless people who do not have a postcode currently required for registration. Champions also asked for explanations of why registrations are rejected.

Lapsing registrations is a concern for contractors, although it was recently announced that payments this year would not be allowed to fall below the level a pharmacy reached in March (PJ, 14 April, p416). “I am not wedded to signing people up every year,” said Mr Scott. “I don’t know how many times a person gets ill every year. So we need to do some research around what is reasonable usage. But I think a year is too short.”

Public health service: July start for tier two

Tier two of the public health service (PHS) will begin in July, Alison Strath, principal pharmaceutical officer, Scottish Executive, announced.

The second tier will involve pharmacies displaying public health materials in pharmacy window or frontage for four national campaigns every year, each lasting for six weeks. A scoping exercise carried out in Lothian had determined pharmacy’s minimum and maximum window sizes in order to produce a standard frame in which to place campaign posters. Options for standard frames were now being considered by the Scottish Pharmaceutical General Council, with materials due to be finalised shortly, she explained.

“We have been looking for a maintained contract for tier two,” said Ms Strath. “This will involve having someone who comes into the pharmacy, replaces the material and services the frames, so pharmacists do not have to do anything.”

She added: “PHS will involve a rolling programme of activity so pharmacists know what will happen when. There will also be material to use between campaigns.” For 2007/08, the first campaign will start in July. Its topic will be the minor ailment service. “This will link with the planned national PR campaign for MAS,” said Ms Strath.

The next PHS campaign, in September, will be about the national influenza immunisation programme. Campaigns for January and March 2008 are still being decided. However possibilities are healthy living for January and smoking for March. “We hope to confirm these soon,” she said.