The Pharmaceutical Journal
Vol 278 No 7450 p527
5 May 2007

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Moving pharmaceutical care closer to home in England — a role for PhwSIs

By Beth Taylor

Agenda series

What does “care closer to home” really mean for pharmacists? The 2006 White Paper “Our health, our care, our say” maps what care closer to home looks like. It includes:

• Shifting care within particular specialties into community settings

• A new generation of community hospitals, providing a wider range of health and social care services in the community

• The need for growth in health spending to be directed more towards preventive, primary, community and social care services

• Refining the tariff to provide stronger incentives for practices and primary care trusts to develop more primary and community services

This policy is now beginning to be translated into local action, but what are the implications for pharmacy? Where are the opportunities for pharmaceutical care? What part might pharmacists with special interests (PhwSIs) play?

The White Paper and subsequent Department of Health publications have highlighted some specialty services for early consideration; these include medical specialties, such as dermatology, that are less reliant on facilities only available in secondary care, and straightforward surgical procedures. Some specialties, such as diabetes and substance misuse services, are already well integrated with primary care in some areas, but not everywhere. In addition, many follow-up outpatient appointments could be moved into primary care.

Practice-based commissioners are being encouraged to drive the process through payment by results and 18-week targets for acute care. So there are opportunities for pharmacists here: these commissioners may support pharmacy proposals that could potentially free capacity to provide some specialist care in GP practices. Pharmacies are also well placed to expand their role within key clinical priority areas, such as sexual health and substance misuse services, where they already have a proven track record of public support and where they could fill gaps in local services.

There are two main groups of practitioners who could deliver this specialist care, taking referrals both from colleagues in secondary and primary care. One group comprises NHS staff who provide specialist care and the other comprises accredited practitioners with special interests.

Currently there is a debate (with not a little tension) around who is best placed to carry out specialist roles within redesigned care pathways. Many specialist professionals currently based in hospitals (including pharmacists) are understandably keen to convince commissioners that they are best placed to do this, for instance through expanding outreach service models. They also argue that this course will make best use of scarce specialist skills, especially in view of the predicted future downsizing of some local hospitals.

Commissioners may also consider the role that practitioners with special interests might play within redesigned services. These practitioners include GPs and pharmacists, who share a common definition and approach to the role. The DoH has recently launched a new suite of publications, “Implementing care closer to home — convenient quality care for patients”, to support the commissioning of services using practitioners with special interests. It includes an introduction and overview, a step-by-step guide for commissioners, and a new nationally recognised process for the accreditation of both GPs and pharmacists with special interests.

Unlike NHS specialist staff, practitioners with special interests must retain a core generalist role. In addition, they deliver a clinical service beyond this core role and will have demonstrated appropriate skills and competencies to deliver those services without direct supervision. They argue that the experience they bring from their generalist role adds considerable value to this specific specialist role in ways that benefit patients. In particular, PhwSIs offer the potential to achieve quicker and easier access for patients who need more specialist services and better use, in more convenient locations, of the professional skills available in primary care.

All practitioners with special interests work within their competencies and expertise to deliver care as part of local care pathways to meet patients’ needs. To do this effectively their services need to be well integrated with those in local primary care and specialist centres, and the ability to prescribe could be an advantage. It is essential for emerging PhwSIs to have active support from specialist teams based in secondary care, which may also have a key role in their training and development.

An important distinction is that the role of a PhwSI is not a generic role in the way that a community or hospital pharmacy role is. PhwSIs are appointed to deliver a particular clinical service within a specific care pathway and will be required to demonstrate through a nationally defined, but locally delivered accreditation process, that they are competent to do this. Specialty-specific guidelines relevant for pharmacists are also needed, and any future royal college could play a key part here.

Which models might prevail? Increasingly, local commissioners are using redesigned care pathways as tools for implementing care closer to home, and these may specify roles that could be delivered by practitioners with special interests or by NHS specialist staff. During the 2007 commissioning round, we should be alert to opportunities to put forward business cases for pharmacists to fulfil new roles in either of these models.

An underpinning principle is that the same quality and service standards should apply to all NHS specialist care in the community, whether that care is provided by accredited practitioners or by NHS specialist staff. If we can meet this principle, bringing specialist pharmaceutical care closer to home could be a development that is popular with patients.