| Over the course of the past year, which saw a set of eight evidence
sessions and dozens of written responses, the All-Party Pharmacy Group
has taken a hard look at the current community pharmacy arrangements
in England and Wales.
The resulting report is, Howard Stoate, chairman of the APPG says, one
of the most in-depth analyses of the arrangements for pharmaceutical care
to have taken place for many years. Many of the group’s suggestions
chime with what pharmacy bodies have been proposing for some time. However,
with new leadership at Westminster, this independent, cross-party report
may have come at an opportune time to bring about real change.
Criticism
Dr Stoate believes that the group has been tough in its assessment of
the present system. “We have taken the line that there is a lot wrong
with the current arrangements for pharmacy and a lot wrong with the current
arrangements for primary care,” he says. “In particular we
are disappointed that pharmacy services are not developing fast enough
or consistently enough.” This means, he argues, that patients are
not seeing the speed in improvement in primary care services they are
entitled to expect.
In particular, the current enhanced tier in the community pharmacy contract
is not working as envisaged, the group believes. “Leaving primary
care trusts to commission services locally is simply not delivering anything
like a consistent system,” Dr Stoate says. “Many PCTs are not
commissioning services at all and even when PCTs are, they are often short-term,
they are haphazard and pharmacists are not able to plan far enough in advance.”
Inconsistent and short-term funding has meant that pharmacists are unwilling
to make big investments in enhanced services, and this is holding back
the development of new clinical services, the group believes. “Local
commissioning is causing fragmentation and services that are developing
are patchy and inconsistent,” Dr Stoate says. New advanced services
must, therefore, be developed and be nationally agreed and funded, the
group says. All these services should be available in every PCT and be
managed locally as MURs are at present.
Services
The new advanced services it proposes are designed to tackle a number
of public health issues. They cover:
• Long-term conditions, building on the current MUR service to allow
pharmacists to help manage the treatment of patients with stable, long-term
conditions
• Sexual health, principally chlamydia screening and advice
• Minor ailments, including advice, treatment and management
• Diabetes screening, centred around fingerprick testing and referrals
to GPs as necessary
• Obesity and weight management, including body mass index measurement,
blood pressure monitoring, information, advice, regular reviews and referrals
• Other diagnostic and screening services, coupled to advice and referrals
as necessary
Funding
The group recognises that national funding of these services will require
an increase in overall funding for community pharmacy, but has not
calculated how much more these services will cost — this will
be for the Pharmaceutical Services Negotiating Committee and the Department
of Health to negotiate. Nonetheless, the implementation of these services
would also lead to significant savings in health care costs elsewhere,
the group believes.
“If we can start screening people for diabetes and start managing long-term
conditions in pharmacy, there are significant cost savings for the NHS
to be made,” Dr Stoate says. Secondary care services are extremely
expensive and it is these that are stretching budgets to breaking point,
he adds. “We believe that not only will there be huge cost savings
to be made by keeping people away from hospital, but equally there is
going to be savings in primary care just by preventing long-term conditions
and managing them better.”
Reallocation
As well as additional funding that could be made available by the DoH,
there are also other funds available to PCTs which could be reallocated
to pharmacy, Sandra Gidley, treasurer of the APPG, says. “There
are public health budgets available as well, so some of this money
is already in the system.” Developing nationally agreed advanced
services would send a clear message to commissioners that public health
services can be funded and delivered through pharmacies, she adds.
The group’s call for new advanced funded services has been warmly
received by the PSNC, echoing as it does the committee’s own demands
for national funding for services such as minor ailment schemes. Sue
Sharpe, chief executive of the Pharmaceutical Services Negotiating Committee,
believes that patients and public need to know what services they can
get from pharmacies. “The lack of national funding for services
beyond the essential services means that many patients cannot access
these services, while those in neighbouring primary care trusts can,” she
says.
Awareness
If attempts to increase access to health services through pharmacies
are to be successful, members of the public will need to be aware of
which services are available through pharmacies and national consistency
will be crucial to this, Mrs Sharpe believes. “If patients do
not know whether or not their local pharmacy provides a particular
service, they will go to where they know they can access the service,
which is likely to be their local GP surgery.”
National provision will also be vital to the success of pharmacy-based
sexual health and public health services, she adds. “There is an
enormous need for these services and they can be provided cost-effectively
and conveniently through pharmacies, but there is no value in a big national
campaign promoting pharmacy availability if a large proportion of people
cannot actually access those services at their local pharmacy.”
Collaboration
Aside from problems with the development of enhanced services, the
group’s
other main criticisms centre around the lack of collaborative working
between community pharmacists and other health professionals, particularly
GPs.
“Other professionals and pharmacists are not working effectively together,” Dr
Stoate says. “GPs are very resistant to change. GPs are often territorial
and GPs are frankly sometimes resentful of pharmacy. There is still too
much of the feeling of us and them, too much of a feeling of pharmacists
trying to poach on their territory and a feeling that they are trying
to poach the limited funds of PCTs.” These resentments, concerns
and failures are creating barriers to the development of new services.
Although the fact that GPs and pharmacists do not tend to collaborate
enough is hardly news, the inquiry showed just how wide the problem is,
Dr Stoate says. “We got a real feeling of the depth of this problem.
Not just that there are isolated difficulties, but there really is a
thorough, core problem of difficulties of collaborative working, of pharmacists
getting their feet under the table of practice-based commissioning groups.
They are not being listened to by PCTs and they are simply not able to
develop the services that we think are absolutely essential. There are
some examples where it has worked extremely well but there are far too
many examples where it simply hasn’t worked at all,” he says.
Among the group’s proposed solutions to this problem of non-collaboration
is to make payments available to GPs, under the quality and outcomes
framework, for collaborative working with other health professionals.
The report also suggests that there should be integration between the
community pharmacy contractual framework and the general medical services
contract, that responsibilities and targets should be shared (to encourage
partnership working as a normal part of daily practice) and that joint
enhanced services should be developed.
GPs do recognise the need to work with pharmacists, Dr Stoate insists. “I
don’t think that GPs have any difficulties understanding the principle
that, in order for them to make their job workable they have got to have
professional help.” What GPs do not want, however, is to lose funding,
he says. “That is why we want the funding arrangements to be sorted
out so that we are not directly in competition for the same pot of money.
We need to make sure that, although they have similar funding structures,
they are not directly competing for the same pot.”
Outcomes
The report also suggests that some payments for pharmacists could be
linked to patients’ clinical outcomes. QOF payments have brought
about positive changes in general practice, the group believes, and
a similar principle should be introduced for pharmacists, by which
practitioners who develop genuinely innovative services or make a difference
to patient care would be given additional payments.
The group envisages patients being added to pharmacy lists for services
once they have registered with a GP for the management of their long-term
conditions. The pharmacist would then be reimbursed according to the
number of patients registered and the clinical outcomes of those patients.
Focus
The group makes some recommendations that apply to pharmacists working
in all sectors. For instance, it suggests that the independent prescribing
qualification should be included in all undergraduate pharmacy courses.
It says that there are shortfalls in leadership at all levels and that
the profession’s leadership groups should try, wherever possible,
to speak with a single voice, although it does not go as far as to
suggest any changes to current structures — this should be left
to the bodies themselves, it says.
In addition, the report is complimentary about hospital pharmacy, which
is, it says “moving in the right direction”. It also suggests
that measures should be taken to reduce staff turnover rates among hospital
pharmacists, including introducing national recruitment and retention
premiums.
Nonetheless, the bulk of the 100-page report focuses solely on community
pharmacy. This is a missed opportunity to highlight valuable progress
elsewhere, Paul Bennett, chairman of the English Pharmacy Board believes. “The
report title is broader than its content as it talks about the future
of pharmacy as a whole. However, the main thrust of the content is on
community pharmacy, with some mention of hospital pharmacy, but no acknowledgement
of the work of pharmacists in primary care both in PCTs and working directly
with patients.”
Influence
In many ways the APPG’s report simply repeats much of what the
Society, the PSNC, the National Pharmacy Association and others have
been championing for some time. However its status and timing may augur
well for its potential to bring about real change.
“This should be an influential report,” Mrs Sharpe says. “For
the first time, a group of MPs has taken the time to have an in-depth
look at the pharmacy sector. And it is a cross-party group, rather than
one with a particular political agenda. It would be a strange government
that did not pay serious attention to the report.”
The report is also timely, she argues. “I would expect the incoming ministerial
team to be reflecting on how to make cost-effective use of the money spent
on health, particularly as Gordon Brown has said that the NHS will be his number
one priority as Prime Minister. The PSNC has spoken many times about the potential
for pharmacists to extend their reach so, with a new ministerial team poised
to take office, I hope the report strikes a chord at just the right time.”
Changes
Dr Stoate also believes that the report has come at the right time
to influence Government thinking. “I think the Government recognises
that there are problems in terms of delivering services. I don’t
think the Government is going to shy away from that,” he says.
There is also a desire to see more demonstrable signs of return form
the investments that have been made in health care over the past seven
years, particularly at primary care level, he adds, and so the Government
may well be receptive to the group’s recommendations.
The Government has no obligation to respond to the APPG report, but
has said that it will consider and make a response to the recommendations,
and the APPG will be having a series of meetings with the Government
over the coming months to discuss the report’s recommendations.
Dr Stoate believes that changes in leadership in the Government will
put a different flavour on decisions and that if Lord Hunt retains responsibility
for pharmacy he will be keen to see developments. “I think he would
very much like a change of direction from the Department of Health. He
is looking for evidence, I think, to make that more possible,” he
says. “I get the distinct feeling that the DoH wants a new look
at this and actually wants some sensible suggestions as to how that might
be achieved.”
APPG inquiry and report
The All-Party Pharmacy Group launched its
inquiry
into the future of pharmacy last June (PJ, 24 June
2006, p739). It set out to
assess recent developments in pharmacy, identify health care priorities
that could be met by pharmacy, examine challenges for the profession,
policy-makers and the NHS and examine what changes would be needed
to realise pharmacy’s potential.
The group sought written
evidence from a wide range of groups and supplemented this with
eight evidence sessions, conducted between August 2006 and April
2007, at which evidence was heard from:
• Lord Hunt
• Keith Ridge
(chief pharmaceutical officer)
• Jeannette Howe (head of pharmacy
at the Department of Health)
• the Company Chemists’ Association
• the National Pharmacy Association
• the Pharmaceutical Services Negotiating
Committee
• the Royal Pharmaceutical Society
• representatives
of schools of pharmacy, primary care trusts, local pharmaceutical
committees, multiple pharmacies
• Which?
• the nursing
and medical professions
The group’s report, entitled “The
future of pharmacy — report of the APPG inquiry” is
available online (PDF 2.8MB) |
|
The
Pharmaceutical Journal