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Medicines are the most frequent healthcare intervention in the NHS.
In 2006, expenditure on medicines in primary care exceeded £8bn
and 752 million prescriptions were issued.
However, at the same time, there remains the challenge of under-treatment,
harm and waste from medicines use. These key issues need to be addressed
to ensure that the quality of prescribing is improved and benefits maximised
without detriment to patient care.
Primary care pharmacists, largely employed by primary care trusts, have
played a significant part in managing medicines over the past 15 years.
Their range of activities has evolved over this period but in essence
has retained a focus on maximising benefit and minimising risk of medicines.
Primary care pharmacists can also play a significant part in practice-based
commissioning (PBC) by engaging with commissioners in the prescribing
and medicines management agenda. PBC is currently a hot topic within
primary care, but a report last year by the National Audit Office (www.nao.org.uk)
highlighted the fact that its potential as a lever for improving value
in prescribing has yet to be fully realised.
Primary care pharmacists have a potential role in both the strategic
management of medicines and the provision of services such as the management
of long-term conditions and medication review. In addition, their skills
in managing information and knowledge and influencing changes in behaviour
can be applied to an agenda beyond just medicines.
What does PBC mean for pharmacists?
So what does PBC actually mean for pharmacists and what resources are
there to help them understand this new way of working? Many will so far
have had a limited involvement in PBC, and many of the documents related
to PBC do not recognise the valuable input pharmacists can make in both
the commissioning and the provision of services.
At a national level many representative bodies are lobbying for the involvement
of pharmacists in PBC, so now is a good time for pharmacists to get involved
locally.
What is practice-based commissioning?
Practice-based commissioning is a tool to improve the quality of services
and access for patients. PBC supports the move of funding to front-line
staff to enable the delivery of system reforms, patient choice, plurality
of service provision and investment. It supports the intention that commissioning
should take place as close to the patient as possible to ensure cost-effective
use of resources.
Under PBC, all practices will be given a minimum indicative budget which
will be increased over time to enable the purchase of a range of services
agreed with the PCT. A number of PCTs have already started the move to
fair share budgets (the allocation of the practice spend on a capitation
rather than historic allocation of practice budget basis) for 2007/08.
Many practices have chosen to pool their fair share budgets and operate
as consortia, with shared responsibility and decision making.
PBC should involve a number of other healthcare professionals, voluntary
organisations, private sector organisations, etc. The challenge of PBC
will only be met if there is effective collaboration between all professional
groups.
World-class commissioning focuses on how improved patient outcomes will
be delivered through strong local commissioning arrangements. The aim
is for PCTs to be better able to invest in order to achieve high-quality
and personalised services that improve health and well-being for their
local population.
It is expected that commissioners (PCTs working with PBCs) will take
the lead on behalf of their population. Commissioners need to ensure
that medicines management is considered in all relevant commissioning
arrangements.
What are the benefits of PBC involvement?
Involvement with PBC has several benefits for primary care pharmacists:
• Linking the use of medicines into the commissioning process
• Working with commissioners to develop policies on high cost drugs
• Developing medicines management programmes
• Improving cost-effective prescribing
• Providing medicines input into care pathways
• Linking into health economy policies and area prescribing committees
• Providing links into the community pharmacy programme, eg, medicine use
reviews
What are the risks of not getting involved?
PCTs need to be clear about how medicines management services fit within
the overall commissioner/provider split. It is important that existing
medicines management services remain fit for purpose and that opportunities
are taken to develop new services.
As PBC develops, one of the initial aspects that commissioning groups
tend to consider is how to optimise the use of the prescribing budget
and generally improve the use of medicines. As experts in the field of
medicines management and analysis of prescribing data, primary care pharmacists
are well placed to provide this service. If they do not engage with commissioners
now, this service may be gained from other providers.
It is a possibility that current PCT medicines management teams will
devolve to PBC clusters. Alternatively, PCT medicines management teams
could set up service level agreements with PBC clusters for the provision
of defined services.
What needs to happen at a local level?
PCT heads of medicine management and medicines management teams, including
practice based pharmacists, need to:
• Agree structures, service level agreements etc with the PBC cluster
leads
• Agree rules of engagement with PBC clusters
• Support the development of PBC cluster prescribing policies and action
plans
• Ensure PBC clusters link into the development of health economy prescribing
policy through area prescribing committees, etc
• Link the community pharmacy contract with the medicines management and
prescribing agenda
• Support the development of PBC prescribing incentive schemes or the devolvement
of PCT schemes to PBC cluster level
• Get involved in the development of care pathways and service redesign
Selling primary care pharmacy
The benefits of the full range of medicines management support, including
provision from primary care pharmacists, need to be made clear to practice-based
commissioners. The benefits include the following:
• Supporting the achievement of key NHS targets and optimising Quality
and Outcomes Framework outcome measures
• Ensuring patient pathways take account of appropriate, evidence-based prescribing
and medicines management
• Helping avoid unplanned hospital admissions by supporting patients with
long-term conditions and optimise medicines
• Reducing workload in general practice to release capacity to deliver PBC
priorities
• Participating in or supporting medication review within clinics and, where
appropriate, using independent or supplementary prescribing skills
A number of these models of engagement with practice-based commissioners
are now emerging in primary care.
Resources for primary care pharmacists
The Panel below sets out sources of information that should be of value
to primary care pharmacists wishing to become involved with practice-based
commissioning.
Sources of useful information
on practice-based commissioning for primary care pharmacists
Department of Health The Department
of Health has set up a separate section on its website which
contains all the resources
it has produced for PBC, including frequently asked questions
and the latest news.
Improvement Foundation The Improvement
Foundation is running the national PBC development programme,
which currently involves 70 per cent of PCTs. The main programme
consists of a collaborative, which is running in three waves.
Local pharmaceutical committees and pharmacists need to be aware
of any teams within their area and either get involved or learn
from these sites.
Details
of the centres and the programme
The local centres are in the process of setting
up PBC days for all PCTs and, again, pharmacists are encouraged
to get involved in these. Other resources include a “Practice
based commissioning assessment framework” (2005).
This framework is designed to help practices and PCTs to undertake
a diagnosis of their capacity and capability to meet the challenges
of implementing PBC and to identify development needs.
The Improvement
Foundation website also contains a great deal of information
on PBC and also “at a glance” guides, as well as examples
of service redesign.
The Improvement Foundation development programmes are also available
to community pharmacists including the leadership programme; and
quality improvement skills training can be delivered locally to
teams. Further details are also available from the foundation’s
regional centres.
National Prescribing Centre The
role of the National Prescribing Centre is to promote and support
high quality, cost-effective prescribing and medicines management
across the NHS, to help improve patient care and services. A
significant number of NPC outputs will facilitate engagement
with PBCs and support implementation of prescribing and medicines
management priorities.
The NPC has recently launched NPCi,
a new interactive
web-based educational resource to support prescribing
and medicines management.
The NPC will be launching a number of initiatives to support individuals
working on prescribing and medicines management issues within practice
based commissioning groups during 2008.
The Information Centre: prescribing support The Information
Centre for Health and Social Care has a prescribing
support unit (PSU) that produces reports and publications
that will help pharmacists see where they fit into the national
picture.
Its publications include:
• Hospital prescribing
• England (annual report)
• Prescriptions dispensed
• Prescription cost analysis
• National prescribing costs and items (monthly section level reports)
• PSU National Prescribing Reports (quarterly)
• PSU Prescribing Monitoring Documents (quarterly)
• National Quality and Outcomes Framework data
See Prescribing
Support Unit (PSU)
Also available is National Quality and Outcomes Framework (QOF)
achievement data derived from the Quality Management Analysis System
(QMAS), a national system that uses data from general practices
to calculate individual practices’ QOF achievement.
See Quality
and Outcomes Framework Database
NHS Comparators NHS Comparators
(an NHSNet site) is a national resource, focused on supporting
practice-based commissioning. It supports comparisons at the
GP practice, PCT, strategic health authority and national levels,
enabling users to investigate aspects of local commissioning
activity, costs and outcomes.
It is designed to supplement information available
through local systems, not to replace local systems. The comparators
have been developed by the Information Centre, Connecting for
Health and a panel of users and experts from across the NHS and
can be found at www.nhscomparators.nhs.uk
The system was launched nationally in June 2007
and is continuing to be developed. The system is available to
all GP practices, in addition to SHAs, PCTs, trusts, and other
relevant organisations. Information on how to register can be
obtained by e-mailing enquiries@ic.nhs.uk or
telephoning 0845 300 6016.
Primary Care Pharmacists Association The Primary
Care Pharmacists Association was founded in
April 1999, primarily as a forum for education, training
and support for pharmacists in primary care. It offers a
service to members to provide national and local peer support
groups, to provide a series of local education events throughout
the UK, to allow members to publish research and to present
work at educational events.
NHS Alliance The NHS
Alliance has published a number of useful documents. However,
these are only available to download for alliance members.
National Association of Primary Care The National
Association of Primary Care has a number of
useful documents for member commissioners and providers,
many of which are related to PBC, including “Prescribing
support and pharmaceutical advice for practice-based commissioners”.
Primary Care Contracting Primary
Care Contracting has provided a wealth of information
on PBC and has developed a bulletin on “Pharmacy
and PBC”. It also has regional advisers
who may be a useful resource locally.
Health Policy Forum The Health
Policy Forum is made up of representatives from the Company Chemists
Association, that National Pharmacy Association, the Pharmaceutical
Services Negotiating Committee and the Royal Pharmaceutical Society.
In December 2006 the forum published “Making
commissioning effective in the reformed NHS in England”,
which sought to determine what makes for good or effective commissioning.
Commissioning Toolkit for Long Term Conditions The
Commissioning
Toolkit for Long Term Conditions brings together
information and resources to help commission effective patient-centred
services.
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Pharmaceutical Journal