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A widely available minor ailments scheme is just one of the proposals
put forward by the Government in its White Paper “Pharmacy
in England — building
on strengths, delivering the future”, which sets out the Government’s
vision for pharmacies in England as healthy living centres — promoting
health, preventing illness and providing a range of new services to complement
the work of GPs.
The White Paper signals a review of the community pharmacy contract,
and the Government has tasked NHS Employers, on behalf of primary care
trusts, to work with the Pharmaceutical Services Negotiating Committee
to examine how best to incorporate these new services into the contract.
Although the White Paper focuses mainly on community pharmacy, its context
is wider, including hospital pharmacy, professional regulation, and education
and training.
Minor ailment schemes
The Government proposes that minor ailment schemes are commissioned
as directed enhanced services from community pharmacies in every primary
care trust area.
Unlike the voluntary mechanism for commissioning these
schemes, which are currently provided in only 24 per cent of pharmacies,
directed enhanced services will be compulsory for PCTs that identify
a need in their area (see news
p423). A goal of spring 2009 is set
for detailed proposals to be made.
The White Paper also envisages pharmacies as playing a key role in
the universal
programme for vascular
risk assessments announced by health secretary
Alan Johnson this month (PJ, 5 April 2008, p387). “Pharmacies
offer an excellent point of contact with the general population, and
also offer
a place of access to services for groups who may not be registered with
GPs,” it says.
The Government wants pharmacies to take a much more visible and active
role in improving the public’s health through provision of smoking
cessation services, NHS LifeCheck services, sexual health screening services,
access to contraception and administration of vaccines. It also wants
to see pharmacies giving timely and opportunistic advice on healthy eating,
increasing physical exercise, weight management and reducing alcohol
intake. To support this, the White Paper says, the Public Health Leadership
Forum for Pharmacy will identify a work programme for 2008–10 to
accelerate pharmacy’s ongoing contribution to public health.
Capturing information centrally about interventions made or advice given
about healthy lifestyles will help to identify pharmacists’ contribution
in this area and the Government has asked NHS Connecting for Health to
scope arrangements for electronically capturing these data.
Further contributing to its aim of creating healthy living centres, the
Government expects that in future more pharmacy staff will want to become
accredited health trainers. It will be asking for proposals from pharmacy
bodies and employers on how pharmacy staff can be supported to do this,
the White Paper states.
Communications
The Government believes that the breadth of services
that pharmacies can offer needs to be more widely publicised. Over
the coming
months, it plans to develop a communications programme that
will:
• Highlight the breadth of services and skills available
within pharmacies
• Illustrate the role that pharmacies can play in promoting good
health
• Raise awareness and knowledge of the role that pharmacy can
play in managing long-term conditions and reducing health inequalities
• Increase the use of pharmacy services among target audiences |
Innovative services
One of the innovative services proposed by the Government is support
for people who are newly prescribed a medicine to treat a long-term
condition.
Appropriate information and advice when a patient first comes to the
pharmacy should be supplemented with structured follow-up and further
advice or referral if necessary, the White Paper says.
It adds that pharmacies
should develop support for patients with long-term conditions beyond
what is currently offered by making an increased contribution at three
levels:
- Supported self-care
- Disease management
- Case management
Another
innovative service mooted is supporting cancer patients to receive oral
chemotherapy from community pharmacies: “It is possible within
a multidisciplinary clinical network for oral chemotherapy to be safely
dispensed in the community.” The Government expects PCTs to commission
well designed, safe services to meet these
patients’ needs, says the White Paper.
Closer relationships
The Government believes that effective working relationships
are important for the future development of services. It has therefore
asked NHS Employers to put together and lead a working group
of pharmacy and medical representatives and members of the
public.
The group will come up with an action plan to promote
more effective professional relationships, which will include: • Achievable
and realistic goals
• Incentives and outcome measures for delivering services that
ensure closer working and
co-operation between pharmacists and GPs
The group will start by
focusing on the repeat dispensing and electronic prescription
service. The Government hopes that, in
time, this approach will stimulate service providers to think
about how they can work creatively together and contribute to shared
care plans, integrated care pathways, shared information and
clinical
networks. |
Medicines use reviews
Medicines use reviews are currently remunerated based on the number
completed, rather than on the quality of the reviews. This has led to
some PCTs
being concerned that MURs are not being targeted to local needs and
patient priorities, and that their quality is inconsistent, the White
Paper says.
The Government proposes to make stronger provision for PCTs to target
MURs to meet their local health priorities. It also suggests that the
funding structure needs to be reviewed to ensure that the service is
targeted to those who might benefit most and to reward the health outcomes
that are achieved.
The Government also suggests that new MUR audit arrangements are put
in place so that there is an effective way for PCTs to monitor delivery
and outcomes and to decommission services from pharmacies that consistently
fail to meet agreed standards.
To further improve effective use of medicines, the White Paper indicates
that there will be a greater push to roll-out repeat dispensing. Although
the Government recognises that release 2 of the electronic prescription
service will bring benefits in this area, it says that there are elements
that need to be considered now, such as patient recruitment and communication
between prescribers and dispensers.
Expanding access to urgent care is another area addressed in the White
Paper. “PCTs, as planners and commissioners of urgent care services,
should ensure that pharmacy is playing a key role in a set of integrated,
easily
accessible services that best meet the needs and wishes of its local
communities,” it says.
It adds that pharmacy also has a role in
ensuring that it develops strong interfaces between other providers of
urgent care services to ensure that people receive a seamless service.
To improve access, the Government says that it will consider extending
the provision of emergency supply to enable 28 days’ worth of medicines
to be dispensed. Electronic prescription service
Access to the summary care record is essential for pharmacists to carry
out the wider role the Government describes in the White Paper. This
is recognised, but the importance of addressing concerns about patient
consent and confidentiality is also highlighted.
The Government makes a commitment to undertake further work with
an early adopter PCT to consider the benefits, governance and practical
arrangements
of community pharmacists having access to the summary care record.
The work will be used to inform a further programme, which will consider
how access might be achieved, it says.
Dispensing doctors
The White Paper looks at dispensing doctors and
appliance contractors as well as pharmacies. The Government believes
that there are
sufficient grounds to reform arrangements to allow dispensing
doctors to sell over-the-counter medicines. This, it says, will
provide a better service for patients, particularly in relation
to pharmacy medicines.
In addition, the Government proposes that market entry for dispensing
doctors is reviewed. At the moment, eligibility is based on the distance
between a person’s home and the nearest community pharmacy — this
fails to identify the distance travelled when going from home to
the GP and on to a pharmacy, it says.
In addition, some people walk
past a pharmacy to get to their dispensing practice. Both of these
issues could be resolved by considering new control-of-entry equivalent
rules for dispensing practices, for example, the distance between
a surgery and the nearest pharmacy.
The Dispensing Doctors’ Association claims that these proposals
would leave 1,300 dispensing practices across England dependent on
the decisions of contractors as to where they open a pharmacy.
“While
the DDA fully supports the role of pharmacists and is keen to continue
working in partnership with their complementary profession, our view
is that choice should remain with the patients as to where and from
whom they receive their medicines. In their current form, the proposals
threaten patient choice and risk making redundant thousands of dispensers
working in rural practices,” said David Baker, chief executive
of the DDA.
The Pharmaceutical Services Negotiating Committee is also concerned
about both of the proposals relating to dispensing doctors and
says that further negotiations are needed around rural pharmacy.
However,
its chief executive Sue Sharpe commented that, against the background
of the White Paper, pharmacists are now in a stronger position
if the Government decides to undertake a review of regulations
applying
to dispensing doctors. |
Hospital pharmacy
The Government believes that more joint working between hospital and
community pharmacists is needed. The White Paper suggests that hospital
pharmacists could practise in the community to provide clinical care
closer to where people live or they could support others to undertake
this role.
The clinical expertise of hospital pharmacists should be used to help
create virtual “health community clinical pharmacy teams”,
the Government says.
“The team will bring together the expertise and experience needed to support
people with long-term conditions and provide an overview of medicines
and health-related care across both primary and secondary care sectors.
Such teams can impact on the number of admissions caused by problems
with medicines,” it adds.
Clinical leadership
The Government plans to appoint two new clinical leaders later this
year, who will work directly with the chief pharmaceutical officer to
champion
the development of pharmaceutical services and to help implement
the White Paper. One will focus on community and primary care and the
other
on hospitals; a key part of their roles will be to
encourage seamless care between the two sectors.
Pharmacy education
The White Paper highlights the need for clinical experience to be incorporated
into the undergraduate MPharm curriculum to ensure that pharmacists
have the clinical, professional and leadership competencies that will
be demanded in future. It points out that the bulk of pharmacists’ clinical
training currently takes place during the preregistration year, with
limited opportunity for students to develop a professional, patient-focused,
clinical approach to practice to complement their scientific training.
The Government, working with all relevant parties, will begin planning
to ensure that there is meaningful clinical experience throughout the
undergraduate course, possibly by integrating the degree course with
the preregistration year.
It will also seek to ensure that an appropriate
funding framework is in place to deliver the new programme and that
there is sufficient capacity in the academic workforce and an appropriate
infrastructure
in clinical practice to provide high quality
education, the White Paper says.
Health research
The White Paper makes several proposals to support
research and innovative pharmacy practice. Chief pharmaceutical
officer Keith Ridge will
set up an expert panel to advise on research priorities and
feed them into the National Institute for Health Research prioritisation
process.
The White Paper says that the evidence underpinning the value
of pharmacy services is patchy. Since future commissioning
decisions
will be based on sound evidence of improved health outcomes, further
research is needed. The Government intends to explore how it can
create a framework to evaluate pharmacy services, which is likely
to focus on six key areas:
• Patient and public perceptions and satisfaction
• Impact on care and outcomes
• Quality of service provision
• Value for money
• Impact on workload and flow
• Pharmacy staff attitudes |
Structural changes and levers
The Government suggests a number of structural changes and levers to
enable the White Paper proposals to happen. These include new directed
enhanced services that encourage providers to invest, strengthening
and
refocusing commissioning to more clinical services and action to tackle
poor performance.
Proposals for revising 100-hour pharmacy exemptions
are also put forward. These suggested structural changes and other key
proposals will be consulted on this summer (see news
p423).
The White Paper emphasises that an important part of developing the proposed
services will be to identify secure and appropriate funding streams. “It
is recognised that PCTs must be able to ‘own’ these new services.
With different contracting options, funding may require different approaches
depending on the types of services to be commissioned,” it says.
The Government has identified a range of payment options for services
within the current contract, which it says can be applied as appropriate,
including fees set nationally, fees set within a range to give the PCT
better control and reward those who deliver higher levels of service,
and fees set locally.
It is exploring the future development of tariffs
for community-based health services, which it says would support greater
transparency and consistency in commissioning arrangements. “In
future, the payments for some enhanced services could reflect these tariffs,” the
White Paper says.
Future payment mechanisms to fund the proposed new services will be part
of this summer’s consultation. |
The
Pharmaceutical Journal