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Stephen Goundrey-Smith is a pharmaceutical consultant
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The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, deputy editor,
or e-mailed to graeme.smith@pharmj.org.uk for
consideration
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The Government’s long-awaited White
Paper on pharmacy services was published recently, in a blaze
of publicity from the pharmacy press.
It announced a wide ranging raft
of proposals to expand pharmacist roles and, in its pages, a number
of local pharmacy public health initiatives have rightly been publicised
to a wider audience. Not surprisingly, this paper has been welcomed
as a blueprint for the bright future of pharmacy.
Pharmacists with a longer memory might, however, have a curious feeling
of déjà vu. Back in 2005, I scrutinised the provisions
of the new pharmacy contract with the same interest as I now review the
White Paper. Like many pharmacists, I hoped that the new contract would
be the stepping stone for community pharmacists to move towards a clinically
based service that makes the most of pharmacists’ unique expertise
and knowledge base on medicines. Sadly, however, many pharmacists now
acknowledge that the contract has not delivered.
The contract envisaged that, as well as dispensing, pharmacists would
deliver a range of essential services that would enhance their clinical
role, for example,
repeat dispensing, clinical governance, public health, signposting to other healthcare
services and support for self-care.
In addition, there would be the advanced
services of medicines use review and prescription intervention. Moreover, as
a third tier, the pharmacy contract proposed locally commissioned enhanced
services, such as smoking cessation and diabetes screening. However,
time has shown that
these have not been funded universally and consistently by primary care bodies,
leading to considerable local variations in NHS services offered.
The major change to pharmacy practice arising from the new contract, the introduction
of medicines use reviews, has had mixed success. As with other new contract
services, implementation of MUR services has not taken place consistently in
all localities.
On one hand, some pharmacy operators have chosen not to embrace
an MUR service, for a variety of commercial or operational reasons. On the
other hand, MURs,
with their volume-based funding structure, have been seized upon by many
large pharmacy multiples as a revenue stream, and pharmacists have been
under immense
pressure to conduct as many MURs as possible, to the possible detriment of
the efficacy and quality of those reviews.
In addition, some medical researchers
have questioned the impact of MURs on health outcomes and practice research
suggests
that, on only a small percentage of occasions are the recommendations of
a pharmacist MUR taken up by the GP. Overall, therefore, it might be
argued that
pharmacists’ aspirations
to a clinical role have been hindered rather than helped.
In general terms, the White Paper was received warmly. It cites a range
of examples of current pharmacy innovation and makes some optimistic proposals
for the enhancement
of pharmacy services. However, some of these proposals do not bear close
scrutiny, especially for those in the profession who feel they have been
let down by
the pharmacy contract. It should be acknowledged, however, that the White
Paper is
precisely that: a Government White Paper. Its remit is to indicate policy
direction, not set specific terms of service, as a contract would.
To its credit, the White Paper identifies some deficiencies arising from
services under the contract, it also makes proposals to rectify these deficiencies,
for example, the poor take-up of repeat dispensing and the need to refine,
prioritise
and evaluate the provision of MUR services. It also identifies some important
issues in community pharmacy practice where there is an urgent need for
progress, for example, improvement of interprofessional relations in primary
care and
the need for high quality, independent pharmacy practice research.
However, the proposals of the White Paper are sufficiently vague, broad
and poorly articulated to raise questions concerning how they will be implemented.
The paper
groups together proposals as diverse as MUR audits, participation of pharmacists
in the vascular risk assessment programme and expanding access to urgent
care, with no explicit common strategy.
The impression created is that
the
Government
is tasking the pharmacy profession with delivering a mixed bag of politically
expedient issues. While some of these initiatives are laudable in themselves,
it is hard to view them as part of an overarching pharmacy service strategy.
Crucially, the White Paper is reticent on
the details of funding for many of these
proposals.
The White Paper calls for a greater collaboration between professions
in primary care, and this will be necessary to support pharmacy’s
proposed role in the management of long-term conditions. Yet, other proposals
in the paper may
serve to bring the medical and pharmacy professions into conflict, for
example, the
proposed reforms to market entry for
dispensing doctors and the proposal to allow dispensing practices to
supply over-the-counter medicines.
Moreover, some of the proposals are clearly out of touch with pharmacy
practice as it is at present. Given the slow progress of the implementation
of basic
electronic prescription
service functionality to date, it is surely unrealistic to propose, at
this stage, that the EPS could be adapted to gather data on pharmacy
interventions concerning
healthy lifestyles, and to support minor ailments services.
Community pharmacists may also wonder what exactly the Government intends
by promoting pharmacies as “healthy living centres” and encouraging
pharmacists to become accredited health trainers. Many will contend that promoting
healthy living is something they have been doing for years without any government
intervention or endorsement.
Yet, the need to roll out pharmacist-led clinical services in the community
has never been more urgent. Despite the various initiatives of the past
few years,and
the pioneering work of a handful of pharmacy innovators around the UK,
community pharmacy practice remains, for the most part, focused on its
supply function.
I have argued previously that the supply function of pharmacy alone
is one that could easily be provided by non-specialist logistics providers.
Moreover,
this
fact lies at the heart of the public’s perception of pharmacy and the pharmacy
profession’s anxieties about its role.
Although the public, the media and politicians continue to perceive community
pharmacists as concerned primarily with the supply of medicines, they
will never see them as anything other than shopkeepers. It is heartening,
though,
to see
that the Government is planning a communications programme to promote
the role of pharmacists and to increase pharmacy use.
Will the White Paper proposals deliver an enhanced professional status
to the pharmacy profession and open the door to a bright future? Or will
it
struggle
to be translated from vision to reality and suffer the fate of being
stifled by commercial agendas, a lack of funding and a lack of engagement
as the
new contract services were? Only time will tell. When is the next general
election? |
The
Pharmaceutical Journal