Tomorrow's Pharmacist October 1999 p39-42
|
Government Ministers are supported by the Department of Health (England - see panel), the Scottish Office and the Welsh Office Departments of Health, and the Northern Ireland Department of Health and Personal Social Services. These departments all include a pharmacy section with a Chief Pharmacist responsible for advising on pharmacy issues and for leading on relevant aspects of policy development. They work closely with the Society, but have no direct control over professional matters. |
|
The Department of Health in England (DoH) is very much a strategic organisation in addition to supporting the work of Ministers. A separate organisation (but within the DoH) - the NHS Executive (NHSE) - handles the day to day running of the NHS. This Executive - whose main office is in Leeds - manages the NHS with the assistance of eight regional offices (RO) across the country.
The main task of regional offices is to monitor the performance of health authorities (HAs) and trusts in meeting their targets as set by the government. The RO agrees an annual contract with each HA and monitors this through an annual review, and also monitors the financial control of trusts. This performance management currently includes a significant interest in the use of medicines, and each Regional Office has a pharmacist appointed to contribute to this process. The eight pharmacists in the RO meet regularly with the Chief Pharmacist of the DH to discuss common issues and policy. All pharmacists should know the name of their own RO and the appropriate pharmaceutical adviser so that they can follow developments affecting their locality.
The day to day management of the NHS in England and Wales is currently carried out at two levels - that of the health authorities and the NHS trusts. In Scotland and Northern Ireland there are some differences in detail (eg, the HA is called the health board), but the functions are broadly similar. However, the introduction of primary care groups (PCGs) with their expected development into primary care trusts is fundamentally changing the arrangements as well as the role of the general practitioner.
There are about 100 HAs in England each responsible for a population of about 500,000. There role is primarily strategic and they must assess the health needs of their population, formulate a strategy to meet these needs, plan for the provision of services for their residents, and most recently and importantly, support the development of PCGs. The HA also has a public health role in matters such as outbreaks of infectious disease. They also manage the contracts for independent practitioners such as GPs and pharmacists.
Virtually every HA or health board has a pharmaceutical adviser. These advisers contribute to medicines issues, to the strategic planning of the authority, and manage the prescribing budget of the HA - sometimes in conjunction with a medical prescribing adviser. In the larger authorities there is often a team of pharmacists reporting to the pharmaceutical adviser to help both in the implementation of strategic issues and also to work closely with GP practices on the control of medicines expenditure.
The pharmaceutical adviser has an important role in many areas of pharmacy practice. Although the pharmacist contract is mainly negotiated at national level, there are an increasing number of elements on which there is local discretion. In Scotland some of these are written formally into the contract. The level of provision of, and the funding for, several services such as out-of-hours cover, oxygen supply and medicines to residential homes is subject to local negotiation, and advisers will make recommendations to the HA in support of its local strategy. They will normally discuss proposals first with the local pharmaceutical committee (LPC), and it is therefore essential that each contractor pharmacist plays an active part in the work of this group as well as keeps an ongoing interest in the plans and strategy of the HA.
Increasingly, if pharmacy is to extend the services it provides in primary care then the link with the HA through the pharmaceutical adviser will be key. The adviser is also an important link in facilitating projects between hospital and community pharmacy such as discharge planning.
The NHS spends about £4,500m a year on medicines - about 10 per cent of which is through hospitals. The main expenditure is therefore generated by the GP. For many years governments have tried to control medicines expenditure, simply because it is transparent, and viewed by the Treasury as the main part of NHS expenditure which is subject to an element of choice. The expenditure has also been increasing in proportion to total NHS expenditure from a steady 10 per cent up until now, when it is about 13 per cent. Various measures have been tried, including most recently making GPs responsible for a cash limited medicines budget.
Until very recently, funding for the NHS has been achieved through two separate votes of Parliament. That allocated for hospitals and community health services (HCHS) has been subject to a cash limit. This means that once the budget is set the service cannot overspend without carrying forward a deficit into the next budget period. Compare this to a monthly salary. If you overspend, you have to take out a loan or spend less in the next month.
The remainder of the NHS funding - particularly that for primary health services such as for GPs - was not subject to such rigorous control. In 1999, however, the government introduced legislation to introduce a unified budget. This has advantages in that money can be transferred from hospital to primary care if that is where the service is best provided (and vice versa) but also has the disadvantage that all GP prescribing will be cash limited.
The pharmaceutical advisers have an important role in helping GPs manage their prescribing budget. They will often work with doctors to analyse their medicines expenditure and make recommendations for improvement. Many of these recommendations will result in decreased expenditure, but this is not always the case as some doctors may in fact be undertreating certain diseases such as asthma and hyperlipidaemia. The advice the adviser can give is often supported by the recommendations of a local medicines or drug and therapeutics committee, and pharmacists in hospital and community practice regularly work together to ensure that such committees have adequate information on which to base their information. Regional or national drug evaluation committees increasingly support local committees, and the government has also introduced the National Institute for Clinical Excellence (NICE) to consider new technologies (including medicines) which may be of national significance.
There are about 400 NHS trusts in the UK and these are responsible for the management of hospital services, community health services, and ancillary services such as ambulances. The trust structure was established in 1991, and although there have been changes to their operation, they still are the foundation of hospital management. They are independent bodies accountable to the Secretary of State, but their performance - particularly regarding financial targets - is monitored by the RO. They will be increasingly monitored with the introduction of clinical governance to improve quality in the NHS. Many trusts are based on acute hospitals, but some include community services or are based on mental health services. Each trust will have a pharmacy service —often on site - and the chief pharmacist has an important role in the control of medicines within the organisation. Like primary care, this will include an element of cost control.
It is important that trust chief pharmacists and their supporting staff work closely with their colleagues in community pharmacy and at the health authority/board. Each has specific skills and knowledge, which can be harnessed to improve patient care and control expenditure. The wider role of pharmacy is not particular to a single area of practice.
PCGs were established in England in 1999 as the latest step in ongoing reforms to ensure that GPs play their full part in the management of a primary care led NHS. They are paralleled in Scotland by local health care co-operatives and in Wales by local health groups. There are differences in the detailed composition and the level of power in each example, and some issues are still to be confirmed by the appropriate devolved parliament/assembly. English PCGs are formally committees of the HA and have certain functions delegated to them. These include improvement of the health of their community, development of primary and community health services and commissioning of secondary care services. It is planned that over time PCGs will become freestanding bodies called primary care trusts. They will then take over the management of the services for their patients from the HA, and there is speculation that at that time the number of HAs will be reduced.
In England, nearly 500 PCGs were established, and each is managed by a board comprising four to seven GPs, two nurses, one social services representative, one lay member, one HA representative, and chief executive. There was some controversy at the time of establishment that there was no statutory place for a pharmacist. Some of these concerns have been reduced over time, as a few PCGs appointed a pharmacist to the board, and most have appointed at least one pharmacist as adviser.
Some pharmacists have been appointed as chief executive of a PCG. These contributions by pharmacists reflect the importance of medicines at this level of health care. It also gives an important indication of the difference between a board level post and an adviser. As a board member the individual has to make decisions on a corporate basis, including dealing with statutory matters referred to the PCG. In other words there is not great freedom to act on behalf on the individual's profession. An adviser - this can be a senior post - has this freedom.
PCG pharmaceutical advisers have functions similar to those described for the HA, but obviously deal with a smaller population base. Their role is no less important, however, because it is at GP practice level that the introduction of a cash limited unified budget will have most effect. In addition, the PCG is different from earlier models of management, such as GP fundholding, in that there is no element of choice on behalf of GPs. All GPs are members of a PCG and must support the management process, including maintaining expenditure within budget.
Because of the local nature of PCGs it is essential that community pharmacists know the detailed arrangements of PCGs in their area. This will include understanding the boundaries, knowing which GP is in which PCG, and knowing which GPs are leaders in the organisation. Leading on from this is the need to have positive communication with the PCG pharmacist adviser. Many of these are being appointed with a community pharmacy background and will be in an ideal position to develop pharmacy services within the PCG. As PCGs become trusts, there is an unrivalled opportunity for pharmacy to play its full role as part of the primary health care team.
Stephen Curtis is director of the unit for health services development, affiliated to the School of Pharmacy, University of London.
The NHS is an extremely public organisation, with an anticipated expenditure of £39,000m in 1999/2000 that is raised through general taxation. As befits expenditure of this magnitude, the NHS is accountable to Parliament, and this accountability is exercised through the Secretary of State for Health and supporting Ministers. The recent devolution Acts have split some of the control, with for example the NHS in Scotland (NHSiS) contributing about 30 per cent of the budget of the new Scottish Parliament.