Tomorrow's Pharmacist October 1999 p43-45
Edited by Pamela Mason

Community pharmacy

Community and hospital pharmaceutical services

By Patricia Stone, MRPharmS, MCPP

You will probably spend some time working in either a community pharmacy or a hospital or both. This article explains how pharmaceutical services in both these sectors are organised in England.

Community pharmaceutical services

Community pharmaceutical services refers to the services provided by community pharmacies - known under the Medicines Act as retail pharmacy businesses. Found in every high street and often instore in supermarkets, some are also situated within or adjoining health centres. Under the provisions of the Medicines Act 1968, the sale of Prescription Only Medicines (POMs) and Pharmacy (P) medicines and their supply on National Health Service (NHS) or private prescriptions may take place only in a pharmacy registered with the Royal Pharmaceutical Society of Great Britain under the personal supervision of a pharmacist.
Many community pharmacies form part of multiple chains, which may be household names; their pharmacists are employees of the company. Alternatively, a company may own a few pharmacies, while some independent pharmacies are owned by a pharmacist who manages it him or herself. Pharmacy companies must employ a designated superintendent pharmacist, who in law is responsible for managing those parts of the business concerned with the supply of medicines.

Local pharmaceutical committees (LPCs)
Local Pharmaceutical Committees were set up under the NHS Act 1977 to represent the interests of pharmacy contractors in each area by negotiating local issues with the health authority (HA). They have either nine or 15 locally elected members, including both independent contractors and employee pharmacist representatives. A levy is paid by all the local contractors to pay the committee's expenses (eg, the funding of a full or part-time pharmacist secretary).

NHS dispensing
To dispense NHS prescriptions, a pharmacy must hold a contract with the local HA. Without such a contract, only private prescriptions may be dispensed. If an application for a contract is received from a new pharmacy (eg, in a new supermarket), the HA, in consultation with the LPC, has to consider whether it is necessary or desirable in that location. If it decides that the area is already adequately served by existing pharmacies, a new contract will not be granted. Sometimes the owners will be able to purchase the existing contract of a nearby pharmacy, and the HA will permit this minor relocation.
In rural areas, there are special rules because the situation is complicated by the presence of dispensing doctors who may be contracted to dispense for their own patients if they live more than one mile from a pharmacy. The HA has to publish a pharmaceutical list of persons providing pharmaceutical services; this also includes contractors for surgical appliances and oxygen concentrators.

NHS terms of service
The holder of an NHS contract must comply with the terms of service set out in the NHS (Pharmaceutical Services) Regulations 1992. In summary, the key points cover:

• The opening hours of the pharmacy
• Supply of pharmaceuticals, dressings and surgical items
• Prescription charges and exemptions
• Additional pharmaceutical services.

The opening hours of the pharmacy This is normally a minimum of 30 hours per week, spread over five working days between the hours of 9am and 5pm. In addition, the HA has to determine what is needed and pay for additional pharmacist access services (formerly rota services) to cover Sundays, Bank Holidays, and urgently required prescriptions outside normal opening times.
Supply of pharmaceuticals, dressings and surgical items All valid prescriptions for drugs that are presented must be supplied with reasonable promptness. The provision of medicines has to be by, or under the direct supervision of a pharmacist. This is in addition to the supervision required by the Medicines Act. Where branded drugs are prescribed, no generic substitution is allowed. NHS prescriptions may be written by doctors in general practice (GPs), hospital doctors, dentists and certain community nurses and health visitors. Dentists and nurses may prescribe only items from their own prescribing formularies.
The prescribed quantity of drugs must be supplied, and dispensed medicines must conform with stated quality standards (eg, as specified in the British National Formulary or the Drug Tariff). Doctors may also prescribe surgical dressings and surgical equipment (eg, insulin syringes), but only items which are listed in the Drug Tariff.
Prescription charges and exemptions Contractors are responsible for collecting the statutory prescription charges and for monitoring exemptions. Those who detect and prevent attempted prescription fraud are eligible to receive a reward which may range from £10 to £20,000, according to the amount of NHS money saved and the number of contractors involved.

Additional pharmaceutical services
The terms of service provide for contractors to offer additional services as follows:

• In each area, designated pharmacies stock and deliver oxygen cylinders and related equipment, when prescribed for short-term use.
• The HA can also make contracts for the provision of advice about medicines to care homes, including ordering, effective drug administration methods and safe and appropriate storage. Records of visits to the home must be kept.
• Contractors are expected to maintain patient medication records for elderly or confused patients on long term medication. This is one of the criteria for the receipt of the professional allowance. There is an approved postgraduate qualification for undertaking this service.

Remuneration
At the end of each month, completed NHS prescriptions are sent to the prescription pricing authority (PPA), where the payments due to the contractor are calculated according to complex regulations set out in the Drug Tariff. The Department of Health determines what the various fees should be - and also any changes in the terms of service - in national negotiations in which the contractors' interests are represented by the Pharmaceutical Services Negotiating Committee (PSNC). In addition, contractors who submit for payment 1,600 or more prescriptions per month receive a professional allowance (£1,380 per month in 1998/99), provided that certain qualifying conditions are met. There are reduced allowances for contractors with smaller prescription numbers. Fees for additional pharmaceutical services are determined by the local HA.

GP prescribing support
Prescribing data are issued to all GP practices to enable them to audit their prescribing, and to promote cost effective drug usage. Increasingly, pharmacists work with local GPs, advising on clinical issues, assisting in analysing prescribing, and developing practice prescribing policies.

Other pharmaceutical services
A number of other services (see Table 1) may be offered by pharmacies outside the NHS, either free as a professional service, or paid for by the client. Quality standards for some of these services will be found in 'Medicines, Ethics and Practice' published by the Society

Hospital pharmaceutical services

For a typical NHS trust offering a full range of hospital services centred on a district general hospital (DGH), the pharmacy will need about 10 - 15 pharmacists and 30 - 40 supporting staff including pharmacy technicians, ancillary workers and secretarial staff. The staff are employees of the NHS trust managing the hospital. There are nationally negotiated salary scales and conditions of employment, but increasingly trusts are negotiating local pay deals. It is rarely practical or cost effective to have a pharmacy in smaller hospitals, which usually receive their service from the nearest DGH, or alternatively purchase a service or specialist elements of it, from a neighbouring trust. Some hospital pharmacists are attached to specialist units or directorates within the trust; their role is to give specialist pharmaceutical advice (eg, clinical haematology and cancer services pharmacists).
Hospital pharmacies maintain an on-call rota of pharmacists available to attend the hospital out of hours to supply urgently required items. Alternatively, some hospitals run a residency scheme. Some hospital pharmacies are registered with the Royal Pharmaceutical Society, and others have their production units licensed by the Medicines Control Agency to the same quality standards as commercial manufacturing units.

Dispensing
This forms a large part of the work of the pharmacy. A hospital pharmacy may dispense 100,000 - 200,000 prescriptions annually, including discharge medications, items for inpatients and outpatients and weekend leave items. After prescriptions have been checked by a pharmacist, pharmacy technicians dispense the items, and in some hospitals specially trained technicians perform final checks on the accuracy of dispensing.

Preparative services
Undertaken in specialist areas, preparative services would include extemporaneous preparation of non-sterile products and sterile items such as intravenous infusions and cytotoxic preparations. Small scale manufacture of stock items, sometimes for sale to other pharmacies, may also be undertaken. Quality assurance staff work in close liaison with production staff to ensure that standards are maintained; they are also responsible for the quality of medical gases used by the hospital.

Stores
A large DGH pharmacy will receive three to four tons of pharmaceuticals per week, including intravenous fluids and irrigations, and will have a stores organisation capable of ordering and receiving 20 - 30 deliveries daily from wholesalers and manufacturers. This department often also deals with stock drug distribution to on- and off-site wards and departments. Most drugs directly administered in wards, departments and clinics are issued as bulk stocks, rather than being dispensed and labelled for individual patients. This would include orders for Controlled Drugs. In a DGH, this could mean processing over 100 CD orders each week.

Clinical pharmacy services
Clinical pharmacy services are provided by pharmacists who visit wards on a regular schedule, where they monitor prescription charts, arrange for the supply of non-stock medications, and generally offer pharmaceutical advice. Clinical pharmacists often have, or are studying for, a higher qualification - an MSc degree or a certificate in pharmacy practice. In some hospitals, clinical pharmacists attend consultant ward rounds. Further clinical services might include taking medication histories when patients are admitted, preparing patients for discharge, for example, by monitoring self medication schemes and by counselling in the use of discharge medicines.

Information services
Information services are centred on the drug information centre, where specialist staff answer queries from doctors, nurses and pharmacists - from both the hospital and the community. Some centres also handle queries from the public. Other activities may include publishing the hospital formulary, preparing new drug bulletins and briefing documents for hospital committees such as the Drug and Therapeutics Committee. The pharmacy will also prepare financial and drug usage information for the medical and nursing and management accounting staff of the hospital.

Ms Stone is a pharmacy management consultant

Tomorrow's Pharmacist is an annual publication produced within the editorial department of The Pharmaceutical Journal