Tomorrow's Pharmacist (2005)

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What the new contract has in store

Clare Bellingham reviews the overall structure of the new pharmacy community contract

page 60-61

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Community pharmacists in England and Wales are set to have a new NHS contract this year. Contractors voted to accept the new contract late last year (PJ, 27 November 2004, p773) and its implementation is planned for April 2005. (“Pharmacy contract” is used to describe the new contractual framework which, as with the current arrangements, will be national arrangements laid down in secondary legislation.)

Pharmacists’ current contract came into force in 1987 and is now out of step with developments in pharmacy and the NHS. The old contract focused on throughput of a high volume of prescriptions.

The new contract has different aims: it will reward high quality services, harness the skills of pharmacists and pharmacy staff, and provide minimum standards for pharmacy.

Basic structure

Key points 1. Community pharmacists will be working under a new contract from April 2005 2. The new contract is focused on high quality services 3. The new contract is made of three tiers: essential, advanced and enhanced services 4. All contractors will be expected to provide essential services and eventually it is hoped that all will provide advanced services 5. Enhanced services are commissioned locally by PCTs although a national specification for each will be drawn up

The new contract is formed of three tiers: essential services, advanced services and enhanced services.

All contractors will be expected to offer essential services. Advanced services will require accreditation of the pharmacist, the pharmacy premises or both. These two tiers form the national pharmacy contract.

On top is the third tier of enhanced services. Although a service specification and value will be agreed nationally for each enhanced service, these will be commissioned locally by primary care trusts or local health boards.

The contract structure is expected to develop over time, so those services currently classified as enhanced services could be moved to either the essential or the advanced sections of the contract.

Funding for the nationally contracted essential and advanced services has been agreed. In August 2004, the Pharmaceutical Services Negotiating Committee accepted a £1.766bn deal from the Department of Health to fund the contract in England (PJ, 28 August 2004, p277). An announcement on how this sum will be distributed to individual contractors was made in October 2004 (PJ, 30 October 2004, p637). Funding for the contract in Wales will match that of England.

Essential services

There are seven essential services. They must be provided by all community pharmacy contractors and are not open to local negotiation.

First is dispensing. Dispensing covers the supply of medicines and appliances, and the provision of advice about the medicines dispensed and about possible interactions with other medicines. It also includes making a record of what has been dispensed and advice given. The next essential service is repeat dispensing: it will operate along the lines of the repeat dispensing pilots.

Clinical governance is an essential requirement for the contract. Contractors will be expected to ensure that standard operating procedures are used, that adverse incidents are reported to the National Patient Safety Agency, that continuing professional development is undertaken by pharmacists, that services are audited, that patient satisfaction questionnaires are carried out and that interventions are monitored.

Another essential service is in public health. This will include opportunistic one-to-one counselling on smoking cessation and coronary heart disease risk factors, promoting vaccination against influenza and providing education about appropriate use of antibiotics.

Signposting patients to other health care providers is also an essential service. Linked to this is support for self-care; this essential service will include receiving referrals from NHS Direct and provision of advice to patients on treatment of minor ailments, thus reducing burdens on GPs.

The final essential service is medicines waste disposal.

Advanced services

The second tier of the contract is advanced services. In order to provide them, pharmacists will have to be accredited and the pharmacy premises will have to fulfil certain requirements. Although part of the national contractual framework, not all contractors are likely to provide advanced services from day one because of the additional requirements. However, it is hoped that, in time, all contractors will provide advanced services.

There are two advanced services: medicines use review and a prescription intervention service.The medicines use review involves a pharmacist undertaking a face-to-face review with a patient. The review will be concordance-centred and identify any problems the patient has with his or her current medication and then address these problems. It will also examine the patient’s knowledge of his or her medication and help the patient to develop this knowledge. Information will then be fed back to the patient’s GP.

The prescription intervention service is similar to the medicines use review but is initiated differently. Instead of a planned review, the prescription intervention service will be a review triggered by a pharmacist identifying a significant issue with a patient’s prescription.

Enhanced services

Enhanced services will be commissioned locally by primary care trusts. A service specification and value — either in pounds or, like the new GP contract, in points — will be agreed nationally but PCTs will be able to vary these according to local needs.

Because enhanced services are commissioned, how many of them a particular pharmacy provides will be determined by local needs so a definitive list of all the enhanced services pharmacists could offer is impossible to determine. However, some examples of enhanced services that are expected to be commonplace are:

• Minor ailments management
• Smoking cessation services
• Supervised administration
• Anti-coagulant monitoring
• Compliance support
• Care home support
• Full clinical medication review

Scotland Community pharmacists in Scotland will also be getting a new contract soon but it will differ from that in England and Wales. The Scottish contract has two tiers: four core services plus additional locally commissioned services on top. The four core services are a minor ailment service, a chronic medication service, an acute medication service and a public health service. Funding, subject to contractors’ approval, will be a capitation payment for the minor ailment and chronic medication services, a fixed payment for the public health aspect and only the acute medication service will be paid for by prescription volume. This is significantly difference to the England/Wales contract. The new contract will be implemented in 2006 but a transitional phase has already started. Contractors are being paid a fixed sum based on last year’s prescription fees and allowances: the aim is to allow a period of stability in which contractors can prepare for the new contract (eg, adjusting premises and training staff) and is the first step away from payment by prescription volume.

This article is based on one published in The Pharmaceutical Journal (18 September 2004, p385).