Department of Health

Room 528/9

Richmond House

79 Whitehall

London

SW1A ONS

25^{th May 2004}

^{Dear Consultation Team}

^{Choosing Health: A Consultation on Action to Improve People’s Health – how community pharmacy can help}

^{The National Pharmaceutical Association (NPA) represents the vast majority of community pharmacy owners in the UK. We have, in voluntary membership, virtually all pharmacy owners except for Boots the Chemist. The 11,000 pharmacies we represent have always played a key role in promoting, maintaining and improving the health of the communities they serve.}

^{Community pharmacists are based in the heart of local communities – in rural as well as deprived inner city areas, in town centres and suburbs – and they gain a particular understanding of the needs of their local population through daily interactions with the public. Community pharmacy staff are well trained, come from the local community and hence can engage effectively with the local community. Community pharmacists are often patients’ first point of contact, and for some their only contact, with a healthcare professional. The public does not need to make an appointment to visit a community pharmacy. Any member of the public can walk in off the street and advice is available from a healthcare professional or, in the first instance, an appropriately trained member of staff.}

^{By being situated in the heart of neighbourhoods, community pharmacists can make a real difference to improving the health of local communities and this contribution should not be underestimated. Research shows that in small communities, three core businesses make the difference between a viable business community and one that fails. The three businesses are a health centre, a pharmacy, and a source of cash (most often provided by a post office). Where these three are present, business communities are stable and grow, and so are able to contribute to improving people’s health. If any is absent, the business community declines, with an associated reduction in health and well-being for local}

^{people. It is therefore essential that community pharmacies remain at the heart of local communities. The relocation of a GP surgery, and the subsequent closure of the local pharmacy, may be the death knell for local shopping access.}

^{Community pharmacy has much to offer in helping to improve people’s health but is currently underutilised by the NHS. As you know, this underutilisation has been recognised in a number of key policy documents. For example:}

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2. ^{Tackling Health Inequalities: A Programme for Action states that there should be improved access to primary care services in currently under used areas, by e.g. making greater use of community settings and services including community pharmacy.}
   
   
   
   
   
   
   



3. ^{A Vision for Pharmacy in the New NHS foresees an expanding role for community pharmacies as ‘places where patients are able to access readily an increasing range of healthcare services….and as a resource for improving health and reducing health inequalities, especially for vulnerable and deprived populations’.}
   
   
   
   
   
   
   



4. ^{Securing Good Health for the Whole Population states that the role of community pharmacists will need to be developed to expand overall capacity in the management of chronic conditions and to take the pressure off traditionally skilled people.}
   
   
   
   

^{Finally, we understand that the Department is particularly seeking practical suggestions on ways in which public health can be improved, and examples of services that are already working well to fulfil this role. We hope you find the examples of existing services that involve community pharmacy in appendix 1 useful.}

^{Practical steps that could be taken to ensure that community pharmacy is actively engaged in the public health agenda and hence becomes better utilised by the NHS include:}

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2. ^{Ensuring that pharmacies that are located in deprived neighbourhoods are supported so that they do not become non-viable with the development of one stop centres and the proposed change in control of entry regulations. A requirement for PCTs to include a long term strategy for community pharmacy premises in strategic service delivery plans (SSDPs) would facilitate this. This could be supported by the development of CHAI performance indicators around the inclusion of a long term community pharmacy strategy in the SSDP.}
   
   
   
   
   
   
   



3. ^{Making it a requirement for overview and scrutiny committees (OSCs) to consult or work with local pharmaceutical committees (LPCs) when considering local health issues.}
   
   
   
   
   
   
   



4. ^{Ensuring that community pharmacy becomes an integral part of Local Strategic Partnerships.}
   
   
   
   
   
   
   



5. ^{Encouraging the Health Development Agency and the National Primary Care Development Team to engage more actively with community pharmacy, to consider the role of community pharmacy when writing their guidelines, and to spread examples of best practice.}
   
   
   
   

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2. ^{Ensuring that PCTs have sufficient resources to support the implementation of the new community pharmacy contract locally and particularly to develop local enhanced services. The new contract for community pharmacy will be an important vehicle for delivering public health services.}
   
   
   
   
   
   
   



3. ^{Making support and funding streams in deprived areas available to community pharmacy, e.g. from the Neighbourhood Renewal Unit, New Deal for Communities and Sure Start.}
   
   
   
   

^{If you would like to receive a fuller briefing on any of the points that we have raised please contact us by emailing c.jones@npa.co.uk or telephoning 01727 858687 ex3376.}

^{Yours sincerely}

^{Claire Jones}

^{Assistant Head of NHS Service Development}

^{Appendix 1}

^{Examples of existing community pharmacy services that improve the health of the local community}

^{Health inequalities}

^{Sutton and Merton PCT}

^{Merton Horizon Health Living Centre}

^{Specially trained and accredited community pharmacists in Merton run a holistic lifestyle health care management programme for individual clients who attend three community centres as part of the Merton Horizons HLC. Many of these clients, who are residents of the estates surrounding the three community centres, have complex and multiple health needs as well as social problems. The ethnic mix is diverse and clients include all age ranges, from young single mums to older people and people with disabilities and long term illness.}

^{The objectives of the service are}

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2. ^{to improve knowledge of and compliance with medication}
   
   
   
   
   
   
   



3. ^{to increase take-up of screening, and identification of diabetes, cholesterol, blood pressure and hypertension}
   
   
   
   
   
   
   



4. ^{to provide smoking cessation advice and treatment}
   
   
   
   
   
   
   



5. ^{to introduce sustainable lifestyle changes}
   
   
   
   
   
   
   



6. ^{to reduce the demand on primary and secondary care}
   
   
   
   
   
   
   



7. ^{to reduce the number of "information-only" appointments with GPs}
   
   
   
   
   
   
   



8. ^{to establish clear referral pathways to other projects within Merton Horizons.}
   
   
   
   

^{Services available include screening for diabetes, cholesterol, blood pressure and hypertension, smoking cessation, pharmaceutical advice sessions, the provision of information and advice and referral back to the GP when appropriate. A referral system has also been developed from social services, the acute sector and other agencies.}

^Contact

^{Dinesh Patel, Merton Sutton and Wandsworth LPC Secretary. Email mswlpc@compuserve.com.}

^{Smoking cessation}

^{Harrow PCT}

^{Smoking cessation service}

^{Community pharmacists in Harrow provide counseling, support and the provision of NRT to people wanting to quit smoking. The patient group direction for NRT covers everyone within the product license and other high risk groups – pregnant women, young people 16 and over and those with CHD. Community pharmacists also outreach the service to large employers and the local hospital. The service is community pharmacy led and from April GPs no longer prescribe NRT on NHS prescription.}

^Contact

^{Riaz Esmail, PEC Pharmacist. Email Riaz@fairviewpharmacy.co.uk.}

^{East Kent}

^{Smoking cessation counselling by community pharmacists}

^{The aim of this service is to ensure clients who are supplied with NRT by the NHS receive appropriate counselling and support. Clients are referred by the GP surgery using a standard referral form. Smoking cessation counselling is provided by pharmacy staff who have undertaken level 2 training, and a 12 week supply of NRT is provided.}

^Contact

^{Stuart McMillan, Kent LPC Chief Officer. Email kentlpcs@aol.com}

^{Community pharmacy minor ailment schemes}

^{Community pharmacy minor ailment schemes}

^{There are numerous successful community pharmacy minor ailment schemes in England. The introduction of community pharmacy minor ailment schemes has been proven to transfer minor ailment consultations from general practice to community pharmacy which allows GPs to treat patients with more appropriate needs. A community pharmacy minor ailment scheme is where the community pharmacist supplies medication on the NHS (from a limited formulary) free of charge to patients who do not pay prescription charges. Therefore, the payment barrier is removed encouraging more patients to consult with their pharmacist rather than with their GP for minor ailments. For example:}

^{Further information}

^{Implementing a community pharmacy minor ailment scheme: a practical toolkit for primary care organisations and health professionals. National Pharmaceutical Association, Keele University, Northumberland, Tyne & Wear SHA. 2003.}

^{Available at www.npa.co.uk/minorails.}

^{Eastern Hull}

^{In Eastern Hull the minor ailment scheme is aimed at children aged 3 and under who live in a socially disadvantaged area. It is a collaborative scheme run in partnership by Sure Start Noddle Hill, East Riding and Hull LPC and Eastern Hull PCT. The drivers to establish this scheme came from the LPC and Sure Start to improve the health of young children in this area. The scheme particularly focuses on parental education to increase parent’s confidence and ability to self medicate for their children.}

^Contact

^{Graham Hill, Professional Development Pharmacist, East Riding and Hull LPC. Email ghill@tinyworld.co.uk.}

^{Drug misuse}

^Berkshire

^{Management and treatment of substance misuse}

^{The Berkshire four-way agreement is a shared care scheme operating between the substance misuse patient, the substance misuse key worker, the general practitioner and the community pharmacist.}

^{The community pharmacist has a key role in providing supervised consumption and shared care, and also in helping track patients and monitor outcomes.}

^{Further information}

^{www.berkshire.nhs.uk/mentalhealth/professional/substance_misuse.htm.}

^{Sheffield Local Pharmaceutical Committee}

^{Co-ordinated pharmacy services for drug users}

^{This service involves supervised consumption and support to patients collecting their dispensed prescriptions for methadone and other drugs used in the management of drug misuse. The service also provides a syringe and needle exchange scheme for injecting drug users and advice on harm reduction methods and the supply of condoms.}

^{Further information}

^{www.sheffieldlpc.demon.co.uk/cpsdu.html}

^{Collaborative working with local schools}

^{Prentis Pharmacy, Streatham}

^{Work experience scheme}

^{For the past 5 years the pharmacy has had students doing their GCSEs come to pharmacy for 2 weeks work experience. The aim of the work experience is to teach the students how to deal with the public, how to work as part of a team, learn about the procedures in a pharmacy and how to deal with medication in a safe and appropriate manner. The work experience also aims to teach the students the dangers of drug misuse largely through one-to-one sessions with drug misusers in the pharmacy. At the end of the work experience the students produce a written personal statement for the school on what they have learnt. These statements have particularly shown that the students’ eyes are opened to the dangers of drug misuse.}

^Contact

^{Vipul Patel, Prentis Pharmacy. Telephone 0208 677 3145.}

^{Sexual health and teenage pregnancy}

^{Lambeth, Southwark and Lewisham}

^{Emergency hormonal contraception}

^{Within Lambeth, Southwark and Lewisham, clients can obtain emergency contraception from GP surgeries, family planning clinics, Brook advisory clinics, hospital A&E and genito-urinary medicine departments, minor injury units and local community pharmacies. The community pharmacists provide emergency hormonal contraception as a free NHS service, under patient group direction.}

^{Further information}

^{A timely service: A LSL HAZ project on access to EHC via accredited community pharmacies. Available at www.lslhaz.org.uk/emergency_contraception_report.pdf.}

^Contact

^{Beth Taylor, Specialist Principal Pharmacist, Community Care London/South, based at Southwark PCT. Email Beth.Taylor@southwarkpct.nhs.uk.}

^{Manchester, Salford and Trafford}

^{Emergency hormonal contraception}

^{Accredited community pharmacists in the Manchester area supply EHC as a NHS service under patient group direction. Clients have a 10-minute consultation with the pharmacist, who keeps a detailed record, facilitated by a written proforma to ensure appropriate questioning. At the end of the consultation, the proforma is signed by the client and the pharmacist. Where appropriate, the pharmacist supplies EHC free of charge, under patient group direction, with suitable advice.}

^Contact

^{Karen O'Brien, Associate Director Chronic Disease Management & Medicines Management, Central Manchester PCT. Email karen.obrien@centralpct.manchester.nwest.nhs.uk.}

^{Mental health}

^{South Derbyshire}

^{Compliance, concordance and the revolving door of care}

^{In South Derbyshire community pharmacists made joint domiciliary visits with community mental health team key workers to older people with mental health problems. The pharmacist reviewed medication regimes, counselled patients on the use of medicines and developed a pharmaceutical care plan.}

^{This service has now expanded to include any patient who has problems taking or managing their medicines. It is funded by all 5 PCTs and is called The Southern Derbyshire Medicines Support Service. Twenty community pharmacists have completed training, including an MSc module on the pharmaceutical care of older people.}

^{The assessing pharmacist contacts the regular dispensing pharmacist and GP for details of current medication and major medical history. A domiciliary visit is made to the patient, including the carer or referrer, if appropriate. Joint visits are made with the key workers for mental health patients, and with learning disability nurses for their patients. The visit includes a full medication review (including OTC medicines), an assessment of the patients needs and a discussion concerning the medicines based on the principles of concordance, in order to develop an individual, tailored pharmaceutical care plan. Any clinical interventions are suggested and compliance issues are addressed (examples include reminder/tick charts or compliance aids). A copy of the care plan is given to the patient or carer, referrer, dispensing pharmacist and a letter is sent to the GP. This is a busy service and over 1,500 referrals have been received to date.}

^Contact

^{Diane Harris, Community Pharmacy Adviser, Amber Valley PCT. Email diane.harris@amberValley-PCT.nhs.uk}

^Richmond

^{Pharmaceutical support to mental health patients}

^{In Richmond community pharmacists provide care for patients with mental health problems, following the closure of the Richmond Royal hospital pharmacy. The scheme enables patients to receive a treatment plan designed specifically for them which may}

^{include, for example, monitored dose systems or instalment dispensing at pre-agreed intervals. A rapid response system enables community pharmacists to access consultants or nurse specialists, should additional care, advice or compliance issues need to be discussed.}

^Contact

^{Terry Silverstone, Kingston Richmond and Twickenham LPC Secretary. Email TPSCPS@aol.com.}

^Diabetes

^{Green Light Pharmacy, Camden}

^{Diabetes services to the Bangladeshi population}

^{This LPS focuses on providing services outside the four walls of the pharmacy. It provides outreach services in a wide range of community settings focusing mainly on the Bangladeshi population with Type 2 diabetes. The service includes a review of patients medication, monitoring of blood sugar, cholesterol and blood pressure, and group education sessions. There is also an emphasis on lifestyle advice and a structured approach to behavioral change in the attainment of healthier lifestyles.}

^Contact

^{John Foreman, Green Light Pharmacy. Email john.foreman@lineone.net.}

^{Hillingdon PCT}

^{Diabetes management in primary care}

^{This service is delivered through community pharmacies in Hillingdon PCT. The service is available to all adults, taking medication for their diabetes, residing within Hillingdon PCT. Each patient has a consultation with the pharmacist on at least 6 occasions in a 12-month period. Pharmacists measure each patient’s blood glucose, blood pressure, HbA1c and cholesterol level. Pharmacists agree referral criteria with GPs and refer patients to them when monitoring parameters fall outside the target range, or there are other problems (e.g. intolerable side-effects) that cannot be resolved in the pharmacy.}

^{Further details}

^{www.medicines-partnership.org/projects/current-projects/diabetes-programme.}

^{Barnet PCT}

^Screening

^{Specially trained community pharmacists in the Barnet assess selected patients and offer them blood pressure monitoring and urine testing with the aim of identifying undiagnosed hypertension and/or diabetes. When appropriate, patients are referred to their GP. The service is based on an earlier pilot held in North Barnet.}

^Contact

^{Michele Bubb, Pharmaceutical Adviser, Barnet PCT.}

^{Email michele.bubb@barnet-pct.nhs.uk.}