The National Pharmacy Association has in voluntary membership all of England’s 10,500 community pharmacies. The pharmacies we represent provide a range of healthcare services to the public, from dispensing NHS prescriptions through to treatment of minor ailments, health promotion and support for managing long term conditions. We are pleased to provide initial comments to the next stage review of the NHS.
Community pharmacy and the pharmacy profession in general have evolved substantially over the past 5-10 years. The community pharmacy contractual framework increases the focus on quality of service and on cognitive roles, and new professional powers such as independent prescribing and the ability to work as a practitioner with a special interest will enhance community pharmacy’s offering to the NHS.
We would like to comment on a number of areas that need addressing to ensure the greatest range of services and choice from community pharmacy.
Getting maximum value from the community pharmacy network
The current network of community pharmacies provides the general public with ready access to a healthcare professional – in a variety of locations from village setting to community shopping parade, high street location and retail complex. As well as facilitating easy access for patients to their prescribed medication, this supports self care, offers patients the chance to consult a healthcare professional outside normal working hours and provides opportunities for promoting public health.
Unfortunately, certain developments in primary care estate threaten to undermine the potential of community pharmacy expanding its role to contribute to the attainment of key NHS targets. In some cases, they may even lead to pharmacy closures and a knock-on impact for other community services. One factor is the development of one-stop primary care centres (and other co-located facilities) without reference to existing networks of care. For example, polyclinics could dislocate the existing accessible, community-based network of pharmaceutical care. This presents a real threat of some neighbourhoods becoming ‘health deserts’, with neither GP nor pharmacy services in the places that people live, work and shop. On the other hand, a well designed hub and spoke model of provision, with neighbourhood pharmacies providing a range of access-critical services could significantly enhanced healthcare.
Ensuring momentum for an expanded role for pharmacists
The contractual framework for pharmacy should be enabling of pharmacy service expansion and provide appropriate rewards for quality of service as well as volume of supply. Well established and already widely commissioned services, such as NHS minor ailments schemes and numerous public health services should be drawn into the essential and advanced tiers of the contract – and commensurate remuneration guaranteed – so that service users in all areas across the country can enjoy benefits.
This point has been echoed by the All Party Parliamentary Pharmacy Group, in its report on ‘The future of pharmacy’. The group called for more services to be specified and funded nationally and made available from pharmacies in every PCT.
Meanwhile, dispensing medicines should remain the principal essential service in community pharmacy. The accurate and timely supply of prescribed medicines is the backbone of the community pharmacy service and improves safety. The dispensing process provides the opportunity to build close relationships with service users – to the great benefit of all concerned – and also a platform on which to set other services. Community pharmacy buying practices also drive down costs of drugs, for the benefit of the NHS.
Establishing a level playing field between providers
The advent of contestability in the England primary care market will provide patients with greater choices about how they access services. But the potential for pharmacy based services (and the benefit the public will gain from them) will not be realised unless pharmacists are treated equitably by commissioners in relation to other would-be service providers. Current evidence suggests this is frequently not the case.
We believe the guidance produced by Primary Care Contracting around multi-professional involvement in practice based commissioning defines the exemplar practice around engaging and getting best value from all health professions in practice based commissioning. We have received anecdotal reports that guidance is being ignored as the pressure of achieving universal coverage of PBC mean concerns around stakeholder involvement are being considered ancillary.
We therefore suggest that genuinely inclusive PBC governance structures are mandatory and that their implementation is robustly monitored. Only then will the skills and expertise of all those who work in, with and for the NHS be effectively marshalled.
Better integrating community pharmacy within the NHS
It is important that health services should be responsive to patient need and ‘seamless’ from the patient’s point of view. To achieve this, community pharmacists and other primary care practitioners must strive to overcome bureaucratic and professional boundaries where they are a hindrance, such that multidisciplinary working becomes a habit and a norm.
There are many good practice examples emerging, especially around the management of long term conditions. We wish to highlight that pharmacists in some areas are beginning to work more closely with community matrons to deliver medicines-related support to patients in their care.
Geographical distinctness from GP surgeries and health centres continues to present challenges to collaborative working between community pharmacists and other healthcare professions. And yet the position of community pharmacists in high streets and local communities is vital if community pharmacy’s potential for contributing fully to the NHS agenda is to be fully realised. A vital factor in alleviating this problem is to connect community pharmacies electronically to other healthcare providers.
Community pharmacists need to be provided with full role-based access to the NHS intranet and the electronic care record when it emerges – within the bounds of patient consent. Connectivity and integration is necessary if pharmacy is to expand its range of services in a manner that is safe and convenient for patients. This is perhaps especially the case with services that involve pharmacist prescribing. Current essential and advanced pharmacy services, notably repeat dispensing and MUR, would also be improved by pharmacist access to more patient information and simplified communication with general practice.
To encourage collaborative working between GPs and community pharmacists, consideration should be given in the future to linking the two contracts in some way so that there is some interdependence on service delivery.
Conclusion
Enlightened commissioners will be receptive to pharmacists’ proposals for services that help people avoid expensive, hospital-based ‘reliant care’ – for example medicines management, near patient testing, integrated (with A+E) pharmacy minor ailments schemes, and out of hours medicines supply. The really imaginative commissioners might also see the potential for pharmacists with a special interest taking on elements of dermatology, sexual health, pain management and substance misuse services currently often delivered in secondary care.
Some PCTs have already made use of community pharmacy in particularly innovative ways, for example:
Smoking cessation clinics
Sexual health clinics – screening and treatment of Chlamydia and provision of emergency hormonal contraception
Flu vaccination service
Weight management clinic
Providing health trainer services from a community pharmacy location
Diabetes screening and management services
H Pylori testing
Anti-coagulation monitoring
Expanded commissioning of community pharmacy services would provide better services and greater choice for patients. By supporting the creative use of elements in all three tiers of the community pharmacy contract and by using their commissioning powers, PCTs can help pharmacists to do still more to improve the health and well being of the population.
We hope that we can be involved with the ongoing consultation on the “Next stage review of the NHS”, by providing input to the SHA working groups and the national consultation meetings.
