Healthcare for London
Response jointly from the London Local Pharmaceutical Committees Forum and the National Pharmacy Association
General
Do you have a view on what works and what doesn’t work at present?
Many Government documents including Our Health, Our Care, Our say, the NHS Plan, and Choosing Health call for an expanding role for community pharmacists, to support the access, public health and long term conditions agendas. Most recently, the Commissioning Framework for Health and Well-being (DH March 07) encourages PCTs to ‘commission more easily accessible, extended self care through the effective use of, among others, community pharmacists….’.
Community pharmacists, like general practitioners, are independent contractors and an integral part of the NHS family.
There are around 1,800 community pharmacies in London situated in high street locations, in supermarkets and in the heart of deprived communities. Many are open when other mainstream health services are not. In London it is estimated that 1.2 million people visit a pharmacy every day. This is an unrivalled level of contact with the public among health care professionals.
All pharmacies have practising pharmacists, pharmacy technicians and other support staff providing a wide range of accessible services to people who are well, in addition to those in poor health. This means pharmacists and their staff can effectively promote health to a wide section of London’s population, as well as commuters and tourists and detect health and social problems early on. Pharmacists have a role to play throughout people’s lives – mothers with young children and older people being the biggest users of community pharmacy.
Of all health professionals, pharmacists have the most comprehensive education and training in the use of medicines for the prevention and treatment of disease. From this base pharmacy is growing into the provision of a wide range of primary care services – encouraged by the community pharmacy contractual framework that rewards quality services, and new professional powers, such as the ability to independently prescribe medicines.
All three tiers of the community pharmacy contractual framework provide opportunities to support the ambitions of Healthcare for London: ‘Essential’ services, which all pharmacies are expected to provide, such as support for self care, signposting and advice on health living, can improve health and reduce demand on local services. Pharmacists managing repeat medication through repeat dispensing can free up GPs to treat patients with more serious conditions, who might otherwise have been referred to hospital. Through medicines use review (an ‘Advanced’ tier service), pharmacists can identify problems that people may have with their medicines usage and help resolve them before they become serious, preventing unnecessary hospital admissions. The ‘Enhanced’ service tier enables pharmacists to be commissioned to supply NHS services such as minor ailment schemes and a wide range of public health services including smoking cessation, emergency hormonal contraception and substance misuse support. While there are examples of successful schemes in London, there are still locations in which pharmacy is not delivering such services within the NHS. In addition, the types of services that could be part of radical service re-design within the development of patient pathways – including point of care testing, hospital follow up and the management of long term conditions, although popular where they do exist, are still scarce. These are the types of services that would enable community pharmacists to play a considerable part in patient pathways that are more convenient to users.
What key changes would you like to see?
More creative use of community pharmacy
By supporting creative use of elements in all three tiers of the community pharmacy contract, PCTs can help pharmacists do more to improve the health and well being of Londoners. To illustrate: part of a patient pathway for people with asthma, might include monitoring and self care at the pharmacy or blood pressure monitoring at the pharmacy for those with hypertension. People with long term conditions could, as part of their patient pathway, visit their local pharmacist for testing, monitoring and review of their condition, medicines management and care co-ordination. Their pharmacist would also be able to detect and recognise any deterioration in their condition and refer them appropriately for further support.
Primary Care Contracting is in the process of updating its ‘Strategic Tests’, which help PCTs calculate the extent to which they are utilising the community pharmacy contract to meet key DH targets. SHAs can also use this as a tool for holding PCTs to account in respect of community pharmacy service development. We would like to see the London SHA and PCTs using such tools to benchmark their performance, as part of a continuous drive to increase investment in, engagement with and integration of community pharmacy services.
What do you think would help to make these changes happen?
Engagement with local pharmacy leaders
Community pharmacy needs to be seen as a key player, working collaboratively with other partners to develop local patient pathways. To this end, PCTs should work with local pharmacy leaders, such as the Local Pharmaceutical Committees and, where they exist, PEC pharmacists and local pharmacy development groups, to ensure dialogue. Supporting people with long term conditions to self care: A guide to PCTs in developing local strategies and good practice (DH, 2006) recommended as a key action for PCTs ‘to work with your LPC to ensure that community pharmacists are using the new contractual flexibilities to support self care and medicines management’. In London, there is already fruitful dialogue in some places, plus fora for pan-London discussions between commissioners and pharmacy providers.
Latest guidance on practice based commissioning (PBC: Practical Implementation, DH Nov 06) recommends that community pharmacy should be involved in the local population needs assessments that underpin service redesign. It also includes community pharmacies in an illustrative list of providers from whom services might be commissioned. Enlightened GP 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. (NB. Several out of hours palliative care drug schemes are already running in London, including Barnet & Enfield, Brent, Ealing & Hounslow, Harrow and Hillingdon). The really imaginative PBCs 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. PCTs need to encourage dialogue between community pharmacists and general practice. They should also vigilantly apply good governance of PBC such that all ‘willing providers’ are given an opportunity to offer services that fit newly designed care pathways.
Thorough planning for pharmaceutical provision
PCTs already have a great deal of information at their disposal in relation to community pharmacy. They should collate and review the information they already have across their organisation in relation to pharmacy and consider how pharmacy can play an active role. Much information will have been gained from monitoring the implementation of the pharmacy contract. This information provides an ideal opportunity to consolidate knowledge between PCT management teams, including pharmacy demographic locations, staff information, premises capacity and any development plans as well as current and potential service provision.
Roll-out of proven schemes
With 31 PCTs and dozens of practice based commissioning consortia in London, the barriers to roll-out of successful schemes are considerable. Well established and already widely commissioned pharmacy services, such as NHS minor ailments schemes and numerous public health services could be commissioned on a London-wide basis, so that service users in all areas of the Capital may enjoy the benefits.
For more information on any of the points raised or examples highlighted, please contact
Stephen Fishwick - National Pharmacy Association 01727 832 161 s.fishwick@npa.co.uk
Michael Levitan (London LPCs Forum) - themiddlesexgroup@intrapharm.com
Terry Silverstone (London LPCs Forum) - TPSCPS@aol.com.
Staying Healthy
Do you have a view on what works or doesn’t work in this area at present?
Community pharmacists see people who are well, in addition to those in poor health, so they can effectively promote health to a wide population and detect health and social problems early on. In London this includes advice and support to commuters and tourists, as well as the resident population. Community pharmacists are often located in the heart of the most deprived communities in London and are in effect ‘healthy living centres’ for health care information, advice and support. Their neighbourhood location provides opportunities for community involvement as health champions as well as contributing to social capital and neighbourhood renewal as local entrepreneurs. Community pharmacy support staff, often members of the local community themselves, are ideally placed to reinforce health messages and to understand the specific cultural norms of their communities.
In “Choosing Health through Pharmacy” (2005), Rosie Winterton, the then Health Minister, commented “the track record of community pharmacists in areas such as stopping smoking, sexual health advice and substance misuse is evidence of how integral they are to tackling public health issues. But (Government) would like pharmacists to do even more”. This is certainly true in London where pharmacies provide an increasingly wide range of accessible public health services but where more could be made of the recently agreed community pharmacy contractual framework. This provides a good platform for pharmacists and their staff to contribute to public health. Specific examples of what works well include:
But, while smoking cessation, substance misuse/needle exchange and EHC PGD provision for under 16s are widely commissioned, this is still patchy and other services such as flu vaccination, weight management and Chlamydia screening are much more unusual. However there is evidence that these services can make a real contribution to the public health/staying healthy agenda and could be part of patient pathways, if community pharmacy was integrated into public health plans, local obesity strategies etc.
What key changes would you like to see?
- All three tiers of the community pharmacy contract being used to support the public health agenda and to address specific health inequality issues and integrated in patient pathways.
- Much greater and more imaginative use being made of community pharmacy’s potential contribution to the staying healthy agenda with attached funding.
- An expansion of the range of public health services that are considered by PCTs as suitable to be commissioned from pharmacy, including those not traditionally associated with community pharmacy such as vaccination.
What do you think would help to make these changes happen?
- The integration of community pharmacy in the health improvement element of PCT local delivery plans.
- Use the data gathered from the Pharmaceutical Needs Assessment (a key element of the community pharmacy contract) to consider the location of pharmacies in relation to social deprivation and health need and consider the public health contribution community pharmacy can make in these areas. Review PNA on a regular basis.
- Community pharmacy represented on appropriate planning groups for sexual health, smoking, weight management, immunisation and use of existing examples as services models.
- A much greater awareness on the part of Directors of Public Health both at PCTs and Local Authorities of the role that community pharmacy and the pharmacy contract can play in this agenda.
- Directors of Public Health and their teams to facilitate the development of pharmacy networks and help build pharmacy capacity.
- The integration of community pharmacy into the London Public Health network.
- The inclusion of community pharmacy in the public health element of Local Delivery Plans.
- The inclusion of community pharmacy representation in the development of patient pathways – including within practice based commissioning.
For more information on any of the points raised or examples highlighted, please contact
Stephen Fishwick - National Pharmacy Association 01727 832 161 s.fishwick@npa.co.uk
Michael Levitan (London LPCs Forum) - themiddlesexgroup@intrapharm.com
Terry Silverstone (London LPCs Forum) - TPSCPS@aol.com.
Long Term Conditions
Do you have a view on what works and what doesn’t work in this area at present?
Community pharmacies are highlighted in key Government documents as key partners in the management of long term conditions (LTCs), for example “Supporting people with long term conditions to self care: A guide to PCTs in developing local strategies and good practice” (2006). They offer a range of services that help people to live independently in the community, thereby avoiding hospital or other expensive “reliant care” and need to be considered in the development of patient pathways that address the needs of people with LTCs - from self care through the small percentage of “high flyers”, who need a disproportionate amount of hospital activity. The range of pharmacy-based services includes screening, point of care testing, monitoring, self management education and medicines management, as well as health improvement interventions such as stopping smoking. As half of all people on regular treatment do not take their medicines as intended for a number of reasons and problems with medicines may be the cause of as many as 15% of hospital admissions, the community pharmacy contract has been developed to help address this issue by providing more support to improve both compliance and concordance. Community pharmacists can help people with LTCs around the corner and around the clock: they are located in the heart of communities and are open weekends and sometimes extended hours so patients have quick access to advice and treatment, thereby reducing the number of crises.
There are some excellent examples of community pharmacy services in London that support the LTC agenda by providing disease specific support. These include:
Camden, Greenlight Pharmacy – provides an outreach diabetes service to the Bangladeshi population with type-2 diabetes. It includes a review of patient’s medication, blood pressure monitoring and group education sessions.
Hillingdon, Community Pharmacy Medication Management Service for people with diabetes – community pharmacists deliver a primary care diabetes management service, available to all adults taking medication for the condition. Each patient has a consultation with a pharmacist at least six times a year. Pharmacists agree referral criteria with GPs for problems, such as intolerable side-effects, that cannot be resolved in the pharmacy.
Hammersmith & Fulham H-pylori Testing – community pharmacists offer H-pylori testing in the pharmacy.
Anti-coagulation monitoring – a community pharmacist in Islington offers anti-coagulation monitoring in his pharmacy working closely with a local hospital. In Enfield, 11 community pharmacies are starting to offer an INR testing service, again in partnership with local hospitals. Community pharmacists in Lewisham have seen 500 patients from the local hospital for anti-coagulation monitoring.
However such services are the exception rather than the norm and the flexibilities in all three tiers of the community pharmacy contract could be used to much greater effect to support patient pathways for people with LTCs, using the new contractual flexibilities to support self care and medicines management. One example is in Lambeth, where community pharmacists are contracted to provide medicines management support to an intermediate care centre as part of a GP locally enhanced service. The overall aim is to improve medicines safety and effectiveness, reduce waste and promote independence by providing medicines management support to patients and staff at the centre.
Much greater use could be made of the Medicines Use Review, the advanced tier of the pharmacy contract. While some PCTs have identified groups of patients with LTCs to target for MUR support, this is not the case in all PCTs. MURs need to be an integral part of patient pathway development as they support compliance and the effective use of medicines. The can be targeted towards people with asthma, hypertension and other conditions. They can also be used post discharge to ensure people who may have had their medication changed in hospital know how and what to take. MURs can also incorporate some health promotion and signposting advice in line with the essential services element of the contract. MURs could even be integrated with enhanced service elements to provide ‘MUR Plus’ across a variety of long term conditions.
What key changes would you like to see?
- All three tiers of the community pharmacy contract being used to support the long term conditions agenda and to address specific health inequality issues and integrated in patient pathways.
- Much greater and more imaginative use being made of community pharmacy’s potential contribution to the long term conditions agenda with attached funding.
- An expansion of the range of services that are considered by PCTs as suitable to be commissioned from pharmacy, including those not traditionally associated with community pharmacy.
What do you think would help to make these changes happen?
- Community pharmacy represented on appropriate planning groups for long term conditions and consideration of existing examples as services models.
- The inclusion of community pharmacy representation in the development of patient pathways – including within practice based commissioning.
- The inclusion of community pharmacy as part of the multidisciplinary team when patient pathways are developed with closer working relationships with community matrons and other health and social care professionals.
- The integration of community pharmacy in the long term condition elements of PCT local delivery plans.
- Greater use of medicines use reviews, with the development of formal referral processes.
- Creative use of the flexibilities in the community pharmacy contract to support the long term conditions agenda.
- Improved partnership working with Local Pharmaceutical Committees.
- Investment in locally commissioned services from pharmacies that address long term conditions.
For more information on any of the points raised or examples highlighted, please contact
Stephen Fishwick - National Pharmacy Association 01727 832 161 s.fishwick@npa.co.uk
Michael Levitan (London LPCs Forum) - themiddlesexgroup@intrapharm.com
Terry Silverstone (London LPCs Forum) - TPSCPS@aol.com
