Home Pharmacy White Paper
PSNC Briefing on Pharmacy in England Building on strengths – delivering the future
Introduction
The pharmacy White Paper “Pharmacy in England Building on strengths – delivering the future” was published by the Government on Thursday 3rd April 2008. Its publication completes action promised in Our health, our care, our say to develop pharmacy contractual arrangements in line with the ambitions laid out in that White Paper and it responds to Anne Galbraith’s review of NHS Pharmaceutical contractual arrangements.
The White Paper highlights the Government’s continued commitment to pharmacy, its place in the NHS and its role as a leading clinical profession in delivering better access to high quality services to patients and consumers.
While the focus of the White Paper is mainly community pharmacy, its context is wider, including hospital pharmacy, professional regulation and education and training.
The White Paper aligns closely with the developing Primary and Community Care Strategy (part of the Darzi Review) in promoting health, not just treatment; delivering personalised, integrated and convenient care, that is of high quality; and tacking health inequalities.
The Government’s stated aim for community pharmacy is to see:
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a shift in emphasis from dispensing prescriptions to providing clinical services;
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a wider range of services available through pharmacies, exploiting their convenient locations and extended opening times; and
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greater use of the clinical skills of pharmacists and the talents of other pharmacy staff.
Pharmacies will:
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become “healthy living” centres promoting health and well-being and helping people to take better care of themselves;
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be able to supply certain common medicines and be the first port of call for people with minor ailments – saving every GP up to the equivalent of one hour per day or up to 57 million GP consultations a year; and
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provide support for people with long-term conditions, especially those starting out on a new course of treatment.
Two new pharmacist clinical directors will be appointed later in 2008 to champion change in hospitals and in the community to help with implementation of the White Paper; they will also create a network of local pharmacy champions.
Chapter 1 - Background
Chapter 1 outlines the major role that pharmacists, pharmacy technicians and other pharmacy staff currently play. It sets out pharmacy’s strengths and achievements, and identifies further potential for pharmacy to contribute to high quality patient care and improve the population’s health and wellbeing.
Chapter 2 – The context for change
Chapter 2 sets out some of the major health and social challenges we continue to face in addressing health inequalities and securing improved health and wellbeing for everyone. It identifies the current NHS reforms and the impact these reforms will have on pharmacy.
It highlights some key changes, including the important focus on better commissioning of services to meet local population needs, making better and more effective use of resources to deliver the best outcomes and the need to harness new and developing technologies, such as the Electronic Prescription Service (EPS). Annex 1 of the White Paper identifies how and where pharmacy can contribute by providing additional services and support in tackling some of the more pressing challenges.
Action point (by April 2009): The Government will work with the NHS and relevant partners to identify how to apply the worldclass commissioning competencies to the commissioning of pharmaceutical services, and how to support PCTs in developing their capability and capacity accordingly.
Chapter 3 – Expanding access and choice through more help with medicines
Chapter 3 looks at how pharmacists and their staff are helping to improve access to medicines and to promote their safe and effective use. It highlights that there is room for improvement in how patients and the NHS can make better use of medicines. A range of proposals is put forward.
MURs
A mixed picture has been seen with the implementation of the MUR service. Many patients and pharmacists report satisfaction with the service, but questions have been asked about the value for money being delivered; MURs will consequently be a high priority area for future NHS research.
The Government also wishes to see continuous improvements in service quality via mechanisms such as a peer review audit of MURs and related CPD. An effective means for PCTs to monitor delivery and outcomes of MURs will need to be developed, so that PCTs are able to decommission the service from pharmacies that consistently fail to meet the minimum agreed quality standards.
Action point (Proposals by December 2008): The Government believes it is necessary for MUR services to be prioritised to meet health needs and has asked NHS Employers to discuss with PSNC a mechanism for delivering this and ensuring funding rewards health outcomes.
Repeat dispensing and adherence support
The benefits of repeat dispensing are highlighted and the poor uptake of the service and the reasons for this are discussed.
Action point (by April 2009): Part of the remit for the working group to be convened by NHS Employers, including pharmacy and medical representatives to develop professional working (see chapter 5), will be to identify and agree mechanisms that can support further incremental implementation of repeat dispensing.
The need for more support to reduce the amount of unused medicines is discussed.
Action point (outcome available by 2009): The Government is commissioning research to establish the extent to which medicines are not used and to determine the varied and complex reasons why people do not take their medicines as intended. The outcome of this research, which will be available in 2009, will inform what future action needs to be taken to reduce waste.
Other initiatives to support people’s adherence to medicines regimens, including monitored dosage systems (MDS), are discussed. The challenges associated with the use of MDS are highlighted.
Action point (2008 onwards): The Government considers further work is needed to strengthen the commissioning of services to support adherence to medicines and will therefore take forward, in partnership with interested parties, discussions on appropriate measures.
This work will take account of the suitability of original packaging to support people, together with any implications for the wider social care sector.
Urgent care
The challenges of accessing medicines during the out of hours period are discussed and some of the ways to reduce the demand for medicines required urgently, such as the use of prescription collection services, repeat dispensing and publicity campaigns to remind people to order their repeat medicines in good time, are highlighted.
Action point (proposals by April 2009): The Government will consider extending the provision of emergency supply to enable a 28-day supply to be made, subject to full consultation.
The role of dispensing doctors and access to OTC medicines in rural areas is discussed.
Action point (consultation in summer 2008): The Government believes there are sufficient grounds to reform arrangements for selling OTC medicines where the GP practice has consent to dispense. This needs to be linked to the broader reforms of dispensing by doctors in Chapter 8.
The role of appliance contractors and the ongoing review of the supply arrangements for incontinence and stoma appliances are highlighted.
Hospital/Primary Care interface
Best practice in medicines reconciliation when people are transferred between care settings such as primary care and hospital is highlighted; hospital pharmacists will need to lead on this area, but improving medicines information sharing on discharge will need to include community pharmacists.
Action point (proposals by April 2009):The Government will ask the two new clinical leaders (outlined in chapter 4) to support NHS Employers and consider the optimal way in which services involving the transfer of care can best be commissioned within the current contractual framework.
The need to provide more focussed pharmaceutical care for those who would benefit most in the community is discussed; such services would require joint working across primary and secondary care. The transition of hospital pharmacy from a supply service to one which is underpinned by clinical practice is described. The next stage may be for some hospital clinical pharmacists to practice in settings closer to people’s homes or for them to support others undertaking this role. It is envisaged that hospital pharmacist clinical expertise can be used more widely to help create new ‘health community clinical pharmacy teams’.
These ‘virtual’ teams will build clinical networks to provide an infrastructure for hospital and community pharmacists, primary care pharmacists, pharmacy technicians and, potentially, other healthcare professionals to oversee and monitor medicines usage and effectiveness.
Action point: The clinical leaders for hospital and community pharmacy (see chapter 4) will be asked to devise appropriate mechanisms to support implementation of health community clinical pharmacy teams in PCTs and to work with NHS Employers on appropriate commissioning arrangements.
The importance of safety in chemotherapy prescribing is covered and the emergence of new orally active chemotherapy agents is noted.
Action point: The Government expects PCTs to commission well-designed, safe services that comply with the requirements of the Manual for Cancer Services and the NPSA Rapid Response Report on oral anticancer chemotherapy, to meet the needs of people with cancer who can benefit from receiving oral chemotherapy from their community pharmacy.
The importance of reporting and learning from patient safety incidents is discussed alongside a summary of recent NPSA activity linked to medicines safety.
Action point: The Government considers that chief pharmacists of provider organisations, PCTs and other commissioners should have the lead role in ensuring that safe medication practices are embedded in patient care. This includes them:
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working with patients, senior managers and other health professionals, including professional bodies, to identify, introduce and evaluate systems designed to reduce unintended hospital admissions related to medicines; and
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working with other senior health professionals, senior managers and Safety Alert Broadcast System liaison officers to ensure that organisations respond to NPSA and other alerts efficiently and in good time, thereby reducing risk to patients.
Chapter 4 – More pharmacy services supporting healthy living and better care
This chapter sets out a vision for service development in the future – one that the Government believes will help to deliver more choice and more modern, effective and world-class pharmaceutical services.
How the Government sees this vision developing can be summarised as follows, with pharmacies:
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being repositioned, recognised and valued by all as healthy living and health-promoting centres, promoting health literacy and NHS LifeCheck services, offering opportunistic and prescription-linked healthy lifestyle advice, and providing support for self care and pressing public health concerns, such as smoking, sexual health, diet and nutrition – with public perceptions of the potential contribution being transformed;
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directing their focus to delivering to people with expanded access to clinical services – especially for those in the most deprived areas – through new, widespread services, such as treating minor ailments and offering vascular risk assessments; and
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providing more support for people with LTCs – with routine checkups and monitoring, available on a drop-in basis, together with a new service for those who are starting to take regular medicines to treat their condition for the first time. The progress made in changing community pharmacy services over the last three years is highlighted and a vision for what a world-class pharmacy would look like is painted.
| A world-class pharmacy will have several distinguishing features.
It will be known in local communities:
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How pharmacies individually contribute will often depend on local needs and circumstances. By providing world-class services the Government believes that pharmacies will be appreciated and accepted by a much wider range of people as ‘natural’ local resource centres for health and wellbeing.
Action point: To support the development of this vision, the Public Health Leadership Forum for Pharmacy will identify a work programme for 2008-10 to accelerate pharmacy’s ongoing and expanding contribution to health, how it contributes to reducing health inequalities and with a particular focus on community leadership and sustainable development.
Action point: To help further identify community pharmacists’ contribution to public health, the Government will ask NHS Connecting for Health to scope arrangements for electronically capturing information centrally about interventions made or advice given by pharmacists as part of the promotion of healthy lifestyles Essential service.
More pharmacy staff can be expected in future to want to become accredited health trainers. However, there may be gaps between the competencies developed in existing pharmacist assistant training programmes and those of accredited health trainers.
Action point (proposals by December 2008): The Government will invite pharmacy bodies and employers to consider and come forward with proposals on how they can support pharmacy staff to become health trainers, making appropriate links to the Skills for Health’s National Occupational Standards for Health Trainers and the British Psychological Society’s Health Trainer handbook.
Minor ailments
The benefits of supporting self-care and NHS commissioned minor ailments services are described, including the potential time savings for GPs that were quantified by the recent PAGB/PSNC joint study conducted by IMS Health.
Action point (proposals by spring 2009): The Government will examine with PSNC and NHS Employers how best minor ailments schemes can be incorporated within the community pharmacy contractual framework.
Stop smoking
The benefits of NHS Stop Smoking services are described and the contribution that community pharmacy has made to these services. Increasingly, the Government anticipates local stop smoking contracts will be offered on the basis of clear criteria for service delivery and data reporting requirements.
Action point (proposals by spring 2009): The Government will ask NHS Employers to examine any further necessary steps to strengthen contractual arrangements so that stop smoking services provided in pharmacies show clear evidence of close partnership with local NHS Stop Smoking Services.
Sexual health
The historic and emerging role of community pharmacy in providing sexual healthcare is highlighted, including the recent London pilot of Chlamydia screening and treatment.
Action point (by autumn 2008): Drawing on this evaluation [of the London pilot], the Government will publish a national template later in 2008 to support PCTs’ commissioning of chlamydia screening from community pharmacies as part of the National Chlamydia Screening Programme.
New funding was recently announced by DH to improve access to the full range of contraceptive methods, to help reduce unintended pregnancies, particularly teenage pregnancy; SHAs are selecting potential sites with PCTs.
Action point: In doing so, the Government will ask SHAs to ensure that pharmacies are included within local schemes.The Government will evaluate these schemes and publish findings to improve access to sexual health services generally and to ensure that robust standards are in place.
Vascular risk assessment
The Government recently announced a universal programme for vascular checks for everyone between the ages of 40 and 74. Pharmacies offer an excellent location for these checks, including for groups who may not be registered with GPs.
Action point: As the vascular risk assessment programme develops, the Government will discuss with stakeholders, including pharmacies, what delivery arrangements best support implementation to ensure wide availability of this service as soon as possible.
The Government is already working with PSNC and NHS Employers to develop a national template for a service specification for vascular risk assessment and management as a locally commissioned Enhanced service. The vascular risk check could be linked to the online NHS Midlife LifeCheck which will be rolled out during 2008.
Many pharmacies already carry out diabetes testing; the Chief Pharmaceutical Officer and the National Clinical Director for Diabetes are currently considering how best to maximise the safe and effective contribution of pharmacy, within a team environment, to the care of people with diabetes.
Managing long-term conditions
The challenge of managing long-term conditions effectively and the major contribution that medicines make to this task are described. Recent evidence suggests that many people who start to take a new medicine experience problems early on because they do not understand why they need to take the medicine, how it works or how to take it and what the long term benefits of taking it are. GPs may provide a lot of this information to the patient, but it needs to be reinforced as people often do not take on board all the information their GP gives them. Some people may also experience unforeseen side effects or interactions with their other medicines.
As a first step in tackling this problem, the Government believes that pharmacy should offer more support to people in the early stages of taking a new course of medicines to treat an LTC. Existing professional and contractual requirements mean that appropriate information and advice should be provided whenever a prescription for a new medicine is first presented. But just as important, there should be more structured follow-up to ensure that the person is not experiencing problems with their medicines. If so, further advice and support on how to resolve these or onward referral, as appropriate, should be available.
The presumption should be that all such people would receive this service automatically until such time as their new regimen has stabilised and they feel they no longer require regular support from their pharmacy. The service should be available from the pharmacy on presentation of the first prescription. Pharmacists will want to consider innovative ways of communicating patient-sensitive information, depending on people’s preferences, such as text messaging or email messaging.
Action point (proposals by spring 2009): The Government believes more support is needed for people who are newly prescribed a medicine to treat a long term condition. The Government will therefore discuss with the PSNC and NHS Employers how such a support service may best be introduced within the community pharmacy contractual framework.
Community pharmacy also has an important role to play in the early detection and prevention of some cancers.
Action point (proposals by spring 2009) The Government believes it is important that effective systems are in place for the efficient referral of people with symptoms, which may be indicative of cancer, from the pharmacy to their GP. The Government will therefore ask NHS Employers, the RPSGB and the PSNC to explore how professional and contractual arrangements can best support this.
The role that pharmacy will play in the management of a ‘flu pandemic is described and the need for pharmacies to develop robust response plans.
Pharmacy ‘Czars’
The Government believes that the initiatives set out in this White Paper will require strong, authoritative, clinical leadership at both local and national levels - leadership that will galvanise the profession and providers along new clinical pathways and ensure a reinvigorated clinical focus remains at the forefront of delivery and service development in the coming years.
Action point (by mid 2008): The Government will appoint two new clinical leaders this year. These new leaders will work directly to the Chief Pharmaceutical Officer to champion the development of pharmaceutical services and to help implement the actions in this White Paper.
One will focus on pharmaceutical service delivery in the community and in primary care; the other on delivery in hospital pharmacy. A key aspect to both roles will, however, be to devise and implement effective joint strategies and mechanisms to promote better patient experience and pharmaceutical outcomes for people across the different healthcare sectors. They will focus on promoting and stimulating the delivery of service models which best meet the needs of people going into and coming out of hospital and other clinical settings. In addition, they will have an important role in shaping future models of care flowing from the primary and community care strategy.
They will also be responsible for supporting the development of local clinical champions, to identify and spread best practice across the country, helping to overcome any barriers to service redesign and seamless care delivery. More details of their roles and remit will be available when these posts are advertised later this year.
Chapter 5 – Communications and relationships
This chapter outlines proposals to develop a communications programme, to support the delivery of key messages to patients, the public, the NHS and other stakeholders and to improve awareness and understanding of the role of pharmacy in providing services. It also sets out the Government’s plans to commission and develop further research into the extent and pattern of use of pharmacy services.
Pharmacy is highly regarded by the public. A MORI survey carried out in 2003 showed that people use pharmacists as a health resource second only to GPs. The public has expressed considerable satisfaction with pharmacy services, saying they were ‘accessible, friendly and expert’.
Action point: The Government will plan a programme of communications that seeks to: • highlight the breadth of services and skills available within pharmacies;
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illustrate the role that pharmacies can play in promoting good health;
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raise awareness and knowledge of the role that pharmacy can play in managing long term conditions (LTCs) and reducing health inequalities; and
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increase the use of pharmacy services among target audiences.
Anne Galbraith’s report concludes that professional relationships between pharmacists and GPs have not developed as expected. In particular, the report found that integrated care would require a need for closer professional co-operation, e.g. in developing a local indicator for repeat dispensing services and how the provision of the medicines use review (MUR) service could best reflect local priorities.
A clear strategic focus and direction is needed to support further change; to effect this, the Government believes effective professional relationships are important for the future development of services.
Action point: It has therefore asked NHS Employers, on behalf of PCTs, to convene and lead a working group of pharmacy, medical and public representatives to formulate a series of actions to promote more effective professional relationships. These will include setting achievable and realistic goals, incentives and outcome measures for delivering services that ensure closer co-operation and closer working between pharmacists and GPs.
This will start with repeat dispensing and the Electronic Prescription Service. NHS Employers will shortly invite representatives of PSNC and the General Practitioners’ Committee of the BMA to join them in this important work.
Chapter 6 – Research and innovation in practice
This chapter looks at proposals to support research and innovative pharmacy practice, and to promote the development of a sound evidence base that underpins and demonstrates how pharmacy delivers effective, high quality, value-for-money services.
Research into pharmaceutical services is a relatively new area. Its focus has largely been on the acceptability and uptake of services by the public and on perceptions of the profession and their job satisfaction. Measures to date have largely been expressed in terms of inputs and outputs, rather than in terms of service quality, outcomes and relative cost-effectiveness.
As yet, the evidence base underpinning the value for money and effectiveness of current pharmacy services on clinical outcomes is, at best, patchy. However, this of itself is not a reason to abandon them, but indicates a need to explore further the development of the evidence base, including research tools.
The Government believes a clearer culture of evaluation needs to be at the heart of pharmacy service development and provision, and service evaluation should be considered alongside the community pharmacy contractual framework and any new service developments initiated as projects. The Government will explore how best to create a clearer framework for the evaluation of pharmacy services. This is likely to focus on six principal research domains:
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patient and public perceptions and satisfaction;
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impact on care and outcomes (including clinical and cost effectiveness, safety and people’s understanding of their medicines);
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quality of service provision;
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value for money;
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impact on workload and flow; and
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pharmacy staff attitudes.
Action point: To do this, the Chief Pharmaceutical Officer will convene an expert panel to advise on priorities for health service research in pharmacy and feed the output of this into the Government’s National Institute for Health Research prioritisation processes.
EPS and NHS Care Record
The chapter also identifies the need for pharmacy to be open to new ways of working, building on good progress in the use of new technologies and systems in hospital pharmacy and on the experience in community pharmacy of the roll-out of the Electronic Prescription Service (EPS) and other initiatives.
The Summary Care Record (SCR) will give healthcare professionals treating a patient secure access to some patient specific information. This will support the healthcare professional in providing the safest and most effective intervention for the patient.
However, it is important that mechanisms are in place to fully address concerns about patient consent and maintaining patient confidentiality. The NHS Care Record Guarantee has been drawn up and agreed by key parties as to what patients have a right to expect about how any information about them in the Care Record Service may be stored, used, shared and transmitted. However, there have been specific concerns about the use of the Care Record Service in community pharmacies. Some PCTs are early adopters of the SCR and are considering issues of patient consent and confidentiality.
Action point: The Government will therefore undertake further work with an early adopter PCT to consider the benefits, governance and practical arrangements of community pharmacists having access to the SCR.
This work and experience will be used to inform a key programme to consider how community pharmacy’s access to the Care Record Service might be achieved. This programme will include the Clinical Reference Panel, the National Advisory Group and Patient Advisory Group, together with professional and representative organisations.
Consideration will also be given to how community pharmacists may be able to utilise other services such as ‘Choose and Book’ as they offer more clinically orientated services.
Chapter 7 – The pharmacy profession
In this chapter, the Government makes clear its conviction that, as health professionals, pharmacists remain a significant untapped resource for delivering accessible services to the people who need them most. As such, the approach to the regulation of pharmacists must be similar to that for other clinical professions – that is, in a way that safeguards patients and the public and supports the strategic development of high quality pharmacy practice.
This chapter sets out:
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action to establish a new professional regulator, the General Pharmaceutical Council (GPhC);
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how the Government looks to the profession itself to develop strong professional leadership to support and sustain pharmacy at this critical time of change, including opportunities now available to pharmacists to become prescribers, to develop special interests in defined clinical areas or to practise as consultant pharmacists; and
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changes in education and training that will help to ensure that pharmacists have the clinical competencies to deliver the types of services needed in the future.
To support the deployment of pharmacists’ clinical skills, the Government is taking forward legislative changes that promote the better use of the pharmacy workforce – pharmacists, pharmacy technicians and other pharmacy staff.
The Government will also begin discussions with relevant representative bodies on professional standards for appliance contractors.
Building on the work already done by the RPSGB, the Government believes it is time to ensure that future pharmacists have the clinical, professional and leadership competencies to deliver the services of the future. This can be achieved in part by increasing the clinical content of undergraduate training. However, good science lies at the heart of knowledgeable, inquisitive practitioners who also recognise their limitations and are keen to address them. In this way, rational, clinical decision-making is achieved.
Action point: The Government, working with all relevant parties, including the profession, schools of pharmacy, the regulator, the Higher Education Funding Council for England, Universities UK and employers, will begin planning to ensure that there is:
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meaningful clinical context and experience throughout the undergraduate programme and determine whether this can be maximised by integrating the degree course with the preregistration training year;
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an appropriate funding framework in place to support academia and clinical practice in delivering the new programme; and sufficient capacity in the academic workforce and an appropriate infrastructure in clinical practice to provide high quality education.
Pharmacy support staff develop their skills and knowledge through vocational qualifications based on National Occupational Standards (NOS). In order to best support new clinical roles in pharmacy, the NOS underpinning the National Vocational Qualifications in pharmacy services at levels 2 and 3 were reviewed and updated in consultation with a wide range of interested parties and regulators in a Skills for Health project during 2006/07.
Action point: The Government will consider what further training may be required to enable pharmacy technicians to supervise certain aspects of the sale or supply of medicines as envisaged by the Health Act 2006.
Chapter 8 – Structural enablers and levers
Control of Entry – Background
The White Paper reports that access to pharmacy is good, with 99% of the population able to reach a pharmacy within 20 minutes. However, location is provider driven, with PCTs having little control. Anne Galbraith recommended that PCTs require strengthened commissioning roles to stimulate competition, they should undertake a more rigorous assessment of pharmaceutical needs and they should be able to terminate contractual rights for poor performance. She proposed two options – complete devolution of contracting responsibilities to PCT or the concept of any willing provider.
The All Party Pharmacy Group highlighted the patchy nature of commissioning and suggested more nationally agreed services as a move away from discretionary funding by PCTs. It also advocated six new advanced services (long term condition management; sexual health; minor ailments; diabetes screening; weight management; and a broader range of screening services).
The Government’s response is to strengthen PCTs’ commissioning as part of the World Class Commissioning (WCC) Programme, whilst recognising that PCTs’ commissioning development is not yet mature. It is felt that pharmacy contractors are not being adequately rewarded for the investment they have made in services and those services commissioned may have no evidence of meeting needs or being cost effective. To stimulate investment in services, the Government knows that there should be greater security of income streams but these must offer value for money and good health outcomes.
Most care pathways involve medicines and early consideration of pharmaceutical governance and logistical requirements relating to medicines are key to successful service redesign. Critical factors for ensuring that sufficient account is taken of medicines in the commissioning of services also include the competency of those undertaking new roles, the support for patients and carers and systems for the responsive handling of medicines issues under Payment by Results. The government believes commissioning must foster a shift away from pure dispensing and towards rewarding clinically focussed pharmaceutical services which will secure promotion of health, wellbeing and independence.
Pharmacies that fully embrace the new direction of change and that invest in staff and infrastructure to support high quality services will be better rewarded. Commissioners will need to encourage innovations that better meet local needs, providing more convenient access and greater choice of provider at a time to suit the public. Commissioners will find these pharmacies to be a readily available asset. This is particularly important for people not normally accessing the NHS and those preferring a less formal health setting, as this will free up NHS capacity elsewhere.
PCTs and commissioners need to encourage and consider a wider perspective on commissioning, and commissioners need to recognise pharmacy is a key and essential element in the delivery of clinical services. Pharmacies can offer opportunities that will help deliver commissioning plans that are responsive to local needs.
The long term strategic direction is to ensure commissioning meets local needs and links to PBC; to revise arrangements for contracting for services; to revise payment mechanisms for such services; and to ensure high quality and safety in the delivery of services. Once these are in place, market entry and exit barriers are unnecessary and can be replaced by criteria that place safety, quality and outcomes at the heart of delivery.
There is to be a major consultation in summer 2008 on the control of entry regime. It will cover 100 hour pharmacies, dispensing doctors and appliance contractors (see later)
Pharmaceutical Needs Assessments (PNAs)
PCTs and local authorities should be working together to produce Joint Strategic Needs Assessments (JSNA). The outputs of the JSNA will inform the development of the Sustainable Community Strategy (SCS) which should include action to tackle national priorities such as reduction in health inequalities; promotion of health, wellbeing and independence; and support for self care. The SCS will inform the negotiations of the Local Area Agreement (LAA) by the PCT and the local authority.
Pharmaceutical Needs Assessments should contribute to the JSNA, SCS and LAA - but having been introduced in 2004–5, and not all having been reviewed since then, there is a need to update PNAs. Some but not all PCTs have reviewed them after mergers in 2006.
Action point (by December 2008): The Government considers that the structure of and data requirements for PCT PNAs require further review and strengthening to ensure they are an effective and robust commissioning tool which supports PCT decisions. The Government has asked NHS Employers to establish a short term working group to review these requirements and to devise an appropriate support programme for PCTs.
PBC engagement with pharmacy has been limited, and the benefits that a pharmacy can bring, such as reducing unplanned hospital admissions; reducing time to treatment; achieving costeffective health outcomes and improving quality could be lost if this is allowed to continue. The Government advocates that commissioners should involve pharmacists in their health needs assessment activities; ensure community pharmacists are included in local planning processes; understand and integrate the work of community pharmacists into care pathways for patients and care plans for patients with LTCs; and link with pharmacy stakeholders to understand where community pharmacy services can have the greatest impact in meeting the objectives for PBC.
PCTs should use the Strategic Commissioning Tests to bring stakeholders together in a structured process to discuss and agree ways of working at a local level. Engaging clinicians and working in partnership with providers are both reflected in the 11 competencies for World Class Commissioning against which PCTs will be judged. The priorities and plans of practice based commissioners should inform the reviews of PNAs. The Government is currently scoping the next phase of national support for implementing PBC.
Pharmaceutical Services (including LPS)
Galbraith sought to encourage more local commissioning through Local Pharmaceutical Services contracts which can tailor the Essential services to more closely reflect local needs. All the services in the White Paper could be provided through LPS contracts, and therefore LPS could be immediately useful whilst the national contractual framework might struggle to accommodate specific configurations.
Enhanced services, which are left to PCTs alone, are not developing quickly or consistently. The APPG believes that more services should be available as Advanced or Essential services.
The Government and NHS Employers have identified a number of factors to be taken into account when commissioning services in order to balance business income security with value for money:
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There should be a sufficient level of need for a particular service or a requirement for a wide availability across the country;
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Contractual structures should be capable of being applied to different kinds of service;
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There should be flexibility so that new services can be linked to and reflect PNAs;
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New services will attract pharmacy interest and investment;
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This should not require extensive legislation, and should conform to the direction set by the primary and community care strategy.
The desire by Government to build momentum to underpin investment and shift the focus from dispensing to clinical services can be aided by introducing Directed Enhanced Services.
Action point (discussions commence in spring 2008): The Government will use Directions in consultation with NHS Employers and PSNC to direct all PCTs that they have to commission certain services from pharmacy contractors according to the local needs they identify and subject to suitable accreditation requirements and service quality standards.
This approach can be used for the national Minor Ailments Service and it is expected that following discussions by NHS Employers and PSNC on the development of service criteria and specifications this will lead to the service being commissioned as soon as possible.
Government is exploring the development of tariffs for community based services, which support greater transparency and consistency in commissioning, and in light of discussions with the NHS and PSNC, consultation on future payment mechanisms will be part of the consultation in summer 2008.
Quality of services
The Government wants to secure immediate improvements in three areas: setting more robust standards for Essential and Advanced services and harmonising accreditation for similar kinds of Enhanced services; introduce financial incentives and penalties; and introduce more effective sanctions to address poor performance.
These comments follow some over-emphasis on quantity rather than quality or relevance, of MURs. Future contractual arrangements should reward pharmacy as a provider of clinical not just retail activities. It is intended to shift the focus so that those who invest in improved facilities and strive to improve the quality of services they offer should be rewarded. Public investment should not provide a permanent reward system for providers who are prepared to deliver the bare minimum, or who concentrate on ‘patient throughput’ rather than ‘patient satisfaction’.
Action point: The Government will work with PSNC and NHS Employers to devise proposals to ensure that effective arrangements are in place to address unwarranted variations in standards and quality of service delivery.
Action point (discussions start summer 2008): The government will also work with the NHS and professional bodies to develop a set of pragmatic, easily measurable metrics or indicators that will serve to demonstrate the quality and outcomes of pharmacy service provision.
Such indicators could form the basis of providing incentives; be utilised to help capture the performance of individual clinicians; and be utilised to indicate where support may be needed to address poor performance. The Department has identified that the Netherlands has introduced a set of 44 performance indicators, and this may be a starting point for England. NHS Connecting for Health will be asked to consider IT support for collection of such data. Publication of these data could help patients choose the pharmaceutical services they want.
Clinical Audit
The contractual requirement for one practice based audit, and one multi-disciplinary audit arranged by the PCT has not lived up to its full potential. Government intends to work with the National Clinical Audit Advisory Group to strengthen the use of audits within the contractual framework to ensure pharmacy systems are safe and effective.
100 hour pharmacies
The Government believes that the 100 hour exemption has been welcomed within pharmacy (i.e. those who have used the exemption). But, many applications have been copycat – resulting in clustering near new developments such as large GP surgeries. The Government sees improvement in access in places where they have opened, with no evidence of an overall adverse impact on the network. However, PCTs have reported problems including lack of control over where they are situated; no match between wider access and local needs; clustering; and unbudgeted additional expenditure of £25k per pharmacy. The problems were also echoed in the Galbraith Report, and in particular there was reference to the effect of impeding PCTs’ commissioning ability. The Government acknowledges the reduction in business certainty for independent contractors.
To address the adverse perception of the exemption, the Government suggests four options:
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introduce a distance restriction of 1.6 – 2km for new applicants;
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require applicants to justify to the PCT the need for a 100 hour pharmacy (a lower test than the necessary or desirable test);
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contract through LPS, which allows a broader range of services; and
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strengthen requirements for the specific services that a 100 hour pharmacy must provide, for example a link to minor ailments and out of hours services.
The Government favours the first and last of those options, but will consult later in 2008. The government believes that in this way the policy on exempt applications can be aligned to the national priorities identified in the interim report of the NHS Next Stage Review.
Dispensing Doctors
The White Paper notes the lack of quality markers for dispensing doctors. There is a voluntary quality scheme covering governance, training and patient reviews. Markers may be developed to reflect those that might be implemented in pharmacy (see above) and cover areas such as service availability; additional services relating to medicines; safe management of medicines; stock control; cost effective prescribing and dispensing; accuracy of dispensing; use of appropriately trained staff; collection of prescription charges; and promotion of health, wellbeing and independence. NHS Employers will work with GPC to develop standards in dispensing.
There are two other concerns of Government – first, the eligibility criteria for patients to access dispensing by their doctor depends on where they live, which can lead to close neighbours being treated differently. Second, the proximity of dispensing practices to community pharmacies. The government wishes to consider alternative eligibility criteria, which could be based on the distance from the surgery to the nearest pharmacy. Under this kind of arrangement a surgery would be entitled to dispense for all its patients.
The second change to be considered is to allow patients to purchase OTC medicines from their dispensing practice.
There is recognition that transition would need to be managed – perhaps using the model that exists currently (gradualisation).
The Government acknowledges that the dispensing doctor market entry arrangements have been the subject of an agreement between PSNC and doctor representatives. Changes to dispensing doctor arrangements should be consulted on with other elements of the control of entry system. It is suggested by Government that the current regulatory arrangements can be streamlined so that dispensing consent in future (doctor or pharmacy) is sought under a single regulatory route.
Appliance contractors
The control of entry system does not work well for appliance contractors, because they often have distance selling business models, so are unable to satisfy the necessary or desirable test in their neighbourhood. Government will develop options that reflect the specialist market (PSNC will need to be involved, as appliance contractors are both competitors and partners to community pharmacy).
Chapter 9 – Conclusion
The Government believes that this White Paper presents a blueprint for action over the coming years for pharmaceutical services and contractors to:
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lead on the safer and more effective use of medicines;
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make a significant impact in promoting better health and wellbeing for all, as well as preventing ill health and supporting independence;
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provide a clear lead for people to help look after themselves, and ensure that there is timely and appropriate self care support for those who need it – particularly the increasing number of people with long term conditions;
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have a central role in contributing to integrated, fair and personalised health and social care partnerships with patients, addressing some of the key health inequalities still apparent in England; and
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make a significant contribution to achieving wider NHS goals for greater patient control, improved choice and local accountability, especially in terms of the patient journey from primary generalist care to secondary specialist care and back again.
The Government recognises that much can be achieved by pharmacists now. However, the future will require developments in education and training that will equip pharmacists and pharmacy technicians for new clinical roles in patient care.
An action plan is included in Annex 2 which summarises the commitments in the White Paper and sets out a timetable for delivery of these commitments, in partnership with the public, pharmacy, other health professionals and the NHS.
A further consultation document on key proposals set out in the White Paper, including the structural changes proposed, will be published this summer after completion of the forthcoming primary and community care strategy.
Supporting documents
Alongside the White Paper a number of other documents were published:
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Anne Galbraith’s report – Review of NHS pharmaceutical contractual arrangements. This report was commissioned by DH in January 2007. The White Paper includes the DH response to the proposals within the Galbraith report.
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Impact assessments and partial impact assessments on the White Paper and specific proposals (changes to the 100 hour exemption, sale of OTC medicines by dispensing doctors, expanding the provision of minor ailment services and expanding the provision of support for people with newly diagnosed long-term conditions).
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Community pharmacy use - quantitative and qualitative research: market research report This report combines a piece of quantitative research exploring community pharmacy usage conducted by Continental Research, and a piece of qualitative research designed to add detail to the quantitative findings conducted by Solutions Research.
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An updated literature review: The contribution of community pharmacy to improving the public’s health: Literature review update 2004-7 (Blenkinsopp et al)
The full White Paper and associated documents can be downloaded from the Department of Health website.
A PDF copy of this briefing can be downloaded by clicking here.
Presentations on the White Paper
PSNC has produced a PowerPoint presentation on the White Paper that can be used by LPCs and pharmacists during meetings on the White Paper. A copy of the presentation can be downloaded here.