UKMi response to the Pharmacy Call to Action consultation
March 2014
1. How can we create a culture where the public in England are aware of and utilise
fully the range of services available from their local community pharmacy now
and in the future?
The current advertising campaign promoting community pharmacy and its utilisation
is to be welcomed. However, changing the public’s perception and cultural attitudes
in relation to community pharmacy is likely to be iterative. We need to recognise
particularly that the public’s perceptions of what to expect from community pharmacy
need to be matched to consistent local delivery of innovative and useful services
such as those highlighted by the RPS in “Now or Never”. Crucial to the public
understanding a revised and consistent pharmacy “offer”, is for pharmacists
themselves to get out of the dispensary and consistently deliver services directly to
patients. This could involve initial screening of prescriptions at the point of receipt to
proactively identify issues. It could also involve working with patients more directly
than happens currently. Such communication could vary from simply relaying
information relevant to the prescription, to seeking to achieve concordance with
complicated regimens for long-term conditions and to optimise long-term medicines
use. To deliver such health and medicines related services, pharmacists would need
to operate in premises which reflected their professional role. Such premises would
clearly signpost medicines related services as opposed to focusing on retail
opportunities; they would also not sell unproven homeopathic and other dubious
treatments in the same premises in which licensed medicines are dispensed.
There are of course many structural and contractual barriers that have historically
prevented pharmacists and pharmacies from developing a more professional
ethos. However, only by overcoming these will we ever address the widespread
cultural indifference of the public to community pharmacy, and, ultimately, improve
medicines’ use through pharmacies in a cost-effective and easily reproducible
way. Key to achieving this is the pharmacy workforce, and pharmacists particularly,
who must adopt now a higher public profile and explicitly utilise and demonstrate
their detail knowledge of medicines much more regularly. Unfortunately, for reasons
that are not immediately apparent, the current MUR process may have actually
complicated this situation and anecdotally at least does not seem to have led to a
change in the public perception of pharmacists and their competence in supporting
patients with their medicines. It may be that this particular programme needs rethinking and re-framing in terms that are more directly relevant to a majority of
patients.
2. How can the way we commission services from community pharmacy maximise
the potential for community pharmacy to support patients to get more from their
medicines?
At present community pharmacy income is predominately dictated by prescription
volume. Hence, community pharmacists focus on dispensing efficiently and realising
a profit on medicines supplied. The predominance of supply in the pharmacy
contract means pharmacists are so involved in the mechanics of supplying medicines
that they have little time to talk to patients. The result is situations whereby the only
communication a pharmacy has with a person being dispensed a medicine is a
member of the counter-staff confirming the patient’s name and address. This lack of
opportunity to establish relationships with patients is compounded by a high reliance
on locum staff in some community pharmacies and on businesses reducing
pharmacists’ salaries as market forces dictate. The factors described must be
recognised and addressed if we are to create environments in which patients
(particularly those with long-term conditions living in large towns and cities) can
establish lasting relationships with motivated and knowledgeable pharmacists whom
they use as their first port of call to optimise their individual medicines use.
Running in parallel to the situation described above, it also seems inevitable that the
traditional pharmacy dispensing and supply function will come under pressure as a
result of broader societal changes in shopping habits. In particular, as an increasing
proportion of the public use the internet to buy many goods and services, so
pharmacy must continue to adapt to this environment. For pharmacy to survive as a
front-line health profession, it must offer a value proposition over and above that
available through the internet. The current predicament of community pharmacies is
similar to that of book shops and record shops, where success and survival in the
internet age has been achieved predominantly through differentiation and
specialisation. It therefore seems likely that there will be two models of “community
pharmacy” in the future. Firstly, a greater reliance on virtual pharmacies for those
patients that are happy to forgo personal service in return for convenience (and it
could be argued that this is entirely appropriate for patients stabilised on one or two
medicines, not experiencing any problems, or being treated for non-serious acute
conditions). And secondly, for community pharmacies that remain in the high street,
an evolving range of more personal service for patients with these necessarily
focussing on optimising medicines use in key groups including the elderly, patients
with multiple long-term conditions, and patients taking complex medication regimens.
For the latter model to succeed requires a change in focus for the commissioning
model. The model needs to move away from a nationally determined contract based
on prescription volume, and towards more locally commissioned contracts in which
pharmacists (individually and in groups) are paid to deliver care for defined
populations of patients. In this scenario the community pharmacist could be required
to take full responsibility for those patient’s medicines and their associated
information needs including, supporting shared decision making and where
appropriate, liaising with hospital pharmacies, care homes, GPs, community nurse,
homecare delivery companies etc. These “medicines managers” need to take
responsibility for ensuring that medicines are monitored appropriately, that patients
have access to an appropriate level of ongoing information and support with their
medicines, that there is a continuity of supply and that medicines are reviewed
regularly so that the intended outcomes are achieved in as cost effective a manner
as is possible. In terms of this latter activity it would also be nice to think that
community pharmacists would be ideally placed to work alongside medicines
management and commissioning colleagues to provide information on bespoke
patient reported outcome measures for some medicines (e.g. those with significant
expenditure used in long-term conditions). Such work would require pharmacists to
have access to the summary care record. It may also require an up-skilling of many
community pharmacists, and will also necessitate the establishment of a much closer
working relationship with local hospital pharmacy staff (in particular perhaps
facilitated in the first instance through increasing access to hospital medicines
information services). It could be argued that there are already examples of this type
of practice in place but we need to create the momentum to move this from being the
exception to the rule.
3. How can we better integrate community pharmacy services into the patient care
pathway?
As described, for the scenario described in Q2 to happen, pharmacists must have
read and write access to the Summary Care Record. Pharmacists would then
become the primary point of contact between the GP and other health (and social)
care workers for any questions relating to that patient’s medicines at every point in
the care pathway. This will require those pharmacists to become much more skilled
in retrieving, evaluating, contextualising and presenting evidence about medicines to
patients and to be familiar with the strengths and limitations of the common sources
of information about medicines. Addressing this training need should be a priority for
consideration by LETBs, the RPS and the CPPE. These pharmacists will also need
to have routine access to the key information sources and the ability to access
additional medicines information support and clinical expertise when necessary.
There may well be a need to further develop and increase awareness of existing
information resources from organisations like UKMI and NICE to support this work
and minimise duplication of effort. The LPN should be the primary mechanism for
some of the logistics and working relationships needed to make this happen.
It would seem that Scotland is already working towards achieving a similar vision of a
future for community pharmacy and it is important that NHS England learns the
lessons from there in terms of what works well, what works less well and what is
needed to make it a reality.
4. How can the use of a range of technologies increase the safety of dispensing?
Clearly routine access to the summary care record would provide a useful source of
triangulation of information about medication history for resolution of discrepancies
and recording allergies and ADRs. As such it would be expected to directly benefit
patient safety. In future pharmacists may also be a vital contributor to patient/carer
held “virtual” medical records and offer value by identifying relevant material to
supplement patients’ understanding of their medicines through tailored individual
resources.