Health and Social Care Committee

Inquiry into the contribution of community pharmacy to health services in Wales

CP 15 – Betsi Cadwaladr University Health Board

Betsi Cadwaladr University Health Board

Pharmacy & Medicine Management Clinical Programme Group

Gathering of evidence to the Health and Social Care Committee: inquiry into the contribution of community pharmacy to health services in Wales.

Please use this document to detail your responses to the consultation on all or part of the issues raised. Please return by the 31^st August.

Many thanks

The committee would like our views on the following:

· the effectiveness of the Community Pharmacy contract in enhancing the contribution of community pharmacy to health and wellbeing services;

The current community pharmacy contract has enhanced the contribution of community pharmacy to the health and wellbeing of population. There is a need to further develop this contribution by reviewing the current contract requirements and services. The financing of the contract is also in need of review as it is still predominantly focused on the item of service fees attracted by dispensing. A contract funding pharmacies to meet patients’ pharmaceutical needs and deliver outcomes would be preferable to the existing reimbursement for medicine supply.

· the extent to which Local Health Boards have taken up the opportunities presented by the contract to extend pharmacy services through the provision of ‘enhanced’ services, and examples of successful schemes;

The North Wales Local Health Boards took advantage of the enhanced services level of service with in the contract. The commissioned services have been public health rather than medicines management led such as EHC, Smoking Cessation, Supervised consumption and NSP.

Barriers to commissioning medicines management type services include overlap between GMS and Pharmacy services, i.e. GMS is funded to provide the service, but, because GMS money is ring-fenced  moving resources to fund a pharmacy scheme is difficult, e. g. minor ailments. Difficulties can also occur where the Health Board’s and contractors’ opinions differ in regards to what is considered contractual and what is an enhanced level of service e.g. public health campaigns and enhanced service interventions, multidisciplinary audit.

The EHC, Smoking Cessation, and NSE have all proved to be successful services and are all planned for national roll-out. Smoking cessation is currently producing quit outcomes rates comparable to Stop Smoking Wales.

· the scale and adequacy of ‘advanced’ services provided by community pharmacies;

The local uptake of advanced services is variable. Nearly all pharmacies in BCU are able to offer MUR, however few reach their full allocation. The independent contractors and smaller multiples seem to have been less concerned with quantity of MURs completed and to have focused more on the quality of the MUR being undertaken. In contrast, it appears that the larger multiples have developed a target driven culture to increase MUR uptake, while being less focused on the quality of the reviews undertaken.

In England, targeting MURs at specific patient groups would theoretically improve the return on the MUR spend, If this approach were to be adopted in Wales, it would also be beneficial if localities were given to opportunity to contribute to the process for deciding target groups, or the authority to set local patient target groups. This would help to target locally identified pharmaceutical needs.

No single pharmacy in BCU has applied to provide the AUR advanced service; this is probably largely due to a lack of knowledge and confidence to provide this service.

· the scope for further provision of services by community pharmacies in addition to the dispensing of NHS medicines and appliances, including the potential for minor ailments schemes;

The scope for community pharmacy to deliver a wider range of services is dependent on the structure and funding arrangements of the current GMS and Community pharmacy contract.

A national minor ailments scheme would require WG funding.. The scope of future services should be more focused on the delivery of evidence based pharmaceutical care planning and interventions rather than the provision of pharmaceuticals. There is a big difference between patients having possession of and taking medicines properly to maximise outcomes.

It is well documented that the more medicine you take the less likely you are to take them correctly, and the more likely the risk of side-effects. Also the more medicines are prescribed, the greater the chance of having multiple co morbidities, to be house-bound and have less contact with GPs and pharmacists. It follows that domiciliary patients on multiple medicines are at much higher risk of harm from unwanted side-effects than any benefits. Community pharmacists are in an ideal position to intervene with these patients and reduce waste and harm.

• the current and potential impact on demand for NHS services in primary and secondary care of an expansion of community pharmacy services, and any cost savings they may offer;

See paragraph above. Many admissions and demands for services (e.g. falls) are due to poor outcomes from medicines or as a consequence of poor medicines management. It is well known from the evidence, which medicines are most likely to cause harm. Taking the GMS contract for example Near Patient Testing (NPT) enhanced services have been commissioned to improve the management of these high risk medicines e. g.  DMARDS management.

One way to improve medicines management and improve outcomes for patients would be to identify these high risk drugs and have community pharmacies targeting MUR at these patients and supporting them in the community.

• progress on work currently underway to develop community pharmacy services.

Current work on enhanced services is focused on consolidation of service provision across the new Health Boards, and the launch and development of national enhanced services. There is some new service development being piloted, for these pilot services support should be sought from PHW to evaluate them effectively and develop the evidence base for further service development.

There are also a number of pilot schemes being undertaken by the primary care pharmacy team, that involve the identification of vulnerable domiciliary patients, and developing and delivering a pharmaceutical care package for the individual patient, in their own home. These schemes utilise more fully the skills of pharmacists and technicians’ to improve outcomes for patients and reduce waste on medicines and hospital admissions.

These pilots should be evaluated and any outcomes used to inform the development of community pharmacy services, community pharmacy is as well placed to identify patients in need of support and to work with primary care pharmacists and GPs to improve outcomes for patients. They are also the largest proportion of the pharmacy workforce so have a greater potential capacity to deliver these of services.

BCUHB Pharmacy & Medicines Management 23.8.11