Health and Social Care Committee
Inquiry into the contribution of community pharmacy to health services in Wales
CP 21 – National Pharmacy Association
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Response to the
National Assembly for Wales
Health and Social Care Committee
Inquiry into the Contribution of Community Pharmacy to Health Services in Wales
September 2011
Contact
Steve Simmonds
National Pharmacy Association
Bay Tree House
Colwinston
Cowbridge
Vale of Glamorgan
CF71 7NL
01656 668430
Email s.simmonds@npa.co.uk
National Pharmacy Association response to the Health and Social Care Committee Inquiry into; the Contribution of Community Pharmacy to Health Services in Wales
Part 1: The community pharmacy network in Wales
1. The National Pharmacy Association
1.1 The National Pharmacy Association (NPA) is the body which represents the entire spectrum and vast majority of community pharmacy owners in Wales and the UK. We count amongst our members nationwide pharmacy multiples, regional chains and independent pharmacies. This spread of members, our Wales and UK-wide geographical coverage, and our remit for NHS and non-NHS affairs means that we are fully representative of the community pharmacy sector. In addition to being a representative voice, we provide members with a range of commercial and professional services to help them maintain and improve the health of the communities they serve.
1.2 The NPA welcomes the Health and Social Care Committee Inquiry into the contribution of community pharmacy to health services in Wales and is pleased to be able to contribute to this important debate.
2. Community pharmacy
2.1 The network of over 700 community pharmacies across Wales together represents the most accessible part of NHS Wales. Located where people work, shop and live they provide convenient advice and support to the people of Wales right at the heart of their communities. To the public, it is perhaps the most accessible face of the NHS. Community pharmacies are – by definition – right in the places where local communities want them.
2.2 Each pharmacy in Wales has at least one highly trained and qualified pharmacist on the premises and available to people visiting the pharmacy. Pharmacists are experts in the use of medicines to treat disease. They undertake five years pharmacological and medical training and work within a code of ethics that requires them to continuously develop their professional knowledge and competence relevant to their field of practice. In addition there has been a significant investment over a long period of time in the knowledge and experience of the wider pharmacy team.
2.3 Community pharmacies, like GP practices, are independent contractors and an integral part of the NHS Wales family. Pharmacists are responsible for the supply of most medicines available to the public. They advise the public and other professionals on the safe and effective selection and use of medicines and other health-related matters. In recent years, pharmacy has expanded its role, and now supplies a broader range of NHS Wales services such as stop smoking support and help for people involved in substance misuse.
2.3 Pharmacies provide services in the heart of neighbourhood communities where they are within reach of the people who need them most – poorer people, older people and people with a disability or chronic condition. In addition to many people who do not have ready access to transport they provide a lifeline and are sometimes the only accessible contact with NHS Wales. For many, community pharmacy is the primary source of patient and public information about medicines, the number one healthcare intervention. Many people who are not registered with GPs visit community pharmacies.
2.4 The location of community pharmacies has a relationship with deprivation. In areas of highest deprivation, higher incidence of ill health results in higher prescribing per head of population. You will therefore find a greater number of pharmacies in areas of deprivation. This again makes community pharmacy the perfect vehicle to deliver healthcare services to those hard to reach communities.
2.5 Unfortunately the potential of the community pharmacy network to make a significantly increased contribution to the health of the people of Wales has not been fully recognised by the Assembly. Development of the role of community pharmacy in Wales has been hampered by a multitude of obstacles to its development and contribution.
2.6 If the Welsh Government is to deliver its Setting the Direction Strategy, to move services from secondary care to service delivery then, when also considered against a background of a large number of GPs approaching retirement and stable nurse numbers, the Welsh Government cannot continue to ignore the potential of community pharmacy to release capacity in GP practices and to bring on board much needed additional capacity.
2.7 In the One Wales coalition document for the last Assembly term there was, for the first time a real commitment and recognition of pharmacy through a commitment to develop a network of ‘Pharmacy NHS Drop-in Centres’. Unfortunately this was a case of rhetoric unrealised as reality, as the commitment battled against prejudice and inertia and eventuality nothing was delivered on the ground.
2.8 The introduction of the new Community Pharmacy Contractual Framework for community pharmacy in 2005 provided the Welsh Government with a vehicle to deliver a wider range of community pharmacy services. Unfortunately this opportunity has not been taken and instead of a focus on development and growth the focus of NS Wales in terms of community pharmacy has been one of monitoring and control.
Part 2: Response to the specific questions posed by the Inquiry
This section looks at the specific questions posed by the Inquiry into community pharmacy’s contribution to healthcare in Wales.
3) The effectiveness of the Community Pharmacy contract in enhancing the contribution of community pharmacy to health and wellbeing services;
3.1 Publicly funded community pharmacy services in Wales are provided across three tiers of a community pharmacy contractual framework. ‘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. Advanced Services such as Medicines Use Reviews allow pharmacists to identify problems patients 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 locally to supply NHS services such as emergency hormonal contraception and substance misuse support.
3.2 A basic contractual architecture is therefore in place to support the development of the community pharmacy network in Wales and to deliver a wider range of services from community pharmacy in line with NHS priorities, however putting a framework in place has little value unless it is accompanied by a clear vision and delivery plan.
3.3 The recently appointed Ministerial Pharmacy Task & Finish Group clearly articulated a strategic vision for the development of community pharmacy in Wales. This vision was fully supported by pharmacists across Wales and was supported by the National Pharmacy Association alongside the other pharmacy bodies. Unfortunately the group lacked ‘teeth’ and the vision was not accompanied by a delivery plan that had Welsh Government support.
3.4 The Assembly would be well advised to look at certain characteristics of the Scottish approach. In Scotland there is an articulated vision, a strategic delivery agenda, dedicated finance and a Chief Pharmaceutical Officer driving through the changes. This approach has resulted in a community pharmacy network delivering a range of national, fully integrated NHS services to the people of Scotland. The appointment of a new Chief Pharmaceutical Officer for Wales has been well received by the network and we would encourage the Assembly to ensure that he is given the tools to do the job.
3.5 Whereas there is much that can be achieved within the framework of the existing community pharmacy contract, there are areas where the contract could be improved. The current contractual framework arrangements which are geared to dispensing prescriptions too often put the community pharmacist and the Health Boards on different sides of the fence as a result of competing priorities.
3.6 The current framework is under pressure from both prescription volume and medicines costs, while the downturn in the public finances is prompting LHBs to scale down or actively decommission pharmacy services, with little thought for the impact on patients and the public.
To unlock the true potential of pharmacy, there needs to be a further shift away from prescription volume towards the provision of services and reward for quality. We would recommend that the Assembly and CPW undertake a radical rethink of the way in which community pharmacy funding is structured and how it incentivises the delivery of services.
The realignment of the national contractual framework with evidenced based interventions that meet the clinical needs of patients and address the health inequalities of our communities would bolster local collaboration and deliver better value for NHS Wales.
There is an urgent need to remove the perverse effects of decisions that are beyond the pharmacists’ control, such as prescribing intervals (decided by prescribers, largely GPs), the Pharmaceutical Price Regulation Scheme (agreed between the Government and the pharmaceutical industry) and currency fluctuations. Community pharmacy needs to be remunerated for the provision of services that are within their direct control.
New models for remuneration and reimbursement will need to be piloted to ensure they deliver a fair return for contractors while recognising the workload associated with safe medicines supply.
The funding system should incentivise the profession to deliver professional services within the context of the patient journey. This will require not just a shift in incentives, but a radical review of the way community pharmacy is remunerated and reimbursed.
The community pharmacy sector is positioned to play a significant role in helping NHS Wales to be more accessible, consumer-driven, efficient and focused on results.
4) 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;
4.1 In many ways the phrasing of the question identifies some of the key issues around the development and delivery of community pharmacy services in Wales. In relation to the strategic development of the network the Welsh Government has adopted a ‘hands off’ approach leaving the Health Boards to introduce community pharmacy services without any strategic direction. The result has therefore been an uncoordinated ‘scattergun approach’ to service characterised by isolated pockets of good practice which are themselves often transitory in nature accompanied by an endless stream of projects which, despite excellent outcomes, rarely evolve into regular services due to a lack of dedicated finance.
4.2 Given a new service to deliver that is supported by dedicated long-term funding the community pharmacy network has shown that it will respond positively and deliver the service professionally and with quality outcomes. When the Medicines Use Review (MUR) Service was introduced, community pharmacists across Wales were asked to undertake additional training and to make changes to their premises to introduce private consultation rooms. The network responded positively and last year the people of Wales benefited from over 100,000 MURs.
4.3 The direction from the Welsh Government, through previous Annual Operating Frameworks has focused LHBs on the monitoring and control of the contract as opposed to the development of the pharmacy network and it is not surprising that this, combined with extremely tight fiscal settlements has resulted in very little service development.
4.4 As LHBs experience fiscal tightening they have been quick to look to community pharmacy services as expendable services rather than properly considering the value of the service.
4.5 One area where LHBs would benefit from clear guidance from the Welsh Government is in the allocation of General Medical Services. The concept of General Medical Services was introduced to ensure that these services could be delivered by providers other than GPs if appropriate standards could be met. Over the years these services have all been earmarked as GP services and the door has been shut on other providers. One example of this was the recent last minute decision to withdraw the planned community pharmacy flu immunisation service in Aneurin Bevan and Cwm Taf areas in the face of GP opposition irrespective of the needs of the local population who were set to benefit from improved access and choice.
4.6 The lack of pharmacy representation on the Boards of LHBs means that community pharmacy is often below their radar and the potential benefits from engagement with community pharmacy are not being realised.
5) The scale and adequacy of ‘advanced’ services provided by community pharmacies.
5.1 At the time of writing the only Advanced Service of any significant scale that community pharmacies can deliver is the Medicines Use Review Service. From a standing start in 2005 the people of Wales are benefiting from over 100,000 MUR interventions. Whereas there are current plans to make the service even more effective it is disappointing to the profession that no other Advanced Services of any significance have been developed in the six years since this category was introduced.
5.2 The NPA understands that there are plans to introduce a new Advanced Service from October designed to reduce medication errors on discharge from hospital that often result in harm to patients and readmission to hospitals.
5.3 The NPA is extremely supportive of this new service and will provide support to its members to ensure that the service is implemented effectively. The NPA is however concerned that the new Advanced Service has arisen as a consequential of service development in England and not as part of a strategic development of the network in Wales.
5.4 The NPA would encourage the Assembly to look to take ownership of the community pharmacy contract in Wales and to develop and deliver a range of services from community pharmacies in Wales that help to deliver the strategic objectives of NHS Wales and meet the specific needs of the people of Wales.
6) 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.
6.1 There are a range of successful services being delivered in isolated locations across Wales. These services tend to fall into three key groups:-
1. Medicines management services. These services are designed to ensure that the patient and NHS Wales receive maximum value from its investment in medicines. This group includes services such as waste management schemes, hospital discharge support, minor ailments supply and compliance support.
2. Chronic conditions management services. These services are designed to support people living with chronic conditions and in particular people diagnosed with respiratory disease and diabetes.
3. Healthy Lifestyle Services: These services are designed to help the people of Wales lead a healthier lifestyle and include services such as sexual health services, substance misuse services, stop smoking, vascular risk assessment and obesity services.
6.2 The NPA would encourage the Assembly to take time to look at the excellent results being achieved in England through the Healthy Living Pharmacy Model and to look at adopting this model to the needs of NHS Wales. The Healthy Living Pharmacy (HLP) framework, and the quality criteria that underpin it, could be developed as the basis for a national quality framework in Wales.
6.3 In Wales there currently seems to be little concrete idea of the role that the Assembly wants community pharmacy to play in the medium term and no clear expression of the service that a pharmacy in Wales should be offering in the future. In Appendix A; the NPA suggests what services could be offered from pharmacies in Wales. It is clear that the pharmacy profession, NHS Wales and the people of Wales would all benefit from having a clear idea of what services they can expect to receive from a community pharmacy in Wales.
6.4 Medicines are the most frequently used intervention within NHS Wales and the backbone of modern healthcare. In recent years, there has been increasing concern about the lack of adherence by patients to medicines regimes, and how poor adherence represents a waste of resources, directly in medicine costs, and indirectly through suboptimal treatment resulting in poorer outcomes for patients. The high level of waste medicines in Wales is well documented and yet only in a handful of locations are community pharmacies commissioned to deliver waste management services. It is our recommendation that the Assembly recognise that as the experts in medicines community pharmacists are placed at the heart of medicines decision making.
7) 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.
7.1 The Wanless report to the Assembly clearly indicated that the priorities of NHS Wales could more effectively be achieved if there was ‘full engagement of all service providers’. In addition the same report recommended a transfer or workload from GPs to community pharmacy.
7.2 NHS Wales is facing unprecedented challenges as it seeks to manage a rising health burden alongside a reduction in funding in real terms. The NHS faces at least two challenges on that front, namely capacity and cost.
7.3 Capacity: The Welsh Government’s own primary care strategy ‘Setting the Direction’ recognise that there needs to be a significant movement away from delivering services in a secondary care setting to delivering services closer to home. If this is to be achieved then there has to be recognition that this cannot be achieved within existing arrangements. If GPs are to take on additional workload then they will need the support of nurses, pharmacists and other allied healthcare providers to manage some of the activities they are currently responsible for. For example the Assembly will need to decide where the treatment of minor ailments and self limiting conditions will take place. Continuing to tie up GPs treating minor ailments is clearly not the best use of resources when pharmacists are eager and capable of taking on this workload entirely. In addition demand for services such as annual healthchecks and healthy lifestyle advice can also be picked up by community pharmacy. The Assembly needs to recognise that the community pharmacy network is capable of releasing capacity in GP practices, to allow GPs to take on new enhanced roles and can in addition bring on stream considerable underutilised capacity.
7.4 Cost: In the current financial situation it is more important than ever to ensure that the NHS reduces costs wherever possible. One way of achieving this is to allow pharmacists to take on some of the workload currently undertaken by GPs as long as this workload is within their area of expertise and confidence. The cost of treating patients through community pharmacy is considerably lower than treating patients through GPs.
7.5 The Unit Costs of Health & Social Care for 2010 as published by the Personal Social Services Research Unit identifies that the cost of patient related activities by a pharmacist is £45 per hour compared to GP costs of £166 per hour. GP costs are therefore more than 3.5 times that of pharmacist costs.
8) Progress on work currently underway to develop community pharmacy services.
8.1 The NPA was pleased to see the many community pharmacy commitments in the Government’s Election Manifesto. We are concerned however that following the lack of delivery on the commitment to community pharmacy in the One Wales document that these commitments may also wither on the vine. Early indications are that the manifesto commitments are already being scrutinised in detail and the minimum action necessary to meet manifesto commitments is being looked at. This is clearly not the intention of the document and the Assembly needs to be supportive of community pharmacy and the commitments it has made.
8.2 The NPA is confident that the newly appointed Chief Pharmaceutical Officer has the both the experience and competence to ensure that the Assembly’s commitments are delivered. This will only be possible however if he is provided with the both the authority and financial allocation to deliver these new services.
8.3 What is required is a strategic approach to the development of the network and to ensure that all new community pharmacy services are fairly funded and fully integrated with other healthcare services. Designing community pharmacy services that are fully integrated and support GP services will support a move at local level from competition to collaboration.
Conclusion
The absence of a coherent and shared vision and delivery plan for community pharmacy is a key factor in the underutilization of the network. Community pharmacy has listened to a number of strategy documents and Assembly debates, each of which has made warm and comforting noises about the role of community pharmacy and how we must make more use of the network.
However, over the last ten years little has changed and next to nothing has moved forward. The NPA would encourage the Health & Social Care Committee to use the information received as a result of this Inquiry, to seek to turn rhetoric into reality and build on the goodwill that exists in community pharmacy to ensure that the people of Wales receive the pharmacy services they deserve.
The NPA is happy for the content of this response to be made public.
NPA, September 2011
Appendix A
A range of services that could be delivered from community pharmacies in Wales, given NHS investment
Medicines Management Services:
Support for self care
Minor ailments services
Medicines use reviews
Medicines compliance support
Hospital admission support
Hospital discharge support
Care home support services.
Carer support services
Waste management services
Independent prescribing services
Palliative care support
Language access scheme
Out of Hours medicines supply
Chronic Conditions Management Support Services
Condition monitoring
Structured patient education
Effective prescribing support
Specialised support services for people living with respiratory disease and diabetes
Osteoporosis medicines management
Stroke reduction support
Mental health services
Monitoring of newly prescribed medicines.
Repeat dispensing services.
Signposting and referral
Anticoagulation monitoring
Healthy Lifestyle Support Services
National health checks
Routine monitoring of blood pressure, blood glucose etc.
Stop smoking support
Alcohol brief intervention
Obesity management
Lifestyle advice on diet, exercise etc.
Sexual health services including contraception, pregnancy testing, conception support, erectile dysfunction and screening/treatment for sexually transmitted infections.
HIV screening.
HPV vaccination
Support to Injecting drug users: including supervised administration, supply of clean syringes and needles, Hepatitis vaccination and naloxone provision.
Helicobacter Pylori screening.
Vaccination services
Travel services.
Patient education
Support for Public Health Campaigns
Falls prevention