Health and Social Care Committee

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

CP 34 – Hywel Dda Health Board

RESPONSE TO THE HEALTH AND SOCIAL CARE COMMITTEE CONSULTATION ON THE EFFECTIVENESS OF THE COMMUNITY PHARMACY CONTRACT.

Jenny Pugh-Jones Head of Medicines Management (Acting) Hywel Dda Health Board

September 2011.

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

The Community Pharmacy contract has the potential to really make an impact on this area as Community Pharmacies are in a unique situation where both patients and the wider members of the public pass through their door. To date the effectiveness of the contract is less than ideal due to a number of issues:

§ Lack of support/signposting at a national level for raising awareness of the services that Community Pharmacy offers.

§ Requires greater working partnerships with other Healthcare Professionals. Often other healthcare professionals are not aware of the contract although this is improving.

§ Public Health campaigns because of no funding often rely on ‘available material’ rather than clear strategic direction of travel. This is improving as Health Boards become more coordinated with their own Public Health Wales teams within organisations and linking in with internal communication teams.

§ The essential services around signposting and self care are not easy to determine clear patient outcomes and would benefit from a clearer focus. Documenting advice in this area is time consuming and often pharmacies struggle to demonstrate compliance with these services although it is well known that they perform a vital function in being the gateway to other services for all the public (not just patients)

§ Lack of clear steps that can be taken within the contract to withhold payment/or fine pharmacies for essential services where compliance is an issue.

§ At the moment the main remuneration aspect of the contact is dispensing, a rework of the contract is required to move this focus onto provision of further services.

§ There is no provision for domiciliary services – a significant proportion of patients will be delivered to hence never see the pharmacy/pharmacist, this potentially is a vulnerable group of patients who would benefit from the community pharmacy services but cannot or do not attend the pharmacy.

· 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;

· Hywel Dda had in place prior to national roll out both EHC and NRT (Level 2). The Health Board also supports provision of needle exchange and substance misuse enhanced services. The Just in Case boxes enhanced service is due to be implemented in the next few months.

· Hywel Dda also has a limited advice to care homes service and also a rota service in certain areas which require it.

· In additional to the above the Health Board supports Medication Administration Scheme which is in place in one of the Counties and is currently due to be rolled out across all of Hywel Dda.

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· The Health Board is also exploring additional services such as influenza vaccination (collating data at present on type of patients presenting at Pharmacies to access private schemes)

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

· There continues to be concern over the adequacy of the MUR and medicines intervention schemes for a number of reasons. The Health Board supports the MUR in principle and recognises the expertise and unique position of the Community Pharmacist to provide this service however concerns are raised as a consequence of target setting and include:

· There is no audit trail of the quality of the MUR (the Health Board has no access to audit the MUR)

· The target of 400 is inflexible, many small pharmacies do not have the opportunities without the need to undertake MURs on the same patients- even though this is annual the  benefits are often reduced by repetition of this service.

· Some Pharmacies have the capacity to do more than 400 MURS but are unable to do so.

· A target of 400 has lead to ‘anecdotal’ evidence of MURs being undertaken in patients that are unlikely to have any benefit, and questions whether this is an appropriate use of significant resource.

· Targeting MURs towards specific patient groups is of benefit but at present the Health Boards have no mechanism to enforce this measure.

· There is a need for MURs to be quality checked with regard to safety and value for money this would enhance the reputation of community pharmacists and MURs in the eyes of other healthcare professionals

· 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 minor ailments scheme in principle is supported but there are concerns on the resource implications of these schemes as although GPs time may be freed up by patients accessing the scheme inevitably there is another patient who requires the appointment so no overall cost efficiencies are seen within General Practice.

There is likely to be increase in paperwork for Community Pharmacy. The self care agenda should be promoted more effectively encouraging people to take responsibility for their ailments, perhaps supported by a scheme where a small payment is made to avoid patients not even considering purchasing often inexpensive remedies?

· Community Pharmacy has a place in the provision of other items such as appliances, enteral feeds, dressings etc and this needs further development as currently there is a trend for outside companies to provide such items direct to patients.

Some suggestions:

· Weight management and offer additional support

· Pain management service- to provide additional support and monitoring of patients to ensure appropriate use of mild to moderate analgesia at an appropriate step in the pain pathway.

· Support the structured lifestyle requirements of NICE in partnership with GP practices

· HF follow up clinics from Pharmacy- needs to be independent prescriber- good example of pilot in Hywel Dda

· Expansion of the stop smoking enhanced service to include provision of all therapies and also behavioural support at the pharmacy (all in one service).

· If services are to be moved closer to the patient’s home there is an increasing need for a motivated clinically driven workforce within CP which requires investment and support to ensure that pharmacist time is appropriately utilised and that MURs reflect the agenda.

• 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;

· Waste reduction is key to improving efficiencies within the Health Service and medicines are no different to other areas of health.

§ With £50million estimated of wasted medicines each year a concerted effort needs to be made to reduce this wastage, this may include;

§ Increase public awareness.

§ Review of GP repeat prescribing procedures.

§ Review of Managed repeat services.

§ Increase use of ‘green bags perhaps look at issuing from Community Pharmacies?

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

§ Along with the previously mentioned services that are in operation across Hywel Dda the following services are being developed:

§ Just in case boxes enhanced service currently to be rolled out

§ Medicines on discharge service

§ Medication Administration Scheme also being rolled out across Hywel Dda

§ Pilot of HF review in Pembrokeshire Pharmacy.

§ Influenza service in 2012-13 following collation of data in this year (2011-12)