Despite the ongoing criticism of the Health Bill as it passes through the House of Lords, structural changes are still happening at ground level. Dr Thoreya Swage outlines the timescale for changes as PCT clusters switch responsibilities to CCGs.

The momentum of reform of the National Health Service in England continues to gather pace. Following a four month hiatus while the wise and the good of the NHS Future Forum pondered and produced recommendations for the adjustment of the Bill, the DH published further guidance on the developing role of the Primary Care Trust (PCT) clusters.

Although the 151 PCTs have been squeezed into fifty-one PCT clusters in preparation for their demise in April 2013, it seems that they have a vital part to play in the development of the emerging Clinical Commissioning Groups (CCGs).

This guidance or ‘shared operating model for PCT clusters’ has been produced by the mandarins at the DH to ensure that the commissioning landscape is as consistent and smooth as possible in time for the takeover by the CCGs. This is so that the nascent NHS Commissioning Board inherits a robust enough system to take account of further developments and improvements in healthcare in early 2013.

 

A shared model

There are six main functions or ways of working for the shared operating model for the clusters. These have been identified where consistency of approach is considered to be of importance and they are listed as commissioning development, financial and operational issues, ensuring quality, emergency planning, development of providers as Foundation Trusts and communications.

 

CCG development

The most important function is the preparation of CCGs for authorisation as soon as possible following the successful passage of the Health Bill through Parliament. The process of authorisation to become fully fledged commissioners is due to begin in the second half of 2012.

Although this is a year away, CCGs can commence their preparations now using a self diagnostic tool – an interactive computer-based assessment that helps them to determine their capability in six domains and identify their development needs.

The areas covered include:

• A clear clinical focus of the CCG commissioning plans to include tackling health inequalities and improving primary care
• Demonstration of meaningful involvement of patients and the wider community
• A plan for development that is clear and credible which, in particular, delivers the QIPP (quality, innovation, productivity and prevention) agenda
• Capacity and capability of the CCG, i.e. robust constitutional and governance arrangements which enable the CCG to commission care effectively and ensure financial control
• Collaborative arrangements for working with other CCGs, local authorities and the NHS Commissioning Board
• Capacity and capability of the CCG leadership which ensures effective working.

The tool helps the CCGs identify priority development areas which form the basis of the developmental plan paving the way to full authorisation.

To support all this work CCGs will receive £2 per head from the PCT clusters as well as extra management resource to help the groups hone their commissioning skills and capability.

CCGs experiencing difficulty in defining their boundaries will have guidance from PCT clusters on how to resolve this. PCT clusters also have the unenviable task of engaging the reluctant practices that so far have not participated in their local CCG discussions, with the aim of being part of a viable commissioning group by October.

 

Separating commissioning functions

All through the last quarter of this year a very detailed exercise is being carried out by PCT clusters to identify and segregate the service areas that CCGs and the NHS Commissioning Board will be responsible for. Although CCGs will be commissioning acute, mental health, community and ambulance care there are other services that PCTs currently commission which will need to be transferred to the Board.

Services such as GP and other primary care contractor groups – primary dental care, pharmacy and optical services – secondary dental care, prison, specialised and military health services are set to go under the umbrella of the NHS Commissioning Board. Even though the contracts for GP services are held by another body, the CCGs are expected to have an input into primary care development and improvement.

 

Quality assurance

A vital component of the commissioning process is ensuring the quality of healthcare. Practices may have been involved to a greater or lesser degree in various quality assurance processes in the past. However, CCGs are required to take on board these responsibilities seriously.

There is a whole raft of procedures and measures including delivery of better health outcomes for patients, meeting the Care Quality Commission (CQC) requirements for safety and quality of services, standard contracts, the NHS Operating Framework, professional guidance and other relevant requirements that CCGs need to get to grips with.

This could potentially be a vulnerable time for the development of the CCGs if attention wanders and serious patient safety incidents are not acted on promptly. Clinical governance processes must therefore be extra secure.

 

Budgets and responsibilities

Over the next year or so there will be a period of dual functioning and handover as the CCGs mature and the PCT clusters delegate more and more responsibilities until April 2013. The handing over of the baton has started now with PCT clusters having identified a “clear percentage of budgets” to CCG pioneers or pathfinders in August and plans for future delegation of budgets set by October.

Sandwiched in between will be the agreement on which mental health and community services will be subject to ‘Any Qualified Provider’ (AQP). This policy is set to be implemented from April next year when GPs can refer to providers of certain services eligible for AQP from a list of approved organisations, including the private sector, drawn up by the DH.

A review of commissioning support required by CCGs has already been undertaken in July with clear arrangements agreed by the end of the year.

In March next year, CCGs will be required to enable the development of the local health and wellbeing boards supported by their PCT clusters – health and wellbeing boards being the mechanism for joint health and social care planning and commissioning locally.

Meanwhile, individual PCTs will continue to carry out their statutory functions through the clusters until their abolition in April 2013. The statutory functions include contract monitoring, ensuring that providers meet their QIPP obligations and other statutory requirements, for example, safeguarding children and vulnerable adults.

The big challenge for CCGs will begin when they will be required to lead the next planning round for 2012/13. This begins in the latter part of this year and is a function previously undertaken by the PCTs.

This will involve doing a needs analysis, identifying local inequalities, understanding demand and activity for local services, negotiating and setting priorities with partners and developing the local strategic vision. Handover of commissioning functions will continue with CCGs being an active participant in the subsequent contract negotiations and agreement.

 

The outside world

It is apparent that despite the pause for reflection on the proposed changes in the NHS earlier this year, the momentum for restructuring and dissolving healthcare organisations continues. The picture remains a little confusing however, as CCGs are in varying stages of development and maturity and it is not clear that all will be truly viable by the tight deadline set for October.

What is clear is that that work of commissioning and delivering healthcare has to go on and now is a good time to find out who the key movers are within the CCGs.

It is at this point in time when the developmental needs of CCGs will be uppermost and it is here that pharma can provide some input. Skills and knowledge in leadership development and highlighting therapeutic areas where evidence-based care really works are two such possibilities.

CCGs will be keen to smooth patient pathways across primary and secondary care and nowhere is this more pertinent than in prescribing effectively. Delegated prescribing budgets are now very real for CCGs and they will be keen to ensure value for money and improvements in care for their patients. This provides a good opportunity for pharma companies to demonstrate the effectiveness of their drugs in specific disease areas.

On the commissioning front, by December of this year, CCGs and PCT clusters will have had to agree what commissioning support they need to carry out this function. Given the requirement to reduce costs, commissioning skills and expertise may actually be thin on the ground within CCGs.

Bearing in mind that effective commissioning will be judged by outcomes achieved as outlined in the NHS Outcomes Framework, pharma is well placed to demonstrate how their products can meet the requirements of domain 1: preventing premature deaths, domain 2: enhancing the quality of life of people with long-term conditions and domain 3: aiding the recovery of people who have an acute illness or injury.

The next few months will be busy while the NHS sorts itself out structurally. Once the picture begins to clear, pharma will need to engage with the new clinically skilled commissioners who now have the financial responsibility for making decisions about healthcare.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

The ABPI has backed proposals from the MHRA to repeal part of the Medicines Act which allows pharmacists to trade overseas without the need for a wholesalers licence.

Pharmacists can currently sell medicines intended for UK patients at an inflated rate to customers abroad and could potentially lead to a shortage for patients and the NHS.

Stephen Whitehead, CEO of the ABPI, says the current practice is “not acceptable” and the repeal of the legislation “is a good first step” for patients and the health service.

The proposal is expected to be approved and implemented in 2012.

The new legislation would mean that pharmacies will only be permitted to trade when there is a necessary public health need, when small quantities are required, the order is infrequent and deals are non-profit.

The UK has some of the lowest medicine prices in Europe. This has resulted, the ABPI says, in “flowing out of the UK” and having a direct effect on supplies.

“The ABPI welcomes the MHRA proposal to end the trading of medicines by pharmacies that do not have a wholesale dealers licence, except in exceptional circumstances to meet a public health need,” said Mr Whitehead.

“To fully address this challenge it is now essential that pharmacies who serve NHS patients directly need to separate wholesaling activities from pharmacy dispensing activities.

“The ABPI looks forward to taking an active role in solving the on-going challenges.”

London & Essex Medicines Management
Cardiology Discussion Forum Hosted by iRx Solutions, July 2011

Pharmacists have the appetite for medicines commissioning

The NHS landscape is changing, the shape of medicines commissioning especially. At a time when the NHS – like other parts of the public sector – is in financial dire straits, the Government is driving a radical overhaul of the structure of health and social care services, in England at least. But incoming CGCs will be crying out of support around medicines management and commissioning. It’s time for pharmacy to step forward.

According to Stuart Saw, Director of Finance at NHS East London and the City Alliance, the recent listening exercise and “pause” of the Health and Social Care Bill’s journey through Parliament has not resulted in substantial changes to the direction of travel. “Irrespective of what people thought the pause might bring, the momentum was already there before the pause was called and it’s impossible to turn around,” he told guests at a cardiology discussion forum, held by iRx Solutions in London last month.

It is this momentum that will, in all probability, see the formation of some 500 Clinical Commissioning Groups, formerly known as GP Consortia, replacing around 150 Primary Care Trusts, which are to be abolished.

Omar Ali (pictured above right, with Jayesh Shah and Victoria Overland), a formulary pharmacist in the NHS, and one of three directors at iRx Solutions, suggests that these commissioning groups will be crying out for support around medicines management and commissioning, and believes that pharmacists have the necessary talent to fill the gap. “We have experienced firsthand how much sway pharmacists have as decision-makers within the NHS. This cultural change has happened over a number of years but has resulted in our profession being in a prime position to help deliver a new outcomes-focused healthcare system, which needs our expertise – and needs it urgently,” he said.

Mr Ali and fellow iRx Solutions directors, Victoria Overland and Jayesh Shah, also NHS pharmacists, came together in 2010 to consider how they could facilitate sharing of ideas and good practice among such influential pharmacists. Their vision: a suite of medicines-related solutions, including specialist education and medicines commissioning support, delivered by expert pharmacists to colleagues in ‘payer’ roles. Their recent cardiology discussion forum was a refreshing mix of good food, sponsored and non-sponsored presentations, and debate – attended by prescribing advisers, heads of medicines management and other pharmacy leaders.

Victoria Overland, who comes from a background as a commissioning pharmacist in primary care, says that pharmacists are now among the key decision-makers and are well placed to influence both prescribing and commissioning in the new NHS. “Therapy choices made by GPs,” she explains, “are currently supported by PCTs, which have a wealth of commissioning experience – balancing effectiveness and outcomes with the costs to the health economy. When the PCTs disband, this requirement for high-quality medicines commissioning support will still exist. What will be different about it is that Clinical Commissioning Groups will be making decisions that they feel best suit the needs of highly localised populations. We know that pharmacists have a great deal of experience in reviewing the efficacy and safety of medicines, and, crucially, their impact on healthcare budgets.”

So what did participants hear about at the discussion forum? Cardiology content was served up alongside presentations from Stuart Saw, who described the challenges being faced with the NHS reconfiguration, and Omar Ali, who gave an express tour of how value-based pricing of medicines might work in the future.

Helen Williams, Consultant Pharmacist for cardiovascular disease in south London, outlined how appropriate changes in drug therapy could support the Government’s QIPP – quality, innovation, productivity and prevention – agenda. Conversely, she questioned the wisdom of switching patients from certain branded angiotensin-receptor blockers (ARBs) to generic losartan. Ms Williams argued that some of the branded ARBs are due to come off patent in the near future and that the healthcare costs associated with switching therapies – not to mention the potential disruption for patients – might not be justified.

“We had nine years between simvastatin patent expiry and atorvastatin patent expiry and, as a result, we’ve saved millions,” she told attendees. She pointed out that the losartan patent expired in March 2010, adding: “We’ve got valsartan [expiring] this year and we’ve got candesartan and irbesartan next year. So I think we’ve missed the boat. If we wanted to make savings . . . from generic losartan, specifically, we needed to plan for it in 2008–09.”

Stable angina was also on the menu, with the profile of the condition set to be lifted following the publication of a new clinical guideline by the National Institute for Health and Clinical Excellence. Making clear that the NICE guideline was only in its draft form (when the discussion forum took place), Sotiris Antoniou, Consultant Pharmacist CV Medicine NE London CV & Stroke Network Barts & London NHS Trust, described the place in therapy of the range of medicines available for treating stable angina patients in the UK. He emphasised the need for clinicians, when interpreting NICE guidance, to “think about the whole patient” and his or her quality of life.

This is something that Jayesh Shah understands all too well from working as a medicines management pharmacist, supporting GP consortia. “With so many changes since the White Paper was published last year, there is a lot of confusion among both clinicians and managers,” he says. “But something we are certain about is that healthcare professionals care a great deal about their patients and want the best outcomes for them. So that’s our passion and driver, and meeting the ambitious goals of the QIPP agenda is also an imperative.”

According to Mr Shah, a healthy dialogue between pharmaceutical companies and pharmacists – “we need to think creatively about this relationship” – will help the industry to align its priorities with those of the evolving NHS. Omar Ali adds: “We are committed to working with the pharmaceutical industry to ensure all aspects of our educational events meet regulatory requirements. Moreover, iRx Solutions is committed to ensuring the quality of the content and speakers is exceptional. But we know that this kind of meeting is about more than the educational programme: both pharma and medicines management attendees see the value in time put aside for networking.”

Progress of the NHS reforms may have slowed, but it appears that momentum is building in at least one profession to tackle whatever the Government manages to push through Parliament. If the opinions of the team at iRx Solutions are anything to go by, pharmacists certainly have a bright future as decision-makers around medicines.

The directors are speaking on behalf of iRx Solutions not the NHS organisations by which they are currently employed. For more information on iRx Solutions, visit www.irxsolutions.co.uk.

Regulators have issued warnings that thousands of packets of Nurofen Plus could have been mixed up with anti-psychotic drug, Seroquel XL.

The Medicines and Healthcare products Regulatory Agency (MHRA) issued the alert after three packets of Nurofen Plus were found containing individual blister packs of Seroquel XL in branches of Boots in the Victoria, Beckenham and Bromley areas of London.

The MHRA decided not to recall thousands of batches of the 32-tablet packs, but to urge “extra vigilance” to consumers, as the affected packets could be in pharmacies across the UK.

Nurofen Plus’ manufacturer, Reckitt Benckiser said “serious investigations” were underway to establish how the mix-up occurred, as Seroquel XL is manufactured by another drug firm, AstraZeneca.

A number of theories have been offered, but the drug makers are not believed to be at fault. The first suggestion hinted a simple mix-up at a wholesaler, but neither company is ruling out sabotage at this time.

Siân Boisseau, Director of Virgo Health, a public relations firm which represents Reckitt Benckiser, told the Guardian that there has been a “suggestion that the packets were deliberately put in the wrong boxes”.

The two drugs are very different. Reckitt Benckiser’s Nurofen Plus is one of the most popular brands of painkiller, whereas Seroquel XL by AstraZeneca is a prescribed anti-psychotic medicine to treat several disorders, such as schizophrenia, mania and bipolar depression.

People who accidentally take Seroquel XL may experience drowsiness and are advised to not drive or operate any tools or machinery until they know how the tablets have affected them. Other side effects include dizziness and headache.

The large capsules of Seroquel XL 50mg have gold and black packaging while the Nurofen Plus tablets are smaller and have silver and black packaging.

Ian Holloway from the MHRA's Defective Medicines Report Centre (DMRC), said: “People should check to see if they have any affected packets of Nurofen Plus. If you do, return them to the pharmacy where you bought them from”.

“If you have taken a tablet and you have any questions, speak to your GP,” he added.

A statement from AstraZeneca said: “Patient safety is the primary concern of AstraZeneca and the company is taking this issue seriously. AstraZeneca is collaborating with the MHRA and Reckitt Benckiser to investigate the root cause.”

In response to the Independent Pharmacy Federation’s (IPF) survey, which noted Eli Lilly amongst the top three pharma companies to present the greatest difficulties in obtaining medicine supplies, a spokesperson for Lilly UK issued the below statement:

“Lilly is committed to ensuring that UK patients have access to our medicines and consequently distributes more than sufficient medicine to meet UK demand, through our direct to pharmacy distribution system.”

This is administered by two Logistic Services Providers (LSPs) and backed up by an emergency service; whereby a pharmacy can phone Lilly direct on our free phone number 0800 012 1178 and we will arrange a delivery at the next available opportunity – typically within 24 hours.”

Lilly UK is confident that our direct to pharmacy procedures provide a good and robust service to patients and pharmacists and adheres to the joint guidance: “Best Practice for Ensuring the Efficient Supply and Distribution of Medicines to Patients” and “Trading Medicines for Human Use: Shortages and Supply Chain Obligations”, issued by the Department of Health (DH).”

While we continually review and update our own procedures to ensure that every UK patient has access to our medicines, the difficulties experienced in providing consistent supply of medicines have been acknowledged by the DH as being caused - at least in part – by product diversion.”

For Lilly, one of our specific concerns is around the diversion of olanzapine (Zyprexa). This is likely to be a significant contributing factor in the IPF’s findings due to the impact these shortages have.”

We encourage the IPF to lend its support to driving adoption of the recent Department of Health guidelines and as well as sharing the results and methodology of its survey with us directly so that we may better understand their findings.”

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Teva has issued a letter to UK pharmacies promising to provide legal support to any facing legal action over dispensing its generic drug atorvastatin.

As part of the ongoing legal battle between Teva and Pfizer, the generics company is currently banned from providing its version of Pfizer’s Lipitor until a full hearing on 11 July.

The temporary injunction also prevents two other generic companies, AAH and Phoenix, from providing generic versions of the drug. Pharmacies are permitted to dispense their current stock of generic atorvastatin, though The Royal Pharmaceutical Society has advised its members to return the stock if possible.

Pfizer is pursuing the case to protect its supplementary protection certificate (SPC) patent for atorvastatin, currently valid until November. The company has also applied for a six-month paediatric extension to the SPC.

At a hearing on 27 June Pfizer failed to obtain an injunction against Rowlands Pharmacy for providing the drug and it was confirmed that Teva is permitted to offer legal assistance to any other pharmacies caught up in the case.

The letter stated: “We feel strongly that we are acting in the interests of sustainable and affordable healthcare delivered via the pharmacy, and we will do our utmost to support our customers.”

A recent survey by MGP and Brainsell reveals pharmaceutical advisers and senior medicines management pharmacists believe the transition to the planned NHS reforms may not be a smooth one.

The White Paper Equity and Excellence: Liberating the NHS sets out the new Government’s strategy for the Health Service. The intention is to create an NHS which is more responsive to patients, and achieves better outcomes, with increased autonomy and clear accountability.

One of the central features of the proposals in Liberating the NHS is to devolve commissioning responsibilities and budgets as far as possible to those who are considered best placed to act as patients’ advocates and support them in their healthcare choices. The aim is to empower GP practices to come together in wider groupings or ‘consortia’ to commission care on their patients’ behalf and manage NHS resources.

PAMMtrak is a bi-annual survey that gathers the views of, and highlights the key issues facing, pharmaceutical advisers and senior medicines management pharmacists. In October 2010, healthcare publisher MGP and specialist market research company Brainsell carried out a specific survey of this PAMMtrak audience to assess how they see the future in the light of the Government’s White Paper.

The results of this online survey are based upon the first 100 responses and make very interesting reading for those working in the pharmaceutical industry.

The new NHS

Only 17% of pharmaceutical advisers and senior medicines management pharmacists who responded to the questionnaire are positive about the future under the new commissioning arrangements; whilst 58% are either quite or extremely negative. Indeed, more than 80% believe that their colleagues feel either quite or extremely negative about the proposed changes.

When asked about their greatest concerns over the new arrangements, typical comments included:

“The destruction of the PCT and SHA organisation and expertise, the loss of their functions particularly in regard to quality and patient safety.”

“The proposals to completely remove PCTs. I agree there is potential opportunity to make some savings in management costs but the many functions and benefits that PCTs bring to the NHS are I’m afraid going to be thrown out with the bath water and we will have a system in total chaos.”

“The disintegration of medicine management services and rising prescribing costs.”

“Fragmentation, particularly with respect to medicines management.”

“Medicines management teams can be quite large in some areas, if we are to be directly employed by GP consortia, how are they expected to pay for the whole team? Will they want to? Therefore, jobs may be lost.”

“The lack of pharmacy networks if pharmacy moves to consortiums.”

“That GPs will not sufficiently comprehend the value of our offering and choose not to use our medicines management services but go elsewhere for them.”

“Uncertainty as to where we will be. Will there be a role for us and will this be within the NHS umbrella?”

“Losing my job.”

Respondents were also asked: “What do you consider will be the major changes to medicines management under the proposed new NHS commissioning arrangements?” Typical responses included:

“The drug budget being passed to GP consortiums.”

“It may become fragmented with individual consortia each taking their own focus. This may have benefits if benchmarking and sharing across consortia are developed.”

“Prescribing teams having to create their own limited companies and therefore not being NHS staff. Working for GP consortia and, again, not being an NHS employee.”

“Loss of capacity, expertise and leadership within medicines management, particularly in primary care, where the majority of the QIPP changes (major cost savings) will be delivered.”

“Greater focus on direct work for GP practices, budget management, formulary management, working on GP agenda rather than PCT agenda. Employed directly by consortia? More outsourcing/industry involvement.”

“It will be positive as working with doctors more closely.”

Assumed responsibilities

When asked to think about which organisations under the proposed new NHS commissioning arrangements will have prescribing formularies, clinical guidelines/care pathways, and provide medicines management advice the results point largely to foundation trusts and GP consortia/consortia federations.

It is interesting to see that under the new arrangements roughly 50% of pharmaceutical advisers and senior medicines management pharmacists consider that they will be employed directly by GP consortia and 28% by GP consortia federations. Additionally, roughly a fifth considers that they will be employed by either a social enterprise spun out from a PCT or a private provider company.

The majority of respondents consider that they will be working in a salaried post. Although interestingly over 16% think that they will be working on a ‘fee per project’ basis, over 10% on a fee related to target achievement and over 8% on a percentage of drug savings basis.

From the list of medicines management activities that they consider that they will be involved in it would seem that these will be in managing the prescribing budget, formulary management, cost minimisation, prescribing reviews and formulary development. More than half also consider that they will be involved in care pathway design and implementing national guidance.

The link with pharma

The respondents were also asked how likely they would be under the new commissioning arrangements to engage in joint working with the pharmaceutical industry in a range of activities.

The responses were largely positive with the leading areas where they would be likely or very likely to engage with the industry being training, patient education, project staff support, economic analysis and guideline implementation. Roughly a third stated that they would be unlikely to engage with pharma in this way, meaning that two thirds may be happy to do so.

With the emphasis for commissioning shifting to GP consortia it seems that those involved in delivering medicines management have an uncertain future. However, this survey suggests that it is important that companies build strong relationships with the emerging GP commissioners and their medicines management teams and that there is a strong opportunity to do so.

The following are just a few examples of how the work of community pharmacists is expanding across the UK.

Local coagulation testing in Essex

Contact: Surinder Singh Kalsi, Pharmacist, Kalsi Pharmacy, Barking

The service: When the local PCT was inviting bids for an anti-coagulation drugs monitoring service, Community Pharmacist Surinder Singh Kalsi put in his bid in collaboration with two GPs. They won the bid and started the service in March 2007.

Why was it needed?
Anti-coagulation monitoring was previously carried out in hospital clinics, but there were frequent problems with GPs not getting results sent through, as well as patients finding it difficult to make the clinic times. Patients on anticoagulant medication need frequent blood tests, often weekly, and not turning up for an appointment can have serious consequences for their health. “We offer patients convenient, flexible appointment times, six days a week. We also run two lunchtime clinics in LIFT (Local Improvement Finance Trust) centres and two further clinics in GP surgeries, which will soon include a third clinic. We’re also doing home visits for those patients who are not mobile,” says Surinder.

Positive feedback: The most recent patient evaluation survey received a 97% satisfaction rate. Patients particularly praise the convenient appointment times, speedy service and efficiency of the system. The GPs are happy too. “Before we took over the service, GPs used to complain that results were not passed on from the hospital clinics quickly enough, or sometimes not sent at all. We send a report to the patient’s GP immediately after each testing and this helps to ensure the patient’s condition is kept stable,” explains Surinder. “We now get invited to the PCT cluster meetings and this gives us the opportunity to air our case in front of the decision makers. GPs are now contacting me for advice on their patients in terms of antibiotic prescribing and choice of other treatment options for other conditions too.”

Prescribing better patient care in Devon

Contact: Karen Acott, Superintendent Pharmacist and Partner, Wallingbrook Health Centre, Chumleigh, Devon

The role: Karen Acott is the fi rst pharmacist to become a partner in a GP practice. “We have a lot of elderly people in our area for whom access to a pharmacy is difficult, so we have a dispensary set up at the surgery,” says Karen. “The GPs were spending a lot of time on medicines reviews which didn’t make the best use of their skills and time. It made sense to have a pharmacist on board to do this for them.”

How it works: All the patients in the practice who are on repeat medication have a medication review once a year. “The doctors still do the more complex medicine reviews such as for cancer patients or mental health patients, but otherwise the doctors will refer any patients with medication queries or problems to me,” explains Karen. “The doctors will often call on me to give advice on medicines queries they have and I also get most of the pain control referrals as this is my specialist area.” Karen also runs a weekly diabetes and epilepsy clinic and briefs the doctors on the latest drugs studies and new National Institute of Health and Clinical Excellence (NICE) medication recommendations.

Breaking new ground: “I think pharmacists should be using their specialist skills in a variety of environments and I’d like to see more of them taking steps to qualify as independent prescribers and use these skills,” says Karen. “I’m often called to give advice to other independent prescribers across the country and invited to participate in Governmentled focus groups, which is really worthwhile as I’m able to give them a realistic and hands-on view of what pharmacists can contribute to the health service.”

Keeping patients out of hospital

Contact: Pam Grant, Medicines Management Pharmacist, Bournemouth and Poole PCT

The problem: Many older people with long-term conditions such as Parkinson’s, type II diabetes and Alzheimer’s have problems taking their medication correctly and the result of this can be hospital admission or moving into a care home.

The solution: In 2002, Pam Grant started developing a medicines management support scheme in Poole. The scheme was designed to help vulnerable patients avoid a hospital stay and remain independent for longer. In 2004 she put a business case to her PCT, presenting data which showed that one in six of the patients she helped had avoided hospital admission. The service was set up in 2005, with three part-time technicians supporting her and 29 pharmacies participating in the scheme.

How it works: The medicines team visits each patient that is referred to them and takes over the ordering of their medicines on a 28-day cycle, as well as providing information and advice, which helps ensure better compliance. “For patients who find it difficult to remember which tablet to take and when, we use specially designed blister packs, with the day and date on each blister. For partially sighted patients we also use dispensing devices, which have an alarm that sounds when it’s time for the patient to take their medication. The device is linked to a call centre, so if the patient doesn’t take their medicines, we’re automatically alerted,” explains Pam.

Is the scheme successful?
Data from 2004 and 2006 shows a reduction in emergency admissions to hospital of 18% and 25% respectively among the patients using the service. In 2006/2007, the service made savings of over £25,000 in prescribing costs. The service only needs to prevent a two-day stay in hospital for each patient managed by the team to cover the running costs.

Preventing medication errors and hospital re-admissions

Contacts: Harriet Lewis, Trafford Pharmacy Network, Trafford PCT; Margaret Ledger-Scott, Chief Pharmacist and Clinical Director Medicines Management, Durham and Darlington NHS Foundation Trust

The problem: When patients are discharged from hospital there is a risk of a communications failure between hospital staff and health professionals in the community, which can result in confusion over medication taken in hospital and that taken at home. Two pharmacist-led schemes have helped to overcome these issues.

Faxing medication summaries: When patients are discharged from Trafford General Hospital, a summary of their discharge medication is faxed to the patient’s pharmacist as well as the GP. “We set up the scheme because we found that the discharge summaries sent from hospital to GP weren’t being acted on quickly enough, so changes to a patient’s medication made in hospital weren’t being followed through,” says Harriet Lewis. “This kind of new service helps to establish the position of the community pharmacist within the wider healthcare team. Pharmacists are the last safety point at the end of the patient care line, and they should be included in the communication links across the interface.”

Treatment booklet: At Darlington Memorial Hospital, the pharmacy team has designed a booklet which is given to patients on discharge and records all aspects of hospital treatment received, including medication. Twelve months after initiation of the project, less than 2% of patients who had been discharged from hospital with a booklet had experienced medication errors. Hospital re-admissions were reduced by 71% “Patients using the booklet became more responsible for managing their own healthcare – they understood what their medicines were for, why they were taking them and they queried any changes,” says Margaret. “The booklet does not only record medication but also risk factors, test results etc. – showing our pharmacists now have a more holistic approach to patient care.”

Published with kind permission from the Royal Pharmaceutical Society of Great Britain.
www.rpsgb.org

The role of the pharmacist is evolving, and with it, community pharmacy’s importance as a customer of the pharma industry. So what do you need to know about these new healthcare providers?

In the not so distant past a sales call to pharmacy customers was often managed with a few boxes of extra stock, pens or note pads for the assistants and a quick chat about the latest discounts or advertising campaigns. However, changes within the NHS and changing roles for community pharmacists means that sales forces have to develop new strategies to work more effectively in community pharmacy and build mutually beneficial relationships.

Clinical experts on the High Street

Pharmacists are no longer simply dispensers, counting and labelling medicines, but are being actively promoted as readily accessible clinical experts on the High Street. NHS patients are increasingly being encouraged to visit their pharmacist for advice and treatment before requesting an appointment with their GP. Last year, almost one in five patients in a Department of Health survey put their pharmacist as their first choice when seeking information about their long-term condition and almost two-thirds of people with long term conditions who visited their local pharmacist felt encouraged to self care. Therefore, pharmacists are taking greater responsibility for prescribing and disease management in association with patients and GPs. Pharmacists are also influencing medicines usage at a number of levels from medicines use reviews (MURs) through to independent prescribing, which makes them an important audience for pharmaceutical companies and their sales forces.

The vast majority of pharmacists welcome this shift to a more clinical role that allows them to become more engaged with their customers and patients. In the past few years over 1800 pharmacists have undergone additional training to become an independent or supplementary prescriber. Understanding the different levels of clinical engagement of your pharmacist customers is important for pitching your sales or product presentation at the appropriate clinical level and building relationships with a new group of prescribers.

Supplementary prescribers

Supplementary prescribing is a voluntary partnership between the independent prescriber (doctor or dentist) and supplementary prescriber (pharmacist). With the patient’s agreement the prescribers implement a patient-specific clinical management plan (CMP) which enables the pharmacist to prescribe any medicine for the patient that is referred to in the plan until the next review by the doctor or dentist. There is no formulary for supplementary prescribing and no restrictions on the medical conditions that can be managed and the pharmacist has the discretion in the choice of dosage, frequency and product as specified by the CMP.

Independent prescribers

Independent prescribing was introduced in 2006 as a means of improving patient care and choice and access to medicines. Pharmacist independent prescribers can prescribe any licensed medicine for any medical condition that the prescriber is accredited to treat. This includes most medicines in the British National Formulary with the exception of Controlled Drugs.

Special interests

Pharmacists with Special Interests (PhwSI) are pharmacists who deliver a clinical service normally through their pharmacy, beyond the scope of their normal professional role. A PhwSI has to be individually accredited by the primary care trust (PCT) to provide a specific specialist service and they will normally work across a locality or PCT within a clinical network. Although they are not required to qualify as prescribers, as they work closely with GPs and other primary care professionals they play an important role in prescribing decisions. Service areas for PhwSI range from anticoagulation services to the management of long term conditions such as diabetes or asthma.

Pharmacists can also deliver prescribed medication through Patient Group Directions (PGDs) and Minor Ailment Schemes. A little research before you visit a pharmacist for the first time can ensure that you provide the appropriate information at an appropriate level of detail.

Medicines Use Reviews

Compliance is a major issue with medication in the UK and can result in patients not getting the full benefit of a medication as well as drugs being wasted.

MURs are an Advanced Service within the Pharmacy Contract and consist of accredited pharmacists undertaking structured concordance centred reviews with patients on multiple medicines, particularly those receiving medicines for long term conditions. The review is intended to help patients understand their treatment and identify any problems they are experiencing along with possible solutions to enable patients with LTCs to manage their condition better. A report of the review is provided to the patient and to their GP. Some pharma companies offer tools to assist pharmacists in carrying out such reviews.

Medicines Use Reviews and Prescription Intervention Services represent an opportunity for pharmacists to improve the service they offer patients and generate additional income. Such reviews also offer pharma companies and sales reps an opportunity to support pharmacists and discuss your products – benefits, interactions etc.

Role of education and training

Top tips for sales reps Raj Patel, superintendent pharmacist at Mount Elgon Pharmacy in London offers his tips to sales reps to ensure a successful call: • It may be obvious but do make an appointment to see the pharmacist and their staff. If you haven’t met them before find out their name before you visit. • Make sure you’re on time – allow plenty of time to find a parking spot, particularly in city centre pharmacies. If you’re delayed or have to cancel always phone to let the pharmacist know. • Keep up to date on changes within pharmacy – those driven by the profession, by government, by local primary care priorities and by consumers – and use your knowledge to identify opportunities for the pharmacist and your company. • Be aware of the priorities of local primary care organisations (PCO) and whether these offer opportunities for you and your pharmacist customers. • Understand what pharmacists and their staff need in terms of marketing support materials and training. Ask for feedback on materials and pass it back to head office. • Know if your pharmacist is a prescriber or has a Special Interest, so you can pitch your discussion at the appropriate level. • Recognise that pharmacists are healthcare professionals as well as business men and women, so presentations based purely on commercial benefits are unlikely to have as much impact as ones that integrate the professional and commercial aspects. • Respect the fact that pharmacists have little time to spare, so keep your presentations short and to the point. • Be polite to counter staff and always leave the door open to come back again. • Be smartly dressed – they will be!

Developing all the new pharmaceutical services proposed by the government in community pharmacies will require trained pharmacists and adequate remuneration will be a key factor in determining where and how pharmacists do this training.

Pharmacy staff will also require training to supervise certain aspects of the dispensing and supply of medicines which will help free up pharmacists to use their clinical skills to better effect, e.g. carrying out MURs, and to improve the range of services available in the pharmacy. The changes in the pharmacist supervision requirements also provide opportunities for pharmacy staff to develop their skills.

Although there are ambitious plans for pharmacies and the services they could offer in the future, you will appreciate from visiting busy pharmacies that most pharmacists are already overstretched with dispensing and the other obligations of running a business and staff management. Another concern for pharmacists is how such new services will be funded, particularly as their NHS income has already been effectively cut by Category M changes in the Drug Tariff.

Pharma companies are ideally placed to offer some support to pharmacists in their new roles. Through development of training materials, sponsorship of equipment and even remuneration for specific MURs, pharma companies could find themselves in the advantageous position of having a key input into emerging practitioners, which would then have positive effects on brand awareness and recommendation. By asking your pharmacists what support you or your company could provide to enable them to carry out these new services, you will build a stronger relationship and perhaps grow your category and brand share.

If you are introducing new product lines or switching a product from POM to P, make sure that your pharmacists and their staff are fully prepared for launch. Many pharmacists find it helpful to have training materials for new products or initiatives presented in brief face-to- face seminars as staff have the opportunity to ask questions.

Share your knowledge and expertise of sales and marketing with your customers. If you are aware of initiatives or promotions that have worked well for other pharmacy customers, discuss with your pharmacist how they could introduce or implement similar changes or training programmes. Television or press advertising drives customers into pharmacies so make sure you give advance notice of campaigns and their key messages.

Fawz Farhan and Paul Lowndes are directors of Mediapharm, a marketing communications consultancy specialising in pharmacy education. Mediapharm produce Pharmacy Insight, a free monthly report for marketeers on pharmacy and the new opportunities for pharma companies.You can subscribe at www.mediapharm.co.uk.

Deborah Evans and Michael Holden look at how the role of the community pharmacist will change as part of the White Paper’s vision for pharmacy, and how this will create new opportunities for partnership working with the pharma industry.

Over the last three years much has changed that has impacted and continues to impact on community pharmacy in England and the pharmaceutical industry (See box 1). These provide both opportunities and challenges for community pharmacy as it realises its full potential within the primary healthcare team. Overcoming these challenges, managing the change, dealing with the insecurities and threats and optimising the opportunities is being met with varying degrees of success by the NHS, industry and pharmacies. The model is moving away from just medication supply to one that increasingly involves the delivery of clinical services.

These provide both opportunities and challenges for community pharmacy as it realises its full potential within the primary healthcare team. Overcoming these challenges, managing the change, dealing with the insecurities and threats and optimising the opportunities is being met with varying degrees of success by the NHS, industry and pharmacies. The model is moving away from just medication supply to one that increasingly involves the delivery of clinical services.

As a consequence of the Pharmacy White Paper (Pharmacy in England - building on strengths, delivering the future), published April 2008, the pharmacy contract in England is now undergoing a review to meet future needs and deliver more quality markers.

Needs

As the NHS moves away from provision and further towards a commissioning role, the roadmap for pharmacy is becoming clearer; it needs to be, and be seen to be, a clinical profession providing quality healthcare services. Financial and distribution changes related to medicine supply have created some tensions between the industry and community pharmacy over recent years.

We must acknowledge that new operating models are here to stay in some form or other, and community pharmacy needs the support of the industry to manage the change, overcome skill and knowledge gaps, support service development and facilitate effective engagement and integration with other primary care providers and commissioners.

The traditional product model for the industry is changing to product-plus-service as financial balance-driven medicines management strategies and evidence based prescribing impacts on turnover and competitive position in the market. Companies are looking for additional strategies to grow and protect their portfolios.

To achieve a win-win, all parties need to identify and address each other’s needs through effective partnership working.

Opportunities

The White Paper highlights pharmacy’s significant place in the NHS, and while the focus is mainly on community pharmacy, its context is wider, including hospital pharmacy, professional regulation and education and training. The vision is one of an enhanced clinical role for community pharmacists as providers of new patient services including case finding, long-term condition support, medicines management and prescribing, plus the improved delivery of existing services like health awareness, self care and compliance support from ‘Healthy Living Centres’.

The White Paper also seeks to:
• improve access to medicines and promote their safe and effective use
• increase implementation of repeat dispensing to deliver benefits to all
• reduce medicines waste through improved management and compliance
• overcome the challenges associated with accessing medicines out of hours
• improve access in rural areas, e.g. Dispensing Doctors may be able to sell OTC medicines
• establish information exchange between secondary and primary care interface
• commission services for the safe delivery of oral chemotherapy
• embed safe medicines practice in primary care to reduce unplanned hospital admissions.

Medicines Use Reviews (MURs) remain a high priority area for the NHS with improvements in service quality and targeted therapy areas based on local health needs. Peer review, Continuing Professional Development, research, audit and decommissioning of MURs from those failing to meet quality standards are all recommended in the White Paper.

Change is essential

Community pharmacy will need to change both culturally and operationally to provide additional patient value, whilst delivering excellence and consistency in services. It will need to:
• be repositioned, recognised and valued by all as healthy living centres
• change the business model to an expanded range of patient clinical services
• deliver the core supply role safely, consistently and efficiently
• adopt legislative changes to deploy the whole pharmacy workforce
• improve inter-professional relationships, particularly with GPs
• have access to Summary Care Records
• electronically capture interventions and use new technologies
• be more focused on measurable quality outcomes
• build on professional, clinical and leadership competencies to deliver services.

What does this mean for industry?

Partnership working, where engagement and outcomes deliver benefits for both parties whilst complying with regulations, guidelines and governance arrangements is the solution; making this happen is the challenge.
• Pharmacy services will increasingly impact on the choice of and compliance with treatment, delivering improved health outcomes and reduced unplanned attendances and admissions.
• Pharmacy will be more actively engaged in the early identification of long-term conditions through integrated screening and risk assessment programmes with an associated increase in pharmacotherapy interventions for these new patients in line with national and local guidelines.
• Extended public health initiatives including smoking cessation, weight management and sexual health services may involve appropriate provision of Prescription Only Medicines.

What should you consider?

• Recognise pharmacy as a key health professional and enabler of improved adherence to medicines; ensure pharmacy is a key customer in national and local plans.
• Support the development, implementation and evaluation of patient services to create the evidence base for commissioning of other services.
• Facilitate multidisciplinary relationships, particularly with GPs, to optimise patient care.
• Work with national and local pharmacy bodies to support clinical development and develop implementation skills, including project management, patient communication and behavioural change (e.g. Motivational Interviewing).
• Ensure that your knowledge of pharmacy is current and credible.

What do you need to know?

• How well do I understand this customer, their needs and how I might add value?
• How long will the full integration into primary care take and which of my customers are moving fastest?
• What services are likely to be commissioned locally? Are these relevant to my portfolio and what value can pharmacies add to the target patient group?
• interdependencies within the local primary care team and how might I add value?
• What are the clinical training needs for pharmacy in my product area and how might I support continuing professional development?
• How many patients on my medicines are not complying with their treatment and if they were, what would this mean to their health outcomes and product penetration?
• How can the pharmacist add value to improving compliance with my medicines?
• What role does the pharmacy have in case-finding in diabetes, vascular risk, osteoporosis and COPD and how can I support this?
• What are my competitors doing with pharmacy?

Pharmacy activities to be implemented widely • Minor Ailments Scheme to be incorporated into contractual framework • Partnership between pharmacy stop-smoking services and local NHS services • National template for commissioning of chlamydia screening • Expand pharmacy-based contraceptive services • Integral in delivery of the vascular risk assessment programme • Enhance the role of pharmacy in the care of patients with diabetes • Support for patients on new treatment for the management of LTCs • Systems in place to support early detection and prevention of some cancers • More robust standards and metrics for Essential and Advanced services • Harmonise accreditation for pharmacists • Financial incentives for quality innovation with penalties and sanctions for poor performers

For more information:
• Pharmacy in England - building on strengths, delivering the future, Department of Health, April 2008: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083815
• PSNC summary: www.psnc.org.uk/pages/whitepaper.html
• The contractual framework for community pharmacy in England and Wales 2005: www.psnc.org.uk
• Scottish Pharmacy Contract: http://www.communitypharmacyscotland.org.uk/
• Northern Ireland Community Pharmacy Strategy – Making it Better: www.dhsspsni.gov.uk/makingitbetter.pdf
• Building the Community- Pharmacy Partnership: www.cdhn.org/bcpp/

About the authors: Deborah Evans MRPharmS and Michael Holden MRPharmS run balance, an operating division of The Tipping Point Ltd, which helps community pharmacy, the pharmaceutical industry and NHS commissioners to meet their needs and those of their patients. www.balancesolutions.org.uk