THE NATIONAL PLAN: a plan for investment, a plan for reform aimed to give the public a health service which:
• Is designed around the needs of the patient
• Provides fast and convenient care
• Offers more choice and promotes ‘one-stop’ care
• Improves the quality of care
• Reduces access and waiting times
A key strand of the government’s agenda and necessary for the achievement of the NHS plan is to give patients both quicker and more efficient access to healthcare including medicines. Several initiatives and recent changes have allowed this to happen. This article will look at some of these and their effects on patient access to medicines.
Reclassification of Medicines
The National Plan sets out a radical action plan to put patients and people at the heart of the health service and to drive every decision made about the organisation and the delivery of care. Making a wider range of medicines available over the counter when it is safe to do so, gives people faster access to the treatments they need. A number of statutory instruments were changed on April 1 2002 to allow a stream-lined process to be developed allowing reclassification of medicines from ‘prescription only’ to ‘over the counter’ in half of the usual time.
Increasing the availability of medicines over the counter may encour-age greater self-management of minor ailments and reduce NHS expenditure.
Patient Group Directions (Directives) (PGD)
The first Review of Prescribing, Supply and Administration of Medicines, delivered by Dr June Crown, focussed on the supply and administration of medicines under group protocols. Group Protocols are generally now called Patient Group Directions (Patient Group Directives in Scotland).
A Patient Group Direction (PGD) is defined as a written instruction for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. It is not a form of prescribing and there is no specific training that health professionals must undertake before supplying medicines in this way. Guidance on the use of PGDs was issued to the NHS in Health Service Circular 2000/026.
The Department of Health has made it clear that the majority of clinical care should still be provided on an individual, patient specific basis. PGDs should be reserved for those limited situations where there is an advantage for patient care without compromis-ing patient safety.
Early PGDs were drawn up to support practice nurses who supply and administer vaccines to patients. PGDs are also commonly used to support community pharmacists supplying emergency hormonal contraception and smoking cessation services. Examples of PGDs are available on the Internet.
The legislation enables PGDs to be used for the supply or adminis-tration of medicines by a variety of Health Professionals as shown in table 1.
PGDs should be drawn up by a multidisciplinary group and must be signed by a senior doctor and pharmacist, both of whom should have been involved in the group. In addition the PGD must be authorised by the StHA, NHS Trust or PCT.
Repeat dispensing within the NHS has been restricted with the unavailability of instalment dispensing on usual prescriptions (this is available for addiction services) and that ‘Prescription Only Medicines’ must be dispensed within 6 months of the date on the prescription. June Crown in the second review of prescribing, supply and adminis-tration of medicines recommended that repeatable prescriptions should be allowed in the NHS. Repeatable prescriptions are common within private practice.
The first 32 pathfinder sites have been announced for the repeat dispensing pilot and more are to be announced in 2004. Patients will obtain a prescription from their GPs and can then have them dispensed in instalments by their community pharmacist rather than going back to their GP practice. The pharmacist has an opportunity to confirm that the prescription still meets their needs and answer any questions they may have about their medicines.
Electronic Transmission of Prescriptions
The electronic transfer of prescriptions (ETP) between GPs, commu-nity pharmacies and the Prescription Pricing Authority, is one of the key elements of ‘Pharmacy in the Future’, the programme for pharmacy in England and is supported by other pharmacy strategies (Table 2). Support can also be found in the new English Pharmacy Services doc-ument ‘A vision for Pharmacy in the new NHS’, although the focus here is in reducing the inefficiency of duplicate entry of key prescription information.
The programme pledged that by 2004 electronic prescriptions would be introduced in the community. Significant benefits for patients are expected, including a safer, more convenient and secure supply of medicine. The three original pilot sites have completed their review and we are awaiting details of the evaluation and future direction. Minor Ailment Schemes
There are now several successful minor ailment schemes around the country. In these schemes the community pharmacist may offer advice to patients on a wide range of minor ailments and then supply medicines free of charge to those who would normally be exempt to prescription charges. Some research has suggested that GPs spend as much as 30% of their time dealing with patients with minor ailments who could be managed under such a scheme by their community phar-macist. Early schemes included the Care in the Chemist scheme and the Tyne and Wear voucher scheme. The National Pharmaceutical Association has also recently produced a resource pack entitled ‘Minor Ailment Schemes: lessons learnt to date’. The development of such schemes has been further supported by the primary care Czar.
New Prescribing Arrangements
The second ‘Review of Prescribing, Supply and Administration of Medicines’ was delivered to the Secretary of State by Dr June Crown in March 1999. The report suggested extending the range of prescribers and the management of pain. Typically, a patient would be seen by a hospital specialist or GP (the independent prescriber). Responsibility would then pass to the palliative care nurse who would, if a dependent prescriber, be able to review and revise medication, within the overall care plan.
Pharmacists in specialist areas, such as oncology, asthma or diabetes clinics. Pharmacists would bring wide experience and knowledge of clinical pharmacy and pharmacology, including potential drug and food interactions, as well as specialist knowl-edge of the particular clinical area. Pharmacists already interpret the results of drug monitoring, undertake assessments, titrate therapy and counsel patients, but currently require any prescrip-tions to be signed by a doctor.
Pharmacists carrying out reviews of patients’ medication, e.g. patients on multiple therapies. Pharmacists in primary care already have extensive experience of medication reviews, where they are able to alert the GP prescriber to possible drug interac-tions or to changes in the patient’s condition. This often leads to a proposal for alternative and more appropriate drug choices. As dependent prescribers, pharmacists could be given limited discre tion to vary treatment on their own initiative, within limits agreed with the independent prescriber. Clear arrangements for such joint working would need to be developed, and should include mechanisms to ensure that the GP is informed as soon as practicable of any change in treatment and that the patient is given clear advice and written information about any variations in treatment.