HC 1048-III Health CommitteeWritten evidence from Pharmacy Voice (PH 89)

Introduction

Pharmacy Voice (PV) represents community pharmacy owners. Its founder members are the Association of Independent Multiple pharmacies (AIMp), the Company Chemists’ Association (CCA) and the National Pharmacy Association (NPA). The principal aim of Pharmacy Voice is to enable community pharmacy to fulfil its potential and play an expanded role as a healthcare provider of choice in the new NHS, offering unrivalled accessibility, value and quality for patients and driving forward the medicines optimisation, public health and long term conditions agendas.

Pharmacy Voice creates a stronger, unified voice for community pharmacy. We are pleased to have the opportunity to provide written evidence on the Public Health Inquiry.

Summary

1. Community pharmacies are increasingly delivering a range of public health services that are producing positive outcomes, notably for people in deprived or vulnerable circumstances. Well established services include harm reduction programmes for substance misusers, stop smoking, sexual health, weight management, NHS Health Checks and flu vaccinations. The Department of Health recently recognised pharmacists as “a valuable and trusted public health resource.”

2. The transition to new commissioning arrangements in England inevitably brings a level of disruption to the management of health and social care. It is important that there is at this time robust monitoring and holding to account of PCTs and local government responsible for the commissioning and decommissioning of public health services. Particular attention should be paid to community pharmacy with a successful track record of providing public health services.

3. Whilst we support the Government’s aim of shifting powers to local communities in order to reduce health inequalities we are concerned there may arise a lack of strategic planning for populations which will lead to fragmentation of provision and a reduced service offering.

Creation of Public Health England

4. The relationships and responsibilities of Public Health England (PHE), NHS Commissioning Board (NHSCB), Local Authorities and Commissioning Consortia in the planning and implementation of public health services are unclear. Clarity is required, to allow health and social care providers to fully engage with this emerging system.

5. Public Health England will have the ability to spread health improvement services that are of proven benefit. This should include community pharmacy based services. The evidence for selecting pharmacy based public health services is included as Appendix A.

6. In our recently published Community Pharmacy: a blueprint for better health we called for strategic advice on pharmacy to be provided to the NHS Commissioning Board through a Director of Pharmacy and Medicines. There should be a similar facility for strategic advice on pharmacy led- public health services within Public Health England and Health and Wellbeing Boards.

7. Pharmacy Voice, the Royal Pharmaceutical Society and Pharmaceutical Services Negotiating Committee are submitting a joint response to UK Influenza Pandemic Preparedness Strategy 2011 Strategy for consultation.

8. Community pharmacy traditionally rises to the challenge of emergencies and will do its upmost to help out in times of need. The flu pandemic 2009/10 was no exception and at national, regional and local levels, the pharmacy profession; pharmacy member organisations, pharmacy owners, local pharmaceutical committees and individual pharmacy team responded rapidly to support the public and primary care organisations, (PCOs), across the UK.

9. It is essential that shared knowledge, capability, capacity and experience of community pharmacy are not lost as reforms of public services take shape.

Future of Local Government in Public Health

10. Plans to transfer certain responsibilities for public health into local government, and possible new arrangements for local authority oversight of health commissioning, mean that ties between councils and healthcare professionals such as community pharmacists are set to grow.

11. Whilst we in principle support the Government’s aim of shifting powers to local communities, we are concerned that there will be a lack of strategic planning for populations which could lead to greater fragmentation of provision and a reduced service offering.

12. Community pharmacies already straddle the ground where the local authority and NHS worlds meet. They are “an integral part of the NHS”, a “vital local service” and a “community facility.” Nonetheless, many of the local authority commissioners of public health will be unfamiliar with the attributes and potential contribution of health service providers including community pharmacies. There is an urgent need for the development of national core service specifications and national recognition of training competences and frameworks to give commissioners assurance that service specifications are robust.

13. Local Government and Improvement and Development published “JSNA best practice guide” in April 2011 but there is no guidance on the types of groups who should be consulted. The Minister should clarify the types of groups, such as pharmacists, that local authorities should be consulting with when developing their JSNAs to ensure that they consult as widely as possible.

14. Community pharmacy teams and pharmacies are important and substantial “health assets”.

15. In addition to being responsible for Joint Strategic Needs Assessments (JSNAs) the responsibility for Pharmaceutical Needs Assessments (PNAs) is proposed to lie with Health and Wellbeing Boards (HWBs). HWBs will have little or no experience of community pharmacy and the understanding of the importance of a robust and accurate PNA yet they must ensure that it is an effective document which is reviewed and updated at regular intervals to inform commissioning decisions.

16. Guidance should be developed by the NHS Commissioning Board to assist HWBs to carry out PNAs, to ensure that they are getting the maximum benefit from community pharmacy services in their area.

17. In the formation of HWBs, as too with commissioning consortia, there must be inclusive and transparent processes of appointment to governing and advisory positions.

18. Legislation should provide for a clear link between the HWBs and the pharmacy sector, either through a nominated individual or a duty to consult.

Arrangements for Commissioning Public Health Services

19. Pharmacists work in the “medicines space” as the experts on medicines. Pharmacy Voice’s vision for the future proposes solutions related to the current issues within the medicines space, ie wastage, poor adherence, medicines-mismatches occurring across interfaces such as admission to hospital and poor discharge planning, and emerging evidence of widespread medicines management and administration errors in residential care.

20. The safe management of medicines has significant public health and patient safety implications and these interactions provide opportunities for public health interventions. We are concerned this aspect of pharmaceutical care should not be overlooked in these changes.

21. Pharmacy Voice understands that the Local Government Association have mixed views on introducing competition into the public sector market which could lead to tension between policy makers, Monitor, commissioners and Any Willing Provider (AWP). Public health services should be open to Any Qualified Provider and decisions should be made on the basis of “best qualified provider”.

22. Community pharmacy could be an example of an AWP model that generates genuine benefits to the community. An estimated 1.6 million people choose to visit a pharmacy each day, of which 1.2 million do so for health-related reasons. People are not constrained by registered lists, geography and the majority receive NHS services free at the point of use yet positive competition operates among community pharmacy where excellence in customer service determines a person’s choice of provider.

The Structure and Purpose of the Public Health Outcomes Framework

23. We are concerned that despite the government’s public recognition of the role of community pharmacy in supporting the public health agenda there is no role for community pharmacy, or eye care providers in contributing to the proposed public health outcomes framework, Healthy Lives, Healthy People, consultation, December 2010.

24. Safe use of medicines is an additional domain which is crucial in keeping people healthy and in preventing poisonings, adverse effects and hospital readmissions.

25. We supported the approach to align across the NHS, Adult Social Care and Public Health frameworks but highlighted some of the difficulties in achieving this. As each of these stakeholders uses information on quality and outcomes for different purposes, they require different types of information and different presentation formats. The selection and design of indicators, and their presentation, must be tailored to the different requirements of these stakeholders. The government will need to ensure:

(a)agreement of shared purpose and goals at a national level of stakeholders;

(b)alignment of public sector policies of health and local government;

(c)national frameworks for commissioning outputs, outcomes and costs are comprehensive by incorporating a holistic approach to the public’s health and wellbeing; and

(d)effective information and communications plans are in place. Enabling IT across organisations is essential and must support data input analysis and outputs which are meaningful, timely and robust.

Arrangement for Funding Public Health Services (including the Health Premium)

26. The proposal that health premiums will incentivise action to reduce health inequalities from funding within the ring-fenced budget will be very difficult to achieve. This is because it is unclear where the monies will come from when other priorities such as efficiency savings and reductions in local authority budgets of up 25% take hold.

27. Structures need to be put in place to ensure that local authorities use ring fenced money appropriately, and not merely to substitute for funds withdrawn from education, leisure amenities or public spaces. These are important wide determinants of public health, but have access to existing funding streams.

28. We support the ring-fencing of funding for public health but there is a need to ensure that ring-fencing occurs nationally as well as locally to support appropriate public health services to all age groups and to those with the greatest need.

29. Capturing outcome data for the unregistered population (ie those not on GP lists) is currently problematic. Services which have the potential to improve the long term health of this population should not be penalized for lack of outcome data. Evidence of service delivery, of target populations accessing support, and possibly patient reported outcome measures should be regarded as legitimate markers in such circumstances.

Future of Public Health Workforce including Regulation of Public Health Professionals

30. Currently there are no nationally recognised points of reference for training and accreditation. PCTs develop service specifications and training requirements for the most part in isolation, based on the service specification they have developed. Core national service frameworks would enable competencies and training frameworks to be mapped to service specifications.

31. Ensuring that all pharmacists working in a pharmacy are accredited to provide a particular service is currently problematic as pharmacists may live and work in different PCTs, indeed locum pharmacists frequently work in several PCTs. The majority of PCTs do not recognise training delivered/accredited by other PCTs. This situation is likely to be exacerbated if NHS structural reforms lead to smaller commissioning units and new commissioners who are unfamiliar with the attributes of community pharmacy.

Transition Period

32. The transition to new commissioning arrangements in England inevitably brings a level of disruption to the management of health and social care. It is important that there is at this time robust monitoring and holding to account of PCTs and local government responsible for the commissioning and decommissioning of public health services. Particular attention should be paid to community pharmacy with a successful track record of providing public health services.

33. Pharmacy Voice seeks early discussion with emgerging organisations to show how we can deliver scalable, sustainable, quality services that meet the needs of people locally and quality assure safe, effective services that people value through national contracts, national frameworks and local relationships.

Other References

A vision for Pharmacy in the new NHS DH 2003.Planning for town centres The Office of the Deputy Prime Minister 2003.Health and Social Care Bill 2011 Part 6 paragraph 190.

June 2011

APPENDIX A

EVIDENCE OF COMMUNITY PHARMACY PUBLIC HEALTH SERVICES

Many locally commissioned pharmacy enhanced services are directly aligned with the Government’s policy emphasis on public health and preventative healthcare:

Stop Smoking services have shown very good results in pharmacy. In 2009–10, 140,000 people chose community pharmacy to set a quit date and 62,000 had successfully quit by week 4, a 13% increase on the previous year.

NHS Health Checks. Birmingham South PCT commissioned a “Heart MOT” pilot, a cardiovascular risk-based assessment, in 30 community pharmacies in Birmingham. The results of the pilot show that males who would not normally see a GP access the pharmacy led- services. In addition those individuals from deprived areas and with a minority ethnic background also accessed this service from community pharmacy.

   Of those assessed, 60% were male, 65% were from the average, less deprived, and most deprived quintiles, and 7.4% and 24.8% were from Black and Asian communities respectively. Importantly, it highlights that a significant number of individuals can be identified for whom intervention for vascular disease risk or other risk factors is required.

Alcohol intervention In the North West of England pharmacy is playing a key role in the provision of alcohol intervention and brief advice (IBA). Around 125 pharmacies across Wirral, Blackpool, Knowsley, Oldham, Liverpool and Warrington are involved in service provision. The service can be targeted to those who may be at high risk such as those who present for treatment of hangovers, gastric problems and falls. Pharmacy sees a different demographic of people from those who may visit a GP practice, especially in areas of health inequality.

   Examples of the benefits are as follows:

Members of the general public chose community pharmacies in NHS Knowsley pilot to seek out advice concerning their alcohol use. The outcome was that 1165 interventions were carried out and 26% of people who participated were identified as having an increased risk and 6% at high risk of alcohol misuse.

Based on these results the potential cost savings could be significantly greater than those estimated by the Department of Health, which makes an assumption that only one in four people would be identified at increasing or high risk.

Directors of Public Health increased their capability and capacity to access people in the community by integrating community pharmacy into their implementations plans.

Sexual Health screening and treatment; Pharmacy has become an increasingly important venue for community sexual health services. Access to emergency hormonal contraception (EHC) is a common enhanced pharmacy service as pharmacies are open in the evenings and at weekends, with no need to book an appointment.

   In the first year of the service, it was found that 50% of women accessed the service at the weekend or on Mondays, when it can be difficult to obtain appointments at family planning clinics or GP, now in some localities; pharmacies are the largest providers of EHC to women.

Weight management services evaluated by the University of Central Lancashire showed statistically significant results for agreed weight maintained for 12 months. The service was more cost effective than prescribing Orlistat over 12 months (£160 per patient vs £419.51). People liked the informal pharmacy environment, the accessibility and the flexibility.

Healthy Living Pharmacies (HLP). Figures from the Portsmouth pilot project showed that 30% of patients seen for a Medication Use Review (MUR) had not seen their GP or practice nurse in the previous 12 months. Research also shows HLP had a 36% increase in the number of people who quit smoking and approximately a quarter women who were provided with EHC were also offered Chlamydia screening and almost half (46.4%) of all those accepted a screening kit. A total of 264 who accepted a kit returned a sample, of whom 24 (9.1%) tested positive, concluding that Chlamydia screening for EHC pharmacy patients was warranted.

Isle of Wight community pharmacy seasonal flu vaccination report. Community pharmacists have an important role to play in the delivery of many services commissioned by public health whether these are health promotion services to raise awareness, services offering health prevention or services offering protection. Top-line results indicate significant success:

Total vaccinated: 2903 (approx. 10% of total vaccinated through all services).

Under-65s with co-morbidities: 36.3% of cohort vaccinated (Other providers: 17.1%).

Percentage Rating Service OK or Excellent: 99.6% (90.9% Excellent).

Percentage receiving flu vaccination for first time: 8.2%.

Percentage for whom vaccination unlikely without pharmacy access: 6.2%.

Percentage indicating they would use community pharmacy again: 98.4%.

Percentage indicating they found the service more accessible: 92.8%.

Minor Ailment schemes. It is estimated that some 57 million GP consultations each year involve minor ailments, which could in most case be dealt with at a pharmacy. The average cost of a pharmacy consultation (£17.75) relative to an average GP consultation (£32) is £14.25 less expensive. If all patients with minor ailments were to receive pharmacy consultations, then over £812 million could potentially be saved from the NHS budget. This equates to just over 4% of the Government’s pledged £20 billion target for efficiency savings.

Prepared 28th November 2011