Health CommitteeWritten evidence from Celesio UK and Lloydspharmacy (LTC 14)
1. Introduction
1.1 Celesio UK, which includes Lloydspharmacy, is one of the largest healthcare providers in the UK with a significant presence across secondary, primary and home care sectors. Each day Millions of people either use or rely upon the services which we provide.
1.2 We are a large and successful group which works in partnership with the NHS to help UK citizens live longer and healthier lives. Our corporate vision is a healthier world where more people can live life to the fullest.
1.3 In 2012, our 1500+ Lloydspharmacies dispensed around 150 Million prescriptions, 70+% of which related to medicines to treat those with long-term conditions. Other Celesio UK businesses also provide essential support and services to those with long-term conditions. Some examples include:
Betterlife: which provides mobility aids and products to those with long-term conditions who require support of that nature to improve their quality of life.
Evolution Homecare: which supports patients with certain chronic conditions to get treatment at home rather than in a hospital setting.
Wilkinsons Healthcare: which—among other services—provides nurse-led care for stoma patients.
1.4 Therefore, from several different angles, but primarily from a community pharmacy perspective, Celesio UK has a broad and deep understanding of the needs of those with long-term conditions, the extent to which those needs are being met currently and where service improvements could be made.
1.5 The vast majority of those who suffer from long-term conditions will be on some form of medication and often multiple medicines for co-morbidity, particularly the elderly. As a result, community pharmacy already plays an important and central role in supporting those with long-term conditions to understand and manage their medicines.
1.6 In England, this is achieved primarily through the New Medicine Service and Medicine User Reviews as well as ad-hoc advice and interventions by pharmacists and pharmacy staff when appropriate.
1.7 The New Medicine Service provides support for people with long-term conditions who have been newly prescribed a medicine to help improve medicines adherence. Medicine User Reviews (MURs) consists of accredited pharmacists undertaking structured adherence-centred reviews with patients on multiple medicines, particularly those receiving medicines for long term conditions.
1.8 As we will argue later these are important services, but not yet developed and embedded in commissioned care pathways as fully as they need to be.
1.9 Community pharmacy also plays a key role helping to identify those most at risk of developing long-term conditions. Community pharmacies provide frontline professional advice and information, refer individuals to their GP and many, including Lloydspharmacy, offer patient services/checks for conditions such as diabetes, high blood pressure etc.
1.10 On its own Lloydspharmacy has provided over 1.5 Million free Type 2 diabetes screening tests with 75,000 people referred to their GP and over 1.8 Million blood pressure tests have completed to date.
2. Community Pharmacy Future Project
2.1 The CEOs from Boots, Co-operative Pharmacy, Lloydspharmacy and Rowlands Pharmacy met with the Department of Health in October 2011 to discuss the future funding for community pharmacy. A “Community Pharmacy Future project” was initiated as a result with a vision of demonstrating the benefits pharmacy can offer, with an approach of reducing primary care admissions and delivering benefits for all parties. The project group looked at the delivery of services that address key objectives for Governments three areas of focus including:
Medicine optimisation.
Public Health.
Self care.
2.2 Two services were developed to demonstrate pharmacies ability to manage long term conditions. The services were developed and a pilot launched in September 2012 with the following services:
A “COPD support and screening” service in the Wirral which recruited 308 patients.
A “4 or More Medicine” service for patients over the age of 65; 627 patients were recruited to this service.
2.2 All local GP practices and relevant professional groups were engaged in the service including the PSNC, LMC, CCA and LPC. The service has been live for over 6 months and the initial results are extremely encouraging. The six month consultations for patients signed up to the service will all be completed by the end of June and the four companies will be able to share the detailed health economic data that will illustrate both the quantitative benefits of the pilot in addition to the qualitative benefits.
3. The Need for a New Approach
3.1 As a consequence of the growing number of those with long-term conditions, healthcare commissioners will need to review how services and support are delivered in the years ahead as current arrangements leave too many patients not accessing advice, getting available checks or taking their medicines as directed if at all. The consequences of this are an unacceptable high number of people dying prematurely, ending up in hospital requiring costly secondary care treatment—and often social care support—or becoming economically inactive (at a wider cost to the economy and benefits system).
3.2 There are several indicators that current approaches to identifying those most at risk of developing long-term conditions as well as providing on-going professional support to those who do are not adequate:
Large numbers of people with long-term conditions who may not be aware that is the case (eg. around 850,000 people with undiagnosed type 2 diabetes).
Large numbers of those with long-term conditions (between 30–50%) do not take their medication as directed if at all leading to premature deaths, avoidable hospital admissions and poorer quality of life.
Avoidable deaths. For example, each year around 1,000+ asthma sufferers die prematurely because they are not using their inhaler properly (according to Asthma UK only 12% of asthma patients receive a written action plan from their GP or asthma nurse while one in five has not been invited for an annual asthma review).
The number of diabetic patients who do not receive the regular check ups they require leading to avoidable amputations, strokes and heart attacks.
3.3 The essential problem is well known: the lack of a joined up approach to healthcare provision which leaves the patient to navigate their way through service silos.
3.4 We support fully the concept of patient-centric care pathways and joint professional working based around the needs of the patient. This is particularly important in the case of those with long-term conditions, many of whom require support from a range of healthcare professionals.
3.5 We want to see patient pathways in which GPs and community pharmacists share responsibility for providing continuing care through a joint care plan for those with long-term conditions.
3.6 An interesting example of this approach is being rolled out in Scotland. The Chronic Medication Service (CMS) is a national core service which all community pharmacies will eventually have to provide in order to be granted a community pharmacy contract. CMS requires GPs and community pharmacists to share responsibility for developing a care plan for patients with long-term conditions with much of the regular continuing care, support and health checks being undertaken by the pharmacist or pharmacy staff. It is not without its issues, but it is an example of how joined up care can be delivery.
3.7 There are other models and approaches worthy of consideration. For example, why don’t we see condition specialist nurses or even GPs undertaking outreach activity based in local community pharmacies working alongside the pharmacist or pharmacy staff to provide better support to those with conditions at high risk of developing avoidable complications? After all, the bricks and mortar, the consultation rooms as well as the professional expertise in medicines already exist. That would better utilise the community healthcare assets which are already in place.
4. So What Do We Need Going Forward?
4.1 There are a number of areas which need to be addressed if we want to improve the service and support given to those with long-term conditions and implement patient-centric care plans.
4.2 1. We need a new fit-for-purpose and appropriately funded community pharmacy contract based on patient services, not almost exclusively on volume dispensing.
4.3 That means a contract which provides the right kind of incentives to encourage partnership working with other healthcare professionals, particularly GPs. That in turn means the GP and community pharmacy contracts need to be aligned. The Chairman of NHS England has stated that he wants to review the GMS contract so now would be an appropriate time to consider alignment with the community pharmacy contract.
4.4 It also means clearly defining the role of community pharmacy—as CMS in Scotland is seeking to do—as a core requirement for managing those with long-term conditions, not an add-on extra.
4.5 Currently, not all community pharmacies provide the New Medication Service which means some patients do not automatically receive it. Similarly, the number of Medicine Use Reviews which a community pharmacy can carry out is capped at 400 per month: again this means some patients who would benefit from this service cannot access it. We believe both services should form a core part of an on-going healthcare plan for those with long-term conditions.
4.6 2. Patient care records
4.7 There needs to be a single patient record which both GPs and pharmacists can access.
4.8 3. Avoiding illness as well as treating conditions
4.9 It is preferable to stop people becoming patients. That will require a greater emphasis to promote healthy living and wellbeing. Community pharmacies are ideally placed to act as local community health hubs.
4.10 4. New models and service delivery
4.11 We need to see service commissioners considering new models to service delivery including online, tele-care and home based support. Companies like Celesio UK already operate across the primary, secondary and home care sectors and are therefore well placed to provide integrated healthcare services in partnership with commissioners.
5. Specific Questions
5.1 Q1. The scope for varying the current mix of service responsibilities so that people are treated outside hospital and the consequences of such service redesign for costs and effectiveness
It is widely recognised that for clinical and financial outcomes it is better to treat people in community settings whenever possible. Part of the provision gap between GP (diagnosis) and hospital (treatment) is best met by community pharmacy. We should be looking at three pillars to our core NHS provision: GP, community pharmacy and secondary care.
5.2 Q2. The readiness of local NHS and social care services to treat patients with long-term conditions within the community
Previous comments refer
5.3 Q3. The practical assistance offered to commissioners to support the design of services which promote community care and provide for the integration of health and social care in the management of long-term conditions
We see a lead role for NHS England. We need local provision based on local needs but within national frameworks which avoid unnecessary bureaucracy (and cost), reinventing the wheel provision and postcode lottery provision.
5.4 Q4. The ability of the NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions
Previous comments refer
Currently we have a professional and condition focused approach. As most long-term conditions require medication (and many of those with long-term conditions have co-morbidity factors) there is a compelling case for community pharmacists to be involved at the core of designing and delivering patient care pathways.
5.5 Q5. Obesity as a contributory factor to conditions and how it might be addressed
Previous comments refer.
Greater use of community pharmacy as a local health hub as part of a wider approach to delivering improved public health outcomes.
5.6 Q6. Current examples of effective integration of services across health and social care
Previous comments refer.
5.7 Q7. Implications of an ageing population
Previous comments refer.
5.8 Q8. The interaction between mental health conditions and long-term health conditions
5.9 Q9. The extent to which patients are being offered personalised services
Previous comments refer.
Patients are still having to navigate their way around the healthcare system.
Patients with long-term conditions will require the involvement of several healthcare professionals: we need to get better at describing from the outset who will support them in which ways for the rest of their lives.
8 May 2013