Health CommitteeWritten evidence from Pharmaceutical Services Negotiating Committee (LTC 43)

Pharmaceutical Services Negotiating Committee (PSNC) promotes and supports the interests of all NHS community pharmacies in England. We are recognised by the Secretary of State for Health as the body that represents NHS pharmacy contractors. Our goal is to develop the NHS community pharmacy service, and to enable community pharmacies to offer an increased range of high quality and fully funded services; services that meet the needs of local communities, provide good value for the NHS and deliver excellent health outcomes for patients.

PSNC is pleased to be able to submit a response to the Health Committee’s inquiry into the management of long-term conditions. In summary PSNC believes that:

To cope with the ongoing pressures on the health service such as the increasing number of patients with long-term conditions, the NHS requires a third pillar to support the pillars of secondary care and GP-based primary care, and community pharmacy must be at the heart of this third pillar.

Community pharmacies already play a key role in helping patients with long-term conditions to get the most from their medications.

There is more that community pharmacy can do, and the routine care of many patients with long-term conditions should shift to pharmacies, freeing up GPs to manage patients with more complicated or multiple conditions.

Through the provision of healthy living advice and public health services, community pharmacies can help patients with long-term conditions to live healthier lifestyles and so reduce the risk of further health complications.

To enable community pharmacy to extend its role, key barriers such as territorialism between professions and pharmacies’ limited access to patient records must be overcome.

The use of national service templates and specifications could be a useful tool to support commissioners as they plan care for patients with long-term conditions.

The Ageing Population

1. NHS services are stretched more than ever before at the moment under the combined pressures of financial constraints and increasing demand for services. And with the patient base only set to expand further as the population ages and long-term conditions, some related to unhealthy lifestyles, increase in prevalence, the challenges are not set to go away.

2. The scale of the challenge is clearly illustrated by a report by the Nuffield Trust published last year (A Decade of Austerity), which estimated that unless health funding could increase beyond inflation the NHS is set to face a funding gap, by 2021–22 of around £50 billion. Improved productivity of 4% per annum across the NHS reduces the deficit by around 40%. But that is a massive demand and still leaves a large funding hole.

3. PSNC believes that the NHS can, and must, meet these challenges. But it will not happen without radical thinking and a commitment from all healthcare professionals to play their part. And PSNC believes that it will not happen unless community pharmacy is used effectively to play a key role in supporting patients to lead healthy lifestyles and make the most of their prescribed medicines and the care available to them. By reshaping the community pharmacy service, large savings in NHS resources and improvements in health outcomes can be made.

4. GPs are fully employed dealing with ill-health and the administration that surrounds it. We therefore urgently need a new, 3rd pillar, to support the pillars of secondary care and GP-led primary care, and the community pharmacy network is the foundation of that pillar. In the 3rd Pillar model the community pharmacist and their team supports the patient in self care. For long-term conditions centrality of supply of medication gives way to taking responsibility for ensuring the patient uses medication appropriately and effectively. The GP will normally diagnose and initiate therapy, but the community pharmacist takes responsibility for ensuring the patient gets the best outcomes and identifies any changes to therapy that may be needed.

5. The routine care of millions of patients shifts to the pharmacy, where it can be accessed more conveniently, and more cheaply, and patients have a range of providers from whom they can choose. The “bricks and mortar” pharmacy service is supplemented by telephone, internet and where necessary, domiciliary support.

Treating People in the Community: Exploring the Role of Community Pharmacy

6. For most patients with long-term conditions, medication plays a key role in the management of their condition and in maintaining their quality of life. Community pharmacies can play a key role here through medicines optimisation services such as the Medicines Use Review (MUR). The role of the MUR in helping people understand their medication and its effects is an important contributor to the goal of having people fully engaged with their own health—the Wanless objective. But lack of engagement by PCTs and GPs with the MUR service and the absence of effective targeting combined with lack of robust data capture and outcomes research has been problematic. The introduction last year of nationally agreed target groups and data capture requirements have started to help address these shortcomings. Research into respiratory MURs conducted on the South Coast provided strong evidence of improved control of patients’ conditions and the correlation between the service and reduced hospital admissions.

7. In future iterations of medicines optimisation services we should focus on the patient groups for which medication problems lead to expensive episodes, primarily hospitalisation. This is where the pharmacy service, properly used, can achieve real cost savings for the NHS, and convenient care for patients with long-term conditions. Ensuring blood pressure levels are monitored, ensuring inhalers are being used properly, ensuring that, so far as possible, patients do not give up on medication regimens prematurely but get optimal health outcomes.

8. These groups—those with high hospitalisation rates—form the eligibility cohort for the New Medicine Service, and its’ introduction has been far smoother: through implementation of MURs pharmacists had gained the skills and confidence to offer the service, and we worked with GPs in advance, to get their support.

9. The gains from these services will come from improved adherence to people’s medication regimen, leading to reduced numbers of complications for patients and to fewer avoidable costs from GP consultations and hospital admissions. Early analysis of the NMS recorded using the PharmOutcomes platform shows significant gains in adherence, as indicated by the initial research that underpinned the development of the service.

10. PSNC believes that there is great potential for community pharmacy to extend services like these, which enable pharmacists to deliver interventions at certain points in patients’ care, and move from delivering episodic care to providing more longitudinal care for patients. Some areas have piloted this sort of ongoing care very successfully, such as the respiratory MUR programme which saw pharmacies offering asthma patients follow-up MURs to improve their management of their conditions.

11. There is much more that pharmacy could do beyond asthma, but a key barrier to the extension of pharmacy’s role has been resistance from other healthcare professionals and we believe focusing on one disease area like this could serve a dual purpose in boosting the sector’s confidence in dealing with patients on a regular and long-term basis, but also in giving other professions confidence in pharmacy’s ability to manage patients on this basis working in collaboration with other healthcare professionals.

Multi-morbidities and other Contributory Factors

12. In this response we have focused on the role that community pharmacies could play in providing the ongoing routine care for patients with single or non-complicated long-term conditions. However, this would have implications for those with more complicated conditions as it would free up GP time enabling doctors to deal more effectively with those patients with multiple conditions.

13. Where other lifestyle factors are having an influence on patients with long-term conditions, community pharmacies are also well positioned to help. Many community pharmacies are routinely offering healthy living advice and services to help patients with a range of issues such as managing their weight, stopping smoking, or understanding alcohol consumption. If community pharmacies were involved in the regular care and management of patients with long-term conditions they would tie this healthy living advice in to their patient consultations to help patients to live healthier lives and so reduce the chance of further complications with their conditions.

14. Some pharmacies are also offering this support through the Healthy Living Pharmacy (HLP) framework which was developed and launched in Portsmouth in December 2009 and led to quality and productivity improvements in community pharmacy with better access to health and wellbeing services for the public. As well as committing to and promoting a healthy living ethos, one of the distinctive features of a HLP is having health trainer champions (specially trained pharmacy staff, who are trained in behaviour change techniques and giving healthy living advice)) on site. HLP community pharmacies in Portsmouth exceeded the PCT’s stop smoking quit target by 138%, achieving 664 quits at four weeks for the year 2010–11. Evaluation results indicate that a person walking into an HLP in Portsmouth is twice as likely to set a quit date and give up compared with a person walking into a pharmacy which is not an HLP. Twenty sites have recently been evaluated to see if the outcomes from Portsmouth could be replicated in different demographies and geographies and the evidence that they could was extremely positive. Today there are over 400 HLPs and 1000 healthy living champions in place. Expanding this type of service could make a very real difference to the health of both the general population and those patients with long-term conditions.

15. For patients with multiple conditions, a range of care delivered by a range of healthcare professionals is likely to be required, and this will be a challenge for the NHS as many patients still do not receive consistent and efficient care when they have to deal with more than one health organisation. Patients going into and out of hospital often end up with duplications in their medicines, with primary care professionals unaware of any care they have received in hospital.

16. To address this and other problems, NHS care pathways need to be designed to ensure seamless care across organisations—the patient journey must be at the heart of these pathways, and they must promote the use of the most appropriate providers and facilitate the transfer of information between health organisations. The radical changes currently being made to commissioning and the provision of health services may provide a good opportunity to examine local care pathways more closely to ensure this across all commissioned services.

Supporting commissioners

17. We have set out here a vision in which community pharmacy could take on the routine management of many patients with long-term conditions. If this vision is to be achieved, several barriers will need to be overcome.

18. A key barrier preventing pharmacy from improving patient outcomes across long-term and other conditions has been the limitations of local service commissioning—this has been patchy and inconsistent meaning patients in some areas have not been able to benefit from high quality pharmacy services. The NHS reforms and emergence of new commissioners present a chance to rectify this, but we believe commissioners will need national direction and support.

19. PSNC believes national service specifications and agreements improve efficiency in the health service by preventing duplication of work, and they improve the outlook for all patients by reducing the chance for inequalities in services to develop. For local commissioners, having national systems and directions in place to inform the services they should commission can have a similar effect. PSNC has previously worked with the Department of Health on such specifications and hopes to do so in with the new commissioning organisations of the reformed NHS also.

20. Public Health England in particular could also play a key role in collating the evidence base for public health focussed services and the impact they can have to inform commissioning.

21. The PharmOutcomes system now being used by some commissioners in primary care could also a useful tool for some commissioners. This IT system enables community pharmacies to record the services they give to patients, noting any patient interventions and outcomes, so that commissioners can clearly see which services are being provided and what effect they are having. This could be a useful tool for those wanting to monitor the effectiveness of community pharmacy services or for people wanting to monitor the care being given to patients with long-term conditions.

Removing other Barriers

22. The government and national health organisations also have a key role to play in the removal of regulatory barriers to better care and in tackling the territorialism that so often blights successful working relationships between professional groups. Tying contractual frameworks together to incentivise more efficient care and sharing of work is likely to be crucial to this. For example, by adjusting the General Medical Services contractual framework the NHS has the power to shift some patients with long-term conditions away from GPs and into pharmacies and self care. It could then also ensure that GPs are fairly rewarded for taking some of the secondary care workload away from hospitals.

23. Without this oversight and intervention from above, encouraging GPs to manage patients’ long-term conditions in partnership with community pharmacies, achieving our vision for the third pillar may always be a struggle.

24. Aspects of pharmacy practice are also in particular held back by regulations. Decriminalisation of dispensing errors could help to incentivise pharmacists to delegate certain tasks to staff, leaving the pharmacist time to deliver medicines optimisation and other services for patients with long-term conditions.

25. And pharmacy must be more effectively integrated into the rest of the health service—making patients the gatekeepers to their own medical records so that those being managed by community pharmacies could choose to make their information accessible to those pharmacies would ensure that pharmacies were aware of any other care being given to patients, and any potential health problems, and tailor their care to better meet their needs.

9 May 2013

Prepared 3rd July 2014