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This is not incompatible with devolved decision-making and service delivery. Needless variations and access to services confuse and disempower the public and add to the cost of delivery. To deliver the full potential of their health improvement promise, pharmacists will also need to secure access to patient records-summary care records, as they are called. This is vital in a great number of cases.

There is another challenge: relations between GPs and the pharmacy profession are not constructive and close enough. For example, although this year some 2 million medicines' use reviews will be carried out by pharmacists, this is not matching their potential; GPs are not making full use of them and the chances we have for benefiting patients most in need are being missed. Above all, there is insufficient encouragement for doctors and pharmacists to work together. We need to provide incentives for GPs under the quality and outcome frameworks to work with pharmacists; and pharmacists should be as proactive as possible in

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seeking to work with GPs and their staff in increasingly complementary ways. We must encourage more co-location in practices, too, not only in GP practices but within the larger community pharmacies.

I shall finish with some remarks about education and training for the future. The pharmacy profession, like every other, needs the constantly improving education and training tools to do better. Despite all the opportunities for better, more cost-effective healthcare, the quality and depth of pharmacy education in this country is under threat. The danger is that, just when pharmacy is in a position to add further value, funding for necessary improvements in undergraduate and postgraduate education will be insufficient to support the changes needed.

We need radically to change and reform the M Pharm degree. Pharmacy degrees are not classed as clinical qualifications. If we are to achieve the desired clinical role for pharmacists, we need to put students in front of patients and give them more of a chance to learn in the way that doctors and nurses do. At least for one year, undergraduate pharmacy education should be funded at a clinical level.

I could not discuss pharmacy education without mentioning the ELQ issue. As a result of the new policy to exclude those with first degrees from being eligible for funding for an M Pharm, my own school of pharmacy is losing £600,000 in fees each year. Pharmacy education as a whole has lost £2 million in fees as a result. More seriously, the public are being deprived of professional practitioners who in many cases would be exceptionally committed and able. Surely pharmacy should be put on the same basis as medicine and dentistry so that those with first degrees can take it up later and acquire a professional qualification.

These are exciting times. There are real opportunities for living healthily for longer. Better pharmacy services are an opportunity for all of us. Given the right conditions, the appropriate investment and the opportunity to go on improving their knowledge and skills, community pharmacists can play a progressively more important role in meeting changing public health needs, preventing and treating illnesses and containing service costs. We must not let this opportunity slip.

8.12 pm

Baroness Gale: My Lords, I thank the noble Lord, Lord Clement-Jones, for bringing this important debate to us today. I shall speak about the role of the pharmacist in the management of Parkinson's disease. In doing so, I declare an interest in that I chair the All-Party Group on Parkinson's Disease.

Parkinson's is an incurable degenerative neurological condition that affects around 120,000 people in the UK. It is caused by a gradual death of the nerve cells in the brain that produce the chemical messenger dopamine, and is mainly treated by a complex cocktail of drugs that needs to be taken throughout the day for people to remain mobile-that is, to be able to walk, get dressed, talk and carry out all the normal activities of daily living. The correct prescription of drugs and, importantly, the correct timing of those drugs are vital to the successful management of a person's condition and ensuring their quality of life.

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Community pharmacists can make an important contribution to the monitoring and management of a person with Parkinson's. They are well placed to support the specialist multi-disciplinary team in making sure that people understand the medication they have been prescribed, are taking it correctly and are not experiencing any damaging side effects.

I welcome the introduction of medicine use reviews, which were first implemented in 2005 and of which 10 Parkinson's-specific pilots have just been launched by GlaxoSmithKline and 10 Manchester pharmacies. A medicine use review is a free appointment with a pharmacist to help patients manage their medicine more effectively. Research by the Royal Pharmaceutical Society has shown that almost one in 10 people say that they do not fully understand what their medication does or how it treats their condition.

Medicine use reviews are especially important to people with Parkinson's, owing to the complex nature of their condition and the numerous drugs that they may need to take. There are a number of side effects of Parkinson's medication, including compulsive behaviours such as compulsive gambling and compulsive shopping. It is vital that these side effects are explained to patients before they start taking the medication and possibly develop those effects, which may have devastating consequences for them and their families. Again, the importance of ensuring that medication is taken on time is another issue on which the community pharmacist is in an excellent position to back up the doctor and nurse and explain the prescription to the person with Parkinson's.

Pharmacists are an integral part in the multi-disciplinary team for people with Parkinson's. Pharmacies are generally easily accessible for people with the disease, who often have mobility problems and are unable to travel far. The pharmacist will also often be able to develop a closer relationship with the person, due to the regular visits that patients will make to collect prescriptions. It may be the pharmacist who is the first to notice that a person with Parkinson's is deteriorating or that their behaviour has suddenly changed. Pharmacists are able to refer a patient back to the specialist team if they feel it is necessary. This can result in cost-saving early interventions, which will occur only if the relationship between the pharmacist and the primary care team is maintained.

Although I strongly welcome medicine use reviews as an extremely positive initiative, I am disappointed that their uptake has been slow. There are still a number of barriers to the take-up of medicine use reviews, particularly for people with Parkinson's. For the reviews to be effective it is necessary for pharmacists to learn a new skill set, such as one-to-one listening and negotiating skills. They also need specific knowledge of complex conditions such as Parkinson's in order to carry out a meaningful MUR with this group of patients. However, there is currently a lack of training of this sort. That is particularly problematic for complex conditions such as Parkinson's.

There is also a chronic lack of awareness among the general public about medicine use reviews and their advantages. People need to be encouraged to use their pharmacies and to take full advantage of these reviews.

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As I mentioned, a pilot for 10 Parkinson's-specific MURs has just been launched. Not only will this scheme help to brief patients on how to manage their condition better, it will also help to identify people with Parkinson's who have failed to see a specialist in the past 12 months. The Parkinson's Disease Society's member survey showed that more than 1,000 people are waiting over a year to have their medication reviewed, in which time their condition may have changed significantly.

With the right information, pharmacists should be able to offer the kind of support that can make a real difference to the quality of life of someone with Parkinson's. I am hopeful that, after this pilot, it will be possible to share best practice and see these pilots duplicated across the country. As chair of the All-Party Group on Parkinson's Disease, which has just carried out an inquiry into access to Parkinson's services, I know the importance of access to a full multi-disciplinary team for a person with Parkinson's and their carer. I feel strongly that the pharmacist should be an integral part of this multi-disciplinary team to enable the best support, monitoring and management of a person with Parkinson's. Will the Minister ensure that there is adequate training in place for pharmacists to conduct medicine use reviews, and that the good practice established in the pilot is rolled out across the country?

8.19 pm

Lord Selsdon: My Lords, all too often in your Lordships' House, I find myself among a group of unqualified enthusiasts. The noble Lord, Lord Clement-Jones, has raised one of the most important issues facing us at this moment. Ever the optimist, I have been searching for some years-and now for some weeks-to try to find one or two gleams of hope for the future of the British economy. One of these is health. The reason for this is quite simple; we employ more people in the health sector than any other country in Europe, spend more money on hospitals, we have greater research and greater benefit-and we have the longest waiting lists of almost anybody in the developed world.

My own qualifications in this field are, perhaps, emotional. The only link that I have with pharmacy is to my great-great grandfather on the female side of the line, who was a pharmacist who farmed and found that his cattle got wind and thought that he should do something about it. His name was J.C. Eno, and he invented fruit salts, initially for cattle although later they were taken by the family-although my great grandmother would often sit on the loo all day and then lose her mind and not quite remember. Those were the pharmacists of those days.

Two of my great heroes of Victorian England were, first, Jesse Boot, who effectively introduced pharmacy to the masses in setting up Boots and, secondly, Thomas Salt, who found a formula for effectively curing cholera, and the relationship between cholera and having outside lavatories.

At the present time, in the pharmacy field, my knowledge is effectively veterinary. Having been brought up on a farm, I knew how to put a mud poultice on a

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hoof, and I knew about foot rot, which at school later we found was called tinea pedis or athlete's foot. I knew how a cow got wind and was shown how to stick a knife in to let the air out. Then I found, to my amazement, that the doctors in my family often, when they had problems that they did not know about themselves, would go to see their local vet, their friend. As your Lordships know, a vet is trained for five years and a doctor only for four. However, a pharmacist is trained for four years, takes an exam and then another exam and is one of the best informed people in the whole medical profession.

In the United Kingdom, with 32,000 pharmacies, we have an interesting conflict of interests. In most countries, roughly 70 per cent of prescriptions are from pharmacies and 30 per cent from hospitals, but that is changing; more and more are coming direct through pharmacies, where the pharmacist is able to prescribe. We have hospitals, which in general should be associated with physical medicine, and we have treatment. I am told that 90 per cent of all visits to a general practitioner lead to a prescription, which takes it back to a pharmacist. If you look at the waiting time and the cost, you find that roughly 20 per cent of all a GP's activities are related in some case to pharmacy, directly or indirectly.

So what can we do about it? The short answer has to be to give the pharmacist a greater opportunity to prescribe and to look after what we historically called ailments, rather than diseases. That could be anything that they know about and prescribe for. I would always go, first and foremost, to what we used to call chemists, which we now call pharmacists. I understand that those who qualify effectively become pharmacists, but there is often a supervisor who may look at a range of things, on a higher level, with other people lower down.

On the continent of Europe, there is a much more significant situation, where more drugs and treatments are prescribed by pharmacists than in the United Kingdom. In a general pharmacy in Germany, France or Switzerland, where I have worked, you will find within the shop or retail outlet a lot of men and women in white or green coats-depending on their standing-with the ability to prescribe. When they prescribe, the code goes into the till or computer, and the end product is automatically delivered down the chute by mechanical systems. An order goes out directly to the supplier and there are four to five deliveries a day so they do not go low on stock. If we moved more to these assistants for general practitioners, they could save possibly 20 per cent of their time at work.

We now come to one of the most interesting areas-pharmaceutical production. We in the United Kingdom are the most advanced in Europe in research. We spend £6 billion every year on research-more than any other European country. In terms of manufacturing sales, we have almost the third greatest surplus. We have a £4 billion a year surplus in trade in the manufacture of pharmaceuticals. Hardly any other sector in the British economy has that sort of support. Some 72,000 people work in the pharmaceutical industry, or, as

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some people derogatorily call it, the drug industry. That is an extraordinary base that could be better used.

I am not sure what form of regulation is necessary, but you need to look at the clinician. I do not know whether they are called "Mr" or "Dr". The pharmacist is known as the pharmacist these days. When people are not well, I often say, "Go and see a pharmacist". The problem is that it is very difficult to find one except when they are open. In almost every other country in Europe, you have the pharmacie de garde. You can ring up and it will tell you which pharmacist is on duty within a certain distance or time from where you were. Here in England at night where do you find one? I found from my recent studies that you should ask the police. Historically, there would always be someone at John Bell & Croyden in Wigmore Street, which was open 24 hours a day. Now, it is pretty difficult to find pharmacies out of hours and waiting lists for hospitals and A&E departments are considerable.

My suggestion is that we should look at the pharmaceutical industry, which is very advanced and would like to do more. We should look at pharmacies and general practitioners and recognise that, in general, hospitals are places for physical medicine rather than for treatment. Somehow, by getting it together, a substantial saving could be made and waiting lists shortened, and people would not have that fear of waiting from the time that they know something is wrong until the time they get their treatment.

8.26 pm

Baroness Murphy: My Lords, I add my thanks to the noble Lord, Lord Clement-Jones, for raising this debate. I want to concentrate on the problem of the relationships between GPs and community pharmacists, which have long been tense, but which can be changed for the better with the right policy incentives.

From the 16th century until the mid-19th century, GPs and pharmacists were one and the same thing. They were both called apothecaries. Here I declare an interest as both a doctor and a member of the Worshipful Society of Apothecaries. For many years, the common enemy, as it were, were the physicians, who were very grand, expensive and out of reach of common folk. A landmark case brought by Sir William Rose in 1704 established the right of apothecaries to prescribe and dispense. The medical Acts of the mid-19th century created tighter controls over the education and regulation of those calling themselves doctors and separated them off, rather sadly in some ways, from those who ran pharmacies and chemist shops.

It is relevant that many countries retain the principle of separation of the role of all dispensing from prescribing because of the obvious conflict of pecuniary interest of a doctor or pharmacist personally profiting from one prescription rather than another. We have never regarded that as a problem, particularly after the National Health Service Act came into effect in 1948, but there is no doubt that dispensing general practices are still perceived by the pharmacist to be a problem. The way that drugs are now paid for in general practice has reintroduced something of the conflict of interest again, and certainly conflicts between the two professions.

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Let me return to the basics for a moment. We must keep singing the praises of Britain's system of general medical and primary nursing care, complemented and supported by an easily accessible community pharmacy network. The noble Lord, Lord Selsdon, can find out exactly which pharmacies are open all the time on the front door of every pharmacist registered in this country. It is very easy to discover who is on duty, so you can find one.

It is a national asset, but without a strong integrated system, the support of people with long-term conditions, who now make up the majority of patients, simply will not work effectively. But we are not really making the best use of pharmacists' skills. We have done a lot in the past few years to encourage better use of them but we could do so much more to enable them to manage less serious acute illnesses and, of course, longer-term conditions.

Community pharmacy has changed significantly. There is a trend towards a proportion of pharmacists being located in health centres and larger GP surgeries. There have also been initiatives to get surgeries into the larger pharmacies. Nevertheless, there is a physical separation and a social distance between most community pharmacists and GPs, reflected by their separate institutional arrangements associated with education, regulation and professional representation. There are no integrated financial incentives within the NHS to get people to work together.

There is no doubt that people are using their pharmacists more for advice about episodes of illness. The latest Mintel consumer spending statistics survey showed that the market in over-the-counter pharmaceuticals has grown enormously, with sales expected to swell by a further 18 per cent in the next five years. Last year we spent a whopping £3 billion, an average of £59 per person, on over-the-counter medicines. The list of drugs for sale in pharmacies grows all the time. Some doctors are, of course, very wary of this trend. Professor Steve Field, chairman of the council of the Royal College of General Practitioners, really lit pharmacists' blue touch paper when he commented recently that a pharmacist makes a profit selling over-the-counter drugs, whereas a GP gets no pecuniary benefit from giving you medicine. It was not true anyway, and especially not true of dispensing GPs, but both GPs and community pharmacists must respect each other as both run small businesses. This is the reality and they should respect each other for it. When it comes to buying drugs over the counter, you can almost hear the cheers from Richmond House. Prescriptions, even when they are paid for, cost the state money. It is not surprising that we would want to encourage more people to go to chemists' shops.

There is a problem, though. While pharmacists have expert knowledge about medicines, they do not have access to a patient's medical history. Strangely, they are not regarded as part of the clinical service. As a result, care could become fragmented. If you have a recurrent problem, you may hope that a doctor or practice nurse will see a pattern and urge you to have it investigated, whereas in the self-medicating model, obviously, you could continue to get the symptoms and ignore the underlying causes. We must try to solve

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this problem by patient-agreed access to online medical records for pharmacists, with the patient's consent. However, you can imagine that over many years this will, again, be an ongoing argument between GPs and pharmacists about who should have access.

Theoretically, the new contracts that were introduced in 2004 have been very positive. These enabling, broader contracts brought the QOF system into general practice and made possible an enhanced role for pharmacists. They have undoubtedly introduced to pharmacy practice some enhanced services, but as the noble Lord, Lord Clement-Jones, said, these make up a very small proportion of the budget. I think £1 out of every £20 in the community pharmacy budget is spent on enhanced services. Two million medicine-use reviews will be conducted. As we heard from the noble Baroness, Lady Gale, these have been valuable in treating Parkinson's disease and many other illnesses. Of the 2 million conducted, 500,000 were conducted by Boots the chemist, the brainchild of Jessie Boot. He was indeed one of us: Lord Boot. Boots is one of the larger providers of these enhanced services and has been most proactive in establishing them. However, GPs often do not value MURs. Indeed, they complain that they cannot even interpret the forms that pharmacists send them. Nevertheless, while they may need tweaking, they have made an important contribution. Another enhanced service would be, for example, the introduction of NHS health checks, aimed at vascular disease risk-assessment and reduction.

So how do we foster this better joint working? Integrated remuneration systems on patient outcomes for monitoring chronic disease would be one way but I would start with increasing direct face-to-face contact that promotes greater mutual respect and professional trust through local practice forums. The only time a GP ever talks to a pharmacist is when the latter rings him up and says, "There's been a mistake". We need to provide a forum where they can meet and gradually come to respect each other. This respect would be much more easily attained if pharmacy degrees were properly recognised as clinical qualifications and pharmacists were trained in broader clinical practice issues so that they become accepted as part of the clinical team.

Doctors should be a little more understanding about the pharmacist who sells those wonderfully useless Seven Seas pills, snake-oil remedies and homeopathic humbug. They are nice little earners but they also enable the customer to choose his own care, and if he is paying for it and it will not poison him, why ever not? GPs and pharmacists need to respect each others' skills more and trust each other more but we need to provide the clinical training for pharmacists that would ensure that they became a larger part of the clinical team.

8.36 pm

Earl Howe: My Lords, the noble Lord, Lord Clement-Jones, in his excellent speech has largely relieved me of the worry of knowing how best to approach this multi-layered question. It is a truth universally acknowledged whenever this House debates pharmaceutical matters

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that pharmacists represent our most under utilised national resource in the delivery of services to NHS patients. It is to the Government's credit that over the past few years they have taken steps to address this situation, in particular with the publication of the 2008 White Paper, Pharmacy in England: Buildingon Strengths. The word "strengths" was appropriate. My noble friend Lord Selsdon reminded us about the impressive level and extent of pharmacy training. We have in England around 10,000 pharmacies, and it is said that 96 per cent of the population is within 20 minutes of at least one of them, including those situated in deprived areas.

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