National
Assembly for Wales
Health
and Social Care Committee
Follow-up inquiry on the contribution of community pharmacy to health services
Evidence from Company Chemists’ Association – CP 8
Introduction
1. As our population ages, the role for community pharmacy in delivering prevention, earlier diagnosis and condition management services will become more important. Narrowing the gap between morbidity and mortality, and supporting the public to live healthier for longer will become a national priority if we are to ensure the NHS in Wales remains sustainable in the longer term. Significant progress has already been made in Wales and we are keen to see these positive developments build into the future.
2. As the workforce crisis in general practice deepens, it will fall to pharmacists in primary care to help support general practice and to continue to support the care of patients and the public. Community pharmacy teams in Wales already play an incredibly important role in safely and efficiently procuring and supplying in the region of 70 million prescription items to the public each year.[1] This vital part of the health service should not be downplayed or underestimated. No other part of the health service manages as many transactions with so few errors and incidents.
3. The Company Chemists' Association (CCA) provides a forum for the large businesses engaged in community pharmacy to work together to help create an environment where pharmacy can flourish and providers compete in a fair and equitable way. The CCA aims to represent our members, empower our members to understand the changing policy environment, and influence that policy environment.
4. Our nine member companies – Boots, The Co-operative Pharmacy, Lloydspharmacy, Tesco, Sainsbury's, Wm Morrison Supermarkets, Asda, Rowlands Pharmacy and Superdrug – own over 6,400 pharmacies between them which represents almost 50% of the pharmacies in the United Kingdom. Our members operate 381 pharmacies in Wales, representing over 53% of the community pharmacies in the Welsh primary care network.
5. The CCA is a constituent member of Community Pharmacy Wales (CPW) and our representation on the CPW Board and its Committees are in proportion to the number of community pharmacies operated in Wales. We would also like to express our support for the CPW submission to this inquiry.
6. We are pleased to have the opportunity to respond, and agree that our comments below may be shared and published as being representative of the CCA. In our response we have highlighted the key recommendations of the Health and Social Care Committee’s inquiry and have provided our evidence of progress in relation to the recommendations made in the 2012 Report and areas where evidence and progress is still required.
The Committee recommends that the Welsh Government promotes further enhanced services with a national specification for community pharmacy, including a national Chronic Conditions Service, and follows the incremental model proposed for the introduction of the National Minor Ailments Scheme to ensure robust monitoring, evaluation and improvement of services. The Committee recommends that where there are clearly national health conditions, the service should be nationally specified, but that some continuing scope should be allowed for the volume and location of such services to be determined locally.
7. As part of any redesign within primary care, care pathways should be designed around the patient. We believe that the NHS in Wales has begun to make positive strides towards the use of community pharmacy as an asset to help people to stay healthy, treat common conditions and use their medicines effectively. National service specifications for enhanced services are one example through which consistent service delivery and outcomes can be achieved across the country.
8. Community pharmacy services help to prevent ill health and protect the public. The provision of smoking cessation services[2], health checks[3], seasonal influenza vaccination programmes and emergency hormonal contraception are all examples of areas where pharmacies help reduce public risk and mitigate potential downstream costs for the NHS in Wales. The recent “Look after your Eye Campaign” demonstrates how pharmacists in Wales have made a real difference to the quality of eyecare for nearly 2,000 patients[4].
9. Local Health Boards (LHBs) have commissioned a number of ‘enhanced’ services since the introduction of the contract; though the national enhanced service specification only began with the introduction of a national emergency hormonal contraception scheme on 1 April 2011. There have been differences in accreditation and service delivery across Wales and this has led to patchy uptake of services, particularly where locum or relief pharmacists are being used and their accreditations are not recognised between Health Boards. Furthermore, the need for all Patient Group Directives (PGDs) to be agreed locally has meant local variation in service, which is undesirable if a national service specification has been agreed. Seasonal influenza vaccination has been available through the community pharmacy network in Wales for the last two seasons, helping to support other sectors in primary care to increase vaccination uptake in at risk patients under the age of 60. Through approximately 200 community pharmacy providers, the network successfully delivered nearly 8,000 vaccinations during the 2013/14 influenza season. This demonstrates the on-going commitment of community pharmacy providers to support and develop the health of the public in Wales. We welcome Welsh Assembly Governments commitment to commission the Flu Vaccination service in at least 25% of Community Pharmacies again for the 2014/15 season and as an organisation our members will work with their LHB’s to build upon the significant increase in vaccinations delivered in 2013/14.
10. The influenza vaccination service was, in-line with the Committee’s intention, described by a national service specification. Although positive progress has been made, further changes in regulations are required in order to allow national PGDs to be developed, which sit alongside national specifications. In the absence of national PGDs being permitted, each LHB has authored variations to service PGDs; thereby tailoring the scope of the service in each locality. The reasons for these changes have not always been clear. As such, we would welcome greater oversight and explanation as to the rationale for local variations to the implementation of national specifications. We are concerned that the additional activity associated with implementing the variations resulted in some service details being released late in the year. This created real difficulties for contractors in delivering the service to the greatest effect.
11. As contractors we would continue to support the approach that, where services are specified nationally, LHBs should agree to utilise and implement the national service level agreements to ensure that a consistent message is maintained across Wales. The current variation has led to confusion for patients about access to this valuable community pharmacy service, particularly in relation to the qualifying criteria. Such differences and confusion, limit the effectiveness of national advertising campaigns, which have the potential to help signpost the public towards community pharmacies. Building national awareness of the community pharmacy service through a concerted communication programme will not only increase vaccination uptake, but will also encourage patients to attend community pharmacies and thereby reduce demand on over-stretched general practices. This confusion is mirrored in other services, such as needle exchange. While these services have improved significantly following the implementation of a national framework, there is still variation in local implementation between health boards, which adds further confusion to clients who may move across borders. This reduces confidence in the primary care network as a whole. However, the recent implementation of a national reporting system for needle exchange is a step towards achieving greater consistency, but this has been imposed on contractors in tight timescales, with a reasonable amount of additional workload for no extra remuneration improving the consistency of service delivery.
12. The CCA has been supportive of the national Common Ailments Service (CAS), which is currently under evaluation until the autumn of 2015, with outcomes expected in the spring 2016. We are confident that the independent evaluation will demonstrate the value that the service offers and look forward to a rapid roll out once this is published. We believe that this service delivers health care that fits the needs and circumstances of patients and the public, and are confident in the benefits that can be accrued from the greater accessibility and convenience that this service provides.
13. We support the Committee’s view concerning the implementation of a national Chronic Condition Management service. We recognise that further commissioning is unlikely to progress in this area until the evaluation of the Common Ailments Service is complete. However, we would urge the Welsh Government to be in a position to accelerate the discussions on the development of a national Chronic Condition Service should the interim findings show promising results, so as to enable the public in Wales to accrue the benefits from this service that have been seen in the other home nations.
14. While the health service needs to change, so does community pharmacy. The progress being made in Wales in changing the nature of services in community pharmacy is commendable, and we are encouraged by the direction of travel of current commissioning arrangements.
The Committee recommends that the Welsh Government should take the opportunity afforded by the recently announced national minor ailments scheme to consider changes to the way in which community pharmacies are remunerated, including a transition to capitation-based payments, underpinned by a patient registration system.
15. The CCA notes the recommendation of the Committee to consider further the way in which community pharmacies in Wales are remunerated. We are concerned that registration and capitation-based payments add unnecessary complexity and expense into what is a very efficient and cost-effective service. In fact, we believe that the prudent healthcare message seen recently could have been written with pharmacy in mind.
16. Such a radical change in funding structure would entail significant cost to Welsh Government and contractors at a time when NHS resources must be focused on maximising health outcomes and health economic benefits to the people of Wales. This would also be a highly complex change, requiring significant economic modelling, complete redrafting of all pharmacy regulations and transition arrangements for contractors to ensure viable levels of funding were maintained while a new contract framework could be introduced.
17. In addition, patient registration would inhibit the key value that pharmacy offers to the people of Wales, in that they have freedom to access pharmacy services and advice at their convenience. We support the current registration of patients to a particular pharmacy for a particular service, such as with the Common Ailment Scheme but do not agree that overall capitation funding can be considered in the current economic climate. This is especially important while, as a result of local commissioning arrangements, not all pharmacies can offer the same range of services to the local populations that they serve.
18. Against this evidence we cannot support capitation-based payments as a wider means of remuneration to community pharmacies as this limits patient choice in accessing services, could destabilise the community pharmacy network and could prove a barrier to competition and improvement in service standards.
The Committee recommends access by community pharmacists to summary patient records where patients are registered with a community pharmacy.
19. We strongly support the view of the Committee that community pharmacists should be allowed access to summary patient records. Positive progress has been made in this area through the access to records afforded by the Common Ailments Service. We are encouraged and enthused by the recent news that NHS Wales Informatics Service (NWIS) has secured funding of £280,000 through the Welsh Government’s Health Technology and Telecare Fund to set up and run a project to improve communication between community pharmacies and other parts of the NHS.
20. Evidence from a community pharmacy in Sheffield that has been piloting access to the Summary Care Record has found that 95% of views occur outside GP practice opening hours and that the majority of views were to assist in the delivery of medicines optimisation services, ensuring patients get the most from their medicines. In all cases the patient consented to the pharmacist viewing their record[5].
21. The number of patients with long-term conditions is increasing and community pharmacists already play a major role in supporting these patients. However, with appropriate access to records, far more support could be provided to these patients. For example, as part of a Chronic Conditions Management service, community pharmacists could access a patient health record during a patient’s regular visit to the community pharmacy to check whether the relevant condition or medicine monitoring is occurring. An audit[6] carried out in 2,773 community pharmacies looking into the use of methotrexate, warfarin & lithium demonstrated the difference pharmacy teams make to improve patient care in these areas. Addressing many of the issues identified would have been much easier with access to the relevant information regarding monitoring and tests. Read and write access to the patient health record will enable registered pharmacy professionals to check diagnoses and care plans, record advice given to patients on medicines and check / advise other professionals on medicines monitoring issues.
22. The network required for implementing this already exists within the IT infrastructure developed for the national Common Ailment Service. Whilst pharmacists can create records that the GP can access and view, the ability of pharmacists to view patient records has not been taken forward.
23. The CCA believes that access to summary patient records will prove to be an enabler for future delivery of services and would greatly increase the community pharmacy networks’ ability to deliver valuable interventions at scale. We are very encouraged by the recent announcement from the Welsh Government that the Discharge Medications Service is to continue as further confirmation of the important role that pharmacy teams play in supporting the health of the population across Wales.
The Committee recommends that the consistent participation of community pharmacies across Wales is secured for the next round of public health campaigns, whether national or local. Close monitoring of community pharmacy’s participation is required by Local Health Boards to ensure that those failing to deliver on their contractual obligations are called to account for their non-compliance.
24. Community pharmacies continue to be committed to the improvement of public health. Running and supporting public health campaigns requires early engagement from both the designers of the campaign and the contractors that are expected to implement them. We believe that early engagement and active dialogue between public health officials and community pharmacy contractors can further improve and enhance these campaigns. We believe that improving the consistency of participation in these campaigns is through a strong partnership approach. Further building the relationship between community pharmacy contractors and Public Health Wales will help to address some of the concerns articulated by the committee.
25. At present the monitoring of participation in national campaigns has been secured through the co-operation of community pharmacies working together with Public Health Wales and Community Pharmacy Wales (CPW). We support the need for on-going dialogue with CPW and Public Health Wales to ensure that the national campaigns help to enable the best possible improvement in the public’s health. We believe that adding this additional burden to resource-stretched Local Health Boards (LHBs) does not represent a pragmatic solution. This would only seek to increase workloads for LHBs and undermine the positive discussions and improvements that are taking place already.
The Committee recommends that the Welsh Government improves the communication mechanisms it uses to inform the general public about the services available at any individual community pharmacy. To this end, we recommend that the Welsh Government makes it an obligation for all community pharmacies to place a prominent notice in their premises identifying the range of services available in that pharmacy.
26. We agree that it is important for the public to be informed about the services that are available from community pharmacies in Wales. As previously suggested, we feel that consistency in service commissioning, through national specifications, would help to create a consistent platform from which a communication strategy could be developed. We are concerned that the current lack of consistency in patient eligibility and implementation between LHBs has undermined the ability of community pharmacy to clearly articulate a rational and coherent message to the public concerning the services that are available to improve their health.
27. CCA members have proactively taken on board the need for prominent notices and have agreed to provide up-to-date information on the publicly funded services that are available at the premises and, where possible, online. Consistency, and longer contractual agreements, in service commissioning across Wales would reduce the work associated with updating these lists on a regular basis and would help to provide a consistency in service delivery that patients and the public can expect.
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CCA Wales XXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX |
Rhodri Thomas CCA Operations Lead, Wales Email: XXXXXXXXXXXXXXXXX Telephone: XXXXXXXXXXX |
Paul Harris
Chair, CCA Welsh
Management Group |
[1] Welsh Assembly Government (2013) Community Pharmacy Services 2012/13. http://wales.gov.uk/statistics-and-research/community-pharmacy-services/?lang=en
[2] Pharmaceutical Services Negotiating Committee (2010). Literature Review: stop smoking services. Aylesbury: PSNC, December 2010.
[3] Anderson C et al. (2009). The contribution of community pharmacy to improving the public’s health: Summary report of the literature review 1990–2007. PharmacyHealthLink
[4] Sisodia (2014) Month Long eye care campaign achieves nearly ,2000 MURS. Available at http://www.chemistanddruggist.co.uk/news-content/-/article_display_list/17374364/month-long-eyecare-campaign-achieves-nearly-2-000-murs
[5] RPS and Pharmacy Voice (2013) Professional Position Statement on Access to Patient Health Recrods. http://www.rpharms.com/promoting-pharmacy-pdfs/professional-position-statement-on-access-to-records-final.pdf
[6] Pharmacy Voice (2013) Practice Based Audit. Available at: http://www.pharmacyvoice.com/images/press/PBA_final_report.pdf