The NHS has many issues to manage. An ageing population, an increase in obesity and ill-health at a time when budgets are tight and new ways of working are required. The NHS Alliance in their manifesto for primary care urges the NHS to break boundaries at every level. They present a broader vision of primary care and ask for the community pharmacy contract to be rewritten to support fuller engagement.
There is a need for community pharmacy to reorganise under a new contract and to work towards delivering a different range of services, which focus on the patient and concentrates on delivering outcomes. We need to be sure that the new contract is flexible and enables and supports the direction of travel, but we also need to understand the changes in the NHS and a vision of community pharmacy in 5 years time.
This article gives one view and describes the service delivery in three sections, which may present an alternative way of looking at the new contract under development. I would consider looking at community pharmacy under four broad headings:
Dispensing and procurement
There is little doubt that pharmacy procurement, supported by the changes in the drug tariff, has allowed the NHS to reduce the overall drugs bill. This should be congratulated and rewarded in the new system. Community pharmacy dispenses nearly a billion prescription items a year, with accuracy and professional support that should be maintained. Pharmacists should be encouraged, through motivational interview techniques to support the patient medicines experience, the patient goal setting and implementing services that enable patients to reach their goals.
Public health and wellbeing
The NHS Alliance in their manifesto asks that every patient has a health and wellbeing plan developed in association with a named healthcare professional. 1.8million people access community pharmacy every day, almost twice the number of people who access general practice. It is important to note that many people who access community pharmacy are perceived as well, but stand to gain considerably from lifestyle changes to avert ill health.
Community pharmacy needs to adopt a healthy living pharmacy or similar status and begin to support people to stay healthy. They are uniquely able to deliver wrap-around services, including stop smoking, obesity management services and signpost patients to other providers. There are many public health initiatives and local campaigns that community pharmacy can lead, particularly with the elderly.
Management of common conditions
There is a requirement within the NHS to ‘downshift’ disease management. By this I mean that people managed within hospitals are moved to primary care and people in primary care moved to self-care. Self-care and supported self-care becomes such an important feature of the NHS that it is able to manage the increase in demands.
Community pharmacy must become a real choice for patients wanting to manage their conditions. Patients must have the choice whether they get their common conditions managed at the general practice or within the community pharmacy. There are many examples of conditions such as asthma, dyspepsia, irritable bowel syndrome, eczema where the community pharmacist can deliver total care and provide appropriate feedback to the GP. Co-registration is essential where the patient decides that they will register with a community pharmacy to deliver specific aspects of their care while retaining their continuing registration with a GP practice.
Community pharmacy can also be a provider of supported self care. The lives of many patients can be improved if they look after themselves. The NHS and other providers supply a whole range of self-care programmes. The community pharmacy should be seen as a centre for self care support, signposting patients into recognised and supported local programmes and providing encouragement and further support in engaging patients and their carers.
Community pharmacy should widen their provision of acute care, expanding from minor ailments to a position where they can advise and treat more conditions that might have been referred to A&E. It would seem sensible for the NHS to take advantage of the longer opening hours of some community pharmacies when considering out of hours solutions.
If all healthcare professionals and AHPs do not fully engage and take part, the NHS Alliance’s request for a new community pharmacy contract and their encouragement to break down barriers in the NHS will not succeed. This presents a new opportunity for community pharmacy to confirm their position in primary care and take their participation to new heights. The new contract must be flexible and enabling, creating a framework for development where both the local authority / public health and the CCG can support community pharmacy growth. Community pharmacies should be able to progress and develop at their own pace, but without the need to bid at every stage.
We must also discuss continuous service progression and the concept of expanding wrap-around services. By knowing the end game then it becomes easier to commission and for pharmacies to develop naturally. I can explain this with a few examples:
Asthma management: Community pharmacists should provide total asthma care for appropriate patients. The starting point is to deliver inhaler technique counselling, but there is an understanding that the community pharmacy team will progress through education and supervision to deliver a full service.
Sexual health: Community pharmacy may start with the delivery of EHC or STD screening, but it is understood that they will progress through education and supervision to deliver wider sexual health services including HIV testing and ultimately a full oral contraceptive service.
Health and wellbeing: All pharmacies should aim to rebrand as healthy living pharmacies or similar. People should be able to obtain a health and wellbeing plan from the pharmacy and the pharmacy should deliver services that wrap around the plan. Services routinely offered should include stop smoking, weight reduction, flu vaccination and signposting to exercise management services.
The contract should support such development and progression, allowing pharmacy managers and owners to plan for controlled service development with guaranteed funding.
The final question may be what to do with MURs and NMS services. I would suggest that these are initially associated with either dispensing or acute care, but also become elements of care, where community pharmacy can decide with their local Public Health Service and CCG as to how these can be used. The Public Health Service and the CCG can ‘commission’ additional elements of care through the NCB in a planned way to ensure that community pharmacy have the confidence to plan to develop.
There is no doubt that the NHS will struggle without the help of pharmacists