There is a lot of discussion about how to solve the current crisis within A&E. I must clarify that it would seem that it is not so much a crisis of ‘blue-light’ patients, but of the walking wounded and worried. There is no use looking to General Practice for a miracle solution because they are already up to their necks in patients and in some small way lack of urgent appointments in general practice contributes to the problem. Here is a simple onlooker’s understanding of the problems and the issues.
Demand: I am trying to understand whether the increasing number of people wanting healthcare represents an increase in demand or whether those people just appear in different ways. I am tempted to conclude that demand has not altered much.
Expectation: It may be true that people have different expectations and I certainly have heard people say ‘I need to see a doctor’ when their condition appears to be fairly understandable. Have we let people believe that they always need to see a doctor? Yes I do think this is true
Availability: There are more appointments in general practice, but because of an aging population and more focus on long term conditions these appointments are of a premium.
Undermining existing services: Absolutely – we have taught people not to visit their community pharmacist (fourth disposition in NHS direct receiving less than 5% of recommendations). And the development of supporting services such as ‘Pharmacy First’ is extremely localised and hampered by inability to supply treatments. And the squeeze on pharmacy income is reflected in more attention to dispensing function. A couple of the new NHS111 services that I have spoken to do not even include community pharmacy as a destination.
NHS111: Everyone has commented so far that this is struggling. We have created a monster through NHS direct and now we want to put it back in its cave. People want simple advice about healthcare when they feel they need it. We don’t want to do it and we can’t do it on the cheap.
Walk in centres and urgent care centres: These have been successful in their own right. They have drawn patients from existing services into new glossy expensive locations. I hate to think of the money that we have spent on these in the past. I don’t think that we can actually afford to build new – and we now find people using them in preference to the service that they should be intended. I have spoken to several patients who have not registered with a GP because the walk in centre is so much more convenient – that wasn’t in the plan!
The Problem: It would seem that the problems are in patient flows. The bottom end is suffering and the top end is taking the pressure. The knock on effect of this is that A&E is suffering and General Practice is being unfairly criticised for trying to work harder and smarter.
The Solution: Isn’t it obvious – we need to change patient flow. We can put temporary plasters over the bit that hurts, but we need to concentrate our time and resources re-building downstream.
Action: Here are some simple actions that we can take:
- Co-commission NHS111 with a new element in the Community Pharmacy contract and publicise these as the first ports of call for patients wanting health advice. Ensure that Community Pharmacy is a more common referral destination from NHS 111 and build a new relationship between the two.
- Commission all community pharmacies to operate a ‘Pharmacy First’ scheme and ensure that they have the ability and resources to ‘advise, treat, refer’ as the specification says. Introduce national PGDs or even better introduce ‘community pharmacy independent prescriber (restricted formulary)’ status and give them prescription pads. Stop community pharmacy sending patients to other services because the patient gets free prescriptions and don’t/can’t pay for simple medicines. Make sure that the community pharmacies can ‘book’ patients into reserved emergency appointments in GP surgeries. Build the relationship between General Practice and Community Pharmacy giving Community Pharmacy the confidence to deal with even more patients.
- Close down the walk in centres and minor injury units and re-commission them in an appropriate geographical spread within community pharmacies. Yes – ask the community pharmacist to have additional training, employ a nurse or even a GP for sessional cover as required. Make full use of the extended opening hours community pharmacy contracts that you already hold. You should be able to double the available patient slots for the same cost.
- Work with General Practice and A&E services to publicise the ‘Pharmacy First’ initiative to create space to cope with their increasing workload. Encourage the GPs not to prescribe simple treatments for common conditions, but to refer the patient back to the community pharmacy for treatment.
You may not agree with my take on the problem and the solution. But we must act now:
- to reduce the pressure on General Practice and A&E services
- to significantly change the flow of patients, encouraging more to appear in NHS111 and community pharmacy
- to stop papering over the cracks creating new and expensive services and building sustainability in the existing NHS