Urgent and Emergency Care

I was invited to speak at the future of urgent and emergency care services. It is unusual for a pharmacist to be invited to this sort of event – well I wasn’t directly, but Dr Michael Dixon felt that I would answer the brief about pharmacy to compliment his opening. As expected, there wasn’t a single pharmacist in the audience. The first batch of speakers talked exclusively about new ways of working in A&E and urgent care centres – somehow I didn’t expect anyone to mention that pharmacists are employed in these services, as well as out of hours and General Practice to provide care for patients with common acute conditions, but as usual community pharmacy was not mentioned.

Feathers slightly ruffled from the start. I had to explain that there was slightly more than General Practice within Primary Care – General Practice is only one of the four independent contractor contracts within primary care – and they all provide urgent care for patients. I had to explain that within NHS England’s report they clearly suggested that a shift all the way down the line was needed with increased focus on self-care and community pharmacy to relieve the increasing pressures up stream. And, with more than 438million healthcare interventions in community pharmacy (2008/9 data) – this was more than any other profession added together. You do realise that the community pharmacy estate is huge – more premises and open longer than GPs and often more convenient for patients.

I mentioned data around the symptom checker – just to remind people that most members of the public who used the symptom checker were young and female. And that 44% still went for a consultation. There is a hint there, that putting symptom checkers in unsupported environments, like libraries might just increase demand on general practice and other services.

I offered a solution of putting NHS Choices symptom checker into community pharmacy, backed up with access to an assistant or technician that can support navigation and a pharmacist should further explanation or an intervention be necessary. Link this to the Healthy Living Pharmacy initiative with qualified health trainers and you could really start to change behaviour and attitudes towards better health.

I talked about minor ailment services – renaming them ‘common acute condition services’ and despite over 1,000 pharmacies being open 100 hours a week and many more open 80 hours a week, this service was commissioned in only 10% of pharmacies. There was service specification variability and access to medicines was generally poor. Access to medical records is still zilch, although access to the summary care record is on the horizon and will help in the future. As a side comment, if I had £1 for every patient that had been passed over to the GP for a prescription, I would have retired long ago! It is also sad that a pharmacist at 21.55 in the evening can’t book a patient into the GP next day or skype call to an out of hour’s service for support – so you can guess where those patients go.

I mentioned that the first minor injury training program, specifically for pharmacists was to be delivered this summer. Not requested by the NHS, I might add, but by pharmacists who, no doubt, will pay for their own training to deliver a higher level of service to their patients.

I was openly critical of the lack of working together in these services and suggested that it should be a basic requirement that GPs and Community Pharmacists work together to develop these services to the level that they need to be. In my opinion this is a serious flaw and limits the success of services. If the GP, Practice Nurse or receptionist simple enquired – “what did the pharmacist suggest” to patients with common acute conditions, perhaps we could turn this tanker around.

I questioned the use of NHS 111 where I am still not sure offers community pharmacy as a disposition. And the very few CCGs that underwrite the supply of medicines from a pharmacy in an emergency situation. There is no more of a heartsink moment in A&E when a patient turns up and says – “I am on holiday and I’ve forgotten my medicines and I’ll die without them”.

Those professions at the ‘bulk’ end of the scale –  General Practice, Community Pharmacy, Optometrists and Dentists must work together to create capacity and deliver more effective and more integrated care. We must share the load, and support more effective self-care to give those clever people at the top end of the system a little more space and time.

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Reworking the NHS

I am going to make this simple. The NHS is not set up right and the current change has not improved much. Everything is still commissioned/contracted in silos; the organisations do not have real cross-commissioning capabilities and as for performance monitoring – still poor.

So we need a different solution that drives integration and supports joint working. Well that is not too difficult really if you think about things slightly differently. And it is not too difficult to divide up existing contracts into parts so that they can be managed and driven in different ways. So her is my thinking:

‘Primary Care’. Primary Care is the delivery of the first element of care. There are several services that provide primary care by this definition. It reflects the continuum that NHS England describes from NHS Choices, through community pharmacy and general practice to out of hours and A&E. Why can’t they be commissioned together? Bring every contract they we hold in which any person rolls up and ask about their health or needs acute care. Include the police, ambulance and paramedic services and others. Fix the total budget and manage it in such a way that co-operation drives profitability and creates a will to manage demand. Look at the capability of each element of the service to one-stop manage as much as possible without unnecessary transfers, signposting and referrals. Build capacity in the most accessible and least expensive elements of the continuum.

‘Continuing Care’. Again there are several services that provide continuing care for patients with medium and long term conditions. General Practice might be considered the backbone, but many patients are admitted to hospital – so called unplanned care – or to care homes. So again, let’s bring all of the contracts together – health and social care. Commission Consultants to work side by side with GPs, community pharmacy, community services, social services, housing with voluntary and charitable organisations. For it to all work people must remain well and in their own homes where possible.

‘Planned and specialist care’. NHS England is already commissioning a range of specialist services to look after people with rare and complex disorders. In this same pot I would commission all planned care from hospitals and the trauma and emergency response services. They should have national standards, national comparisons and controlled providers

‘Public Health’. All services that maintain and improve the health of nation are already commissioned from public health. Is this the one thing that we have right and are they moving in the right direction? Probably yes – they are gathering all of the contracts under their wing, stimulating providers and commissioning across boundaries and silos.

The big question is will it happen? The NHS does not need radical reorganisations and structural change. It just needs a better focus on what it needs to achieve and a better mechanism to drive cross-silo commissioning and inter-service dependency.

Primary Care and Community Pharmacy

Primary care is where a member of the public receives their first (primary) element of their care. Acceptance of this definition is important before moving forward and we must not get confused with the word ‘primary’ when it is taken to mean ‘most important’. Although we could argue that the first element of care is always the most important in determining the pathway, the outcome and the cost to the NHS.

This means that general practice, community pharmacy, optometrists and dentists form the core elements of primary care. We must add into this out of hours services including hospital based accident and emergency services, ambulance services and a wide range of other provider services including housing and social services.

We must also build into this the person themselves, knowing that many people make their own primary care decisions either alone or supported by family and friends or by internet based information such as NHS choices.

There are two important issues to consider:

  • Can people access information from reliable sources and make their own primary care decisions with minimal support. Many people can access the NHS Choices website, but I am surprised that we provide so few opportunities for those who cannot access the internet, have poor computer literacy, limited ability to read or are unable to make a decision without some support/advice.
  • Are all providers of primary care working together to make the first contact count.

The answer to both of these issues is simply no. I think that we know that and have known that for years, but made very little progress. There are some simple solutions that the NHS could consider:

  • All community pharmacies should make a move to healthy living pharmacy status and the availability of a touch screen computer linked to NHS Choices should be a fundamental requirement.

A community pharmacy is an ideal place to direct people who wish to explore their symptoms or better understand their condition and available treatments. Healthy living pharmacies can supply advice, a variety of services and should have easy access to a range of treatments.

  • All services that provide primary (first contact) services should be supported to work together within a locality based contract that operates 24/7.

A number of publications on emergency care have described primary care services into a continuum, from self-care through to A&E, but none of them have suggested contracting first contact services together as a group. From a single budget all providers can offer first contact services, but each provider must be able to offer a full service for a defined population. The starting point is an understanding of the triage principles – who goes where and for what. Each contract has a target number of first contact episodes such that to share in the profits of the contract all providers are interdependent. The positive metric is completed first care episodes in the appropriate environment and the negative metrics are referrals to other providers. The local population must be involved so they can better understand where they could go and what each provider can actually provide.

If we focus on the person then they should understand when to visit the optometrist service, the dentist, the community pharmacy, the GP, the A&E and other local providers. The services should also work out how to work together in hours and out of hours.

All community pharmacies in a locality should be involved. They all should work towards healthy living pharmacy status and should all provide access to NHS Choices to their local community. They should all offer a range of health and wellbeing services and should link together to provide inter-pharmacy referrals.

All community pharmacies should provide minor ailment / common condition / pharmacy first services in which they provide an increasing range of services based on advice and treatment. The contract should be set with targets that support closer working between all providers to make sure that each element delivers on their commitment and all providers benefit when targets are met.

There are no excuses – we have to get primary care right – we have to firstly support people to access appropriate information and advice in a wide range of settings and when they touch the primary care provider, they have to get the best care in the most appropriate setting.

Community Pharmacy and patient pathways

I have sat through many meetings discussing patient pathways for many diseases. It has long been a disappointment that the GPs and the consultants focus on their interface and how to make it better. Doctors and nurses become the sound bites, rather than patients, homes and communities. I hear a bit of rapid access here, direct referral there, intermediate service specification, outreach, locally enhanced services and a plethora of others. And of course the solution is so often a specialist nurse, a GPwSI or a new overlaid service.

 

I often ‘cough’ and remind them that community pharmacy manages 70% of the population with that condition with over the counter medicines and advice before they enter the pathway. If it was 75% would that make a difference?

I might add that a simple campaign with screening in community pharmacy would help identify more people and get them to treatment quicker (on a daily basis, community pharmacy sees more people than all other healthcare professions put together).

Or that even some NICE guidance recommends the final disposition of patients with that condition is community pharmacy. And community pharmacy support might prevent another block of expensive NHS care.

 

I sometimes ‘bang on about’ supported self-care and how a 10% improvement in self-care might reduce healthcare costs by 25% (see Charles Allessi and the NAPC for the reference). I might mention access to NHS choices, healthy living advice, smoking cessation, obesity management exercise signposting and simple treatments. In the end, it is all about people looking after themselves and others around them.

 

A pathway isn’t a conveyer belt and we shouldn’t focus all out attention on the middle bit – the interface between general practice and hospitals. There is a front end where community pharmacy and self-care sits and a back end where community pharmacy and self-care sits and a middle section where community pharmacy and self-care sits.  And I haven’t even mentioned the ubiquitousness of medicines throughout – before, during and after.

 

And all the way through is a patient who should be helped to make a choice. A pathway starts with a patient in their own home and should finish there – you realise that this is a big hint! Does anyone think of including housing in the discussion – don’t be too radical – who ever thinks that housing has any contribution to health – just me then. Patients start in their own homes with their own families in their own communities don’t they? And they want to end there as well – well and in control of their condition, gaining confidence all the time.

 

So the next time I sit at a meeting where pathways are discussed – will I see representatives from community pharmacy there? Will I meet my housing colleagues there?

 

Patient pathways – but what should be the tagline – perhaps from community to community or even from home to home. Definitely not from GP to hospital to GP – that is only part of the story!

The cat with diabetes

I have spent a lot of time with the vet – it is a long story, but I was fascinated in the way they managed a cat with diabetes.

Of course diabetes in animals is very similar to humans – it starts with an inability to manage post prandial glucose and leads to insulin resistance and ultimately pancreatic failure. The diagnosis is through a mixture of blood tests, urinalysis (clean dry gravel in the litter tray) and the typical signs – ravenous appetite, weight gain, always thirsty and peeing often. No GGT or HbA1c in the vet. Treatment is also similar with diet manipulation, weight control, exercise stimulation and some medicines.

The fat cat sat on the mat. As it purred gently it had a continuous glucose monitor attached. It hardly noticed as it was fixed in place. Free feeding was replaced with fixed meals and five days later the data was downloaded. The little machine had measured glucose concentrations every five minutes for 5 days – that’s 288 measurements a day and nearly 1,500 measurements over the 5 days. The line appeared showing the peaks and toughs in use.

The baseline glucose level was abnormal and the peaks showing the post-prandial glucose levels were also abnormal. These peaks were then compared to the diet chart and most peaks were explained through the three meals. Well apart from three which were biscuits – your cat eats biscuits? Yes we sometimes sit together in the evening and we share a biscuit – should have guessed really.

I think that we could identify the calorie content of everything that passed that cats lips over the five days – just amazing. Nowhere to hide that little titbit or mouse or latte and muffin.

The owner left with a greater understanding of the influence of diet, a refined diet plan and some medicines. The medicines were initially targeted towards reducing the basal glucose and the vet was sure that this would help to make the cat feel a little better and ‘get out more’.

The owner was told that the cat should come in for another review and that the vet will do another 5 days of glucose monitoring. The vet warned the informed that an improvement in the basal glucose was expected, but the next stage would be adding in another medicine that effected basal glucose or if the post prandial glucose hadn’t improved then a refinement of the diet and a medicine that targeted post prandial glucose. The vet didn’t want to start insulin, but that was firmly on the cards with a twice daily mixture at the two main meals. This all seemed quite rational to me.

I am sure that you want to know about the biscuits. They were changed to either a reduced amount of the high sugar variety or an increased amount of a low sugar variety. The owner understood this and went away with a list of biscuits and their calorie contents printed from the internet. Actually I didn’t know how bad custard creams were – must cut these down myself.

I asked the vet where continual glucose monitoring had come from and why she used it. Well it would seem that it is an adaptation of the equipment used in humans that transferred to vetinary practice about 5 years ago. She felt it was the only way that she could get the information to guide her advice and treatment. The 5 day 5 minute readings linked perfectly to the diet plan and the owner had no doubt what was right or wrong. Obviously, I asked if the vet used blood glucose testing and she almost laughed in my face. Cats don’t like it and the information is hardly very useful in discussion with the owners and agreeing a management strategy. I had to agree with her.

The management of diabetes in cats is particularly important. The complications, particularly peripheral neuropathy can be particularly nasty and hypoglycaemia a real issue, however they aren’t affected by cardiovascular complications to the same degree. If the diabetes is controlled well and the cat loses weight then they may improve to the point that they don’t require treatment – fascinating.

If I should get diabetes, perhaps I will visit my vet first. Well perhaps until the NHS uses continuous glucose monitoring and follows good vetinary practice in targeting treatment appropriately.

I met a nurse

Yes, I know, that is not a surprising thing; there are a lot of nurses in the UK. But I met her in Superdrug – one of the pharmacies in the centre of Croydon. And no she wasn’t shopping – she was working there.

That’s novel, I thought. It would appear that she is working for Superdrug within their travel service. Actually there are three nurses, supported by a pharmacist running the service. Actually there are other pharmacies doing it as well.

Not just any old service – a very well used one considering when the next appointment is. Oooh how interesting – people traveling all over the place – the information, the algorithms all look fantastic. I am impressed. And I am reliably told by one of my local GPs, just about the only place that you can get rabies and yellow fever.

And I can buy a whole range of holiday health bits and bobs as well. All supported by the pharmacist. Even some advice on how to take medicines to ‘dodgy places’ without being arrested – that is good!

It was interesting to chat for a minute or two. What a great service! And what else can they do…. Well I can have any immunisation including flu, but they have no NHS contract so I would have to have it privately. In fact I could have a whole range of national program immunisations privately. How silly. But actually I might just do it – you know – while the car is getting washed a key cut – buying things – how convenient.

And she was A&E trained. Yes and she had gone out into the shopping centre to help people who had fallen over or collapsed, but that was not in her contract either. It is difficult, she explained, I am a nurse and ably qualified to deal with both minor and major occurrences – so I feel that I have to help – in fact I might be more in trouble if I didn’t. So she could cope with minor injuries as well – a bit of stictching or glueing, bandaging – what a pity they don’t have a local contract.

So what is the point of this blog?

  • Firstly, it is perfectly normal to find a nurse, employed by a community pharmacy to provide a service to their local community. Pharmacists and nurses work well together. And they provide a valuable service to what appears to be an excellent level.
  • Secondly, they could provide so much more. The staff are there; the consultation area is there; the will is there.
  • Thirdly, it is about time local commissioners walked the walk and saw what was going on right under their noses!

Perhaps they might have some inspiration and commission something useful in the main shopping centre where people go!

Solution to A&E

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

A Long term solution to A&E

Throwing money at A&Es? What are Dave and Jeremy thinking about? Not only will it not solve the problem, but it will make things worse. It is a sticking plaster at best. But why on earth do we throw money at bad behaviour? And then look surprised when behaviour gets worse?

A recent assessment of patients in A&E tells us all that we need to know. 1 in 4 patients could have been adequately managed in a community pharmacy. A further 1 in 4 patients could have been managed in general practice or a walk in centre. So at least half of the patients should not have been there in the first place. The number of red light patients has not increased, but the number of ‘walking-wounded’ is increasing at an alarming rate.

If 25% of patients in A&E could have been managed by community pharmacy – why were less that 5% of NHS direct callers referred to community pharmacy – just an observation.

When asked about community pharmacy and in particular ‘Pharmacy First’ or ‘minor ailment schemes’ the majority of patients admitted that they didn’t know about the schemes.

When asked about General Practice, some said that they couldn’t get an appointment, some didn’t want to bother the GP, some hadn’t phoned, some said the GP was closed and some simply believed that the A&E was more convenient. So a really mixed bag of answers here that clearly means that GPs are not really to blame for the current predicament.

So opening a new ward in A&E, putting a GP in A&E or creating new walk in centres will not work!

If we want this system to work better then we need to change the direction of flow for most patients. We need to make sure that appropriate patients access community ‘pharmacy first’ schemes. This would have a direct effect on A&Es and an indirect effect on general practice by freeing up some space. Naturally the space will be rapidly filled, but if this was filled by patients who would have gone to A&E, then we have succeeded. It is all about communicating better options and providing different services within existing providers. It is not about commissioning new providers and applying sticking plasters.

Community pharmacy often has longer opening hours when compared to general practice. There are many (and I mean 2,000+) that are contracted for 85 to 100 hours a week within their dispensing contracts – so access is much less of a problem than you might think. All pharmacies have counselling and / or clinical consultation rooms. And with the current supervisory regulations, a qualified pharmacist is on site and on duty most of the time.

There are, however, four issues within this plan that need urgent attention:

  • Community pharmacy minor ailment or Pharmacy First schemes should become common place. We need a national contract or national framework that can be administered locally
  • These schemes should be supported by giving pharmacists better access to medicines. Naturally pharmacists can sell medicines, but supplying medicines on the NHS to patients on low income is an issue. Pharmacists either need PGDs or a restricted formulary prescriber status to do this, with progress to full independent prescriber status associated with appropriate contracts.
  • These contracts should be transitioned into proper out of hour’s contracts with a required level of service delivery. A small number of geographically appropriate contracts should be enhanced by, for example, the provision of minor injury cover during specified hours
  • The public should be made aware of these services, through national and local campaigns. This service should form part of the doctors on call answerphone message, GP and community pharmacy websites, NHS choices website and a bigger part of the NHS 111 protocols.

It does seem to me that the solutions are not far away. Just need some thought, some planning and throwing the available money at the right place.

Speaking to Ministers

I was happy to be invited to the NHS Alliance AGM and policy day. It gave me two 30 second opportunities to speak to ministers – not a conversation, but two single bullet point opportunities. It is not that easy to blurt out two points, but here are my attempts:

To the Shadow Health Minister: “Please look at the legal framework for prescribing and get community pharmacists simple prescribing status, similar to district nurses so they can prescribe medicines to those who can’t afford to buy their medicines and are directed to general practice.”

I am not sure that she fully understood what I asked, but she duly looked interested and wrote it down. There is a level of ambiguity in what I am asking for and a level of confusion created by pharmacists themselves. Pharmacists often talk about ‘counter-prescribing’ which is a confusing term, much better translated into ‘we sell medicines to those who can afford to buy them’ – and probably to some that can’t, but are desperate. People understand this and those who don’t want to buy go to their GP and contribute to the bulging waiting rooms. It is a situation that is unfair to those on low incomes, unemployed, on benefits, retired – anyone who feels that they can’t afford the price. It is inequitable – if you are wealthy you go to the convenient community pharmacy – if you are poor, you go to the GP practice – simple! It doesn’t help those living in tough communities (I was told not to use deprived any more). I would agree that several localities have identified this issue and have minor ailment systems in place like ‘Pharmacy First’, but there needs to be over 200 systems throughout England, administered through 28 area teams, all with PGDs. And the two options are to commission minor ailment schemes nationally with huge bureaucracy or simply change the law/regulations. Give a community pharmacist a prescription pad and a limited list formulary and they will use it wisely to the benefit of their communities.

I do not understand how, post the Crown Reports, a system where community pharmacists were allowed to prescribe a selection of medicines from a limited list in line with the common conditions that they manage under minor ailment schemes at the NHS expense was not included. Just admit it – it was an error, an oversight – just sort it out please – preferably before general practice implodes.

When introduced to Lord Howe, he smiled and said that he was the minister responsible for Pharmacy: “There are over 800 community pharmacies with 100 hour contracts; many more that are open for 80+ hours a week and none of them have a specific contract for the provision of out of hours care.”

Well that’s another one that hit a quizzical face. No honestly, the regulations were altered to allow community pharmacies a contract if they were open to the public for at least 100 hours a week. And with the additional 600 that were granted last year, I have grossly underestimated the numbers – probably closer to 2,000 now. I thought that I understood the logic of forcing community pharmacies to open longer and provide a much increased service to the population for the same cost to the NHS. Access was the driver and it all made sense. But now I have to ask – “was the Department of Health creating a valuable asset for the NHS to waste?” – “Having a laugh” – “have they lost their way”.

I have read so many documents on urgent care that I now play community pharmacy bingo. ‘Commissioning the whole system (urgent care): why the big picture matters’ – not a single mention – hardly a big picture then. No one has twigged that some community pharmacies are open 100 hours a week with a pharmacist on duty. If the pharmacy had an out of hours addition to their contract; if they employed a pharmacist independent prescriber; if they co-located a nurse; if they co-located a GP – well you have a walk in centre, a minor injury unit, something that will make a difference.

I do agree with commentators that it is important to match supply to demand – the higher the attendances at hospital – the higher the admission rate. But to leave community pharmacy out of the mix – amazing!

Well, they were my two 30 second opportunities to ministers – what would you have said?

Primary Care – a closed shop?

As a member of the public I wonder why I am not able to choose and why I am always directed to a GP practice. I am told that they are overworked and busting at the seams. It can certainly seem that way when I try to book an appointment. And there are certain schemes out there that help – but they are just schemes – sometimes poorly advertised and explained – tinkering around the edges that cause me, as a member of the public, confusion as to where I can go for what.

I Can always pop into the community pharmacy when I need some urgent help, but strangely none of them are contracted to provide out of hours services so I am directed back to my GP or to an out of hours provider. I have looked on NHS Choices, but when I need urgent services it only directs me to a hospital A&E – no wonder I go there – does someone not realise this?

Actually I am used to visiting the community pharmacy – some of them have ‘Pharmacy First’ schemes or ‘Healthcare in the High-street’ schemes and can offer me some advice or treatment for a range of common conditions. But my neighbour doesn’t know this, its not advertised on my GP practice’s website and I can’t find it on NHS Choices. She books an appointment at the GP for a whole range of minor problems – its all she knows.

But it doesn’t have to be that way….. there is half a glimmer of hope.

Take vaccination for example. In Croydon and other parts of South London, I am directed by my GP to a community pharmacy for my travel vaccination. I enter into a world where I see a travel expert and given all the vaccinations I need. It is a nurse run service within a community pharmacy – now that’s a thought. But I can’t get the flu jab while I am there? In fact flu vaccine is available from some selected pharmacies in some selected area, but not where I live. So I have to try and book an appointment at my GP.

There are a range of sexual health services around – I can get my Clamydia screening completed in a small selection of community pharmacies, but they do not all have PGDs to provide the treatment. At £20 a pop, off I go to the GP or I do hear that the local GUM will give it out free, but I understand that costs the CCG £140 for the open access appointment – hey no appointments or waiting there.

I see that several pharmacies can offer stop smoking services, but not all of them can offer all the NICE recommended treatments – you have guessed it – off to the GP to get that prescribed as well. I asked whether they could offer me some patches in line with NICE PH 45 – nope not commissioned yet – off to the GP again.

I wasn’t going to talk about optometrists, but they have an urgent care service here – much better than the GP and A&E, they look after patients with ocular hypertension and share the huge and growing glaucoma load.

With rising demand and with the increasing age and complexity of patients attending General Practice – what is the solution?

One obvious solution is to open up primary care. Primary care is not just GP General Practice. I don’t just mean pharmacists, but optometrists and perhaps dentists as well. Commission a range of services and open up the access. Make it clear which provider provides which service and direct patients to them. If we work together we can manage the increasing population demands.