Healthy Community Pharmacy Strategy

I am doing some research for a ‘Healthy Communities’ meeting that I have been invited to. Lots of clever people will be there – you know counsellors and politicians, but I doubt that there will be a pharmacist.

So I am walking down a high street that I have known for many years. Many of the shops that I remember are closed to be replaced by a charity shop and some fast food outlets with motorbikes parked outside. There is still a ‘corner shop’ that sells newspapers and alcohol and a selection of bits and bobs. It has a heavy duty metal grill and a sign that says ‘only two schoolchildren at a time please’. Even the teashop/bakers were closed – empty tables and broken chairs still visible through the window. It all feels grubby and uncared for – just dirty. There is graffiti on the walls and I would suspect that it is not a nice place to be walking through late at night – even my research doesn’t go that far.

The GP surgery is two streets away in a pair of converted semi-detached houses. The community pharmacy, which used to be an important feature of the high street, is in the GP surgery. So I pop in and ask the question – why did you move?

The answer was simple – more than 90% of our business was in prescriptions. This move protected our business from competition and allows us to keep going.

“What proportion of your business is in prescriptions now?” was an obvious question. The answer was almost 100% – we do sell a couple of bits, but we just don’t hold the stock anymore and we don’t have counter staff – well to be honest we don’t have a counter!

“And the future?” – the reply was quite disappointing – there is little future – our income stays the same, but prescription numbers increase – the owners are waiting for the opportunity to sub-contract a proportion of our work to dispensing factories to save money and cut the overheads or contract some of our staff to the practice.

I walked back to the high street and stopped someone, asking them what they thought of the high street now. You could see the pain in her face – “it was nice a while ago – but now….”and as her voice trailed off she added “well that’s called progress”.

I asked her where she bought simple medicines from or which pharmacy do they ask for advice. The answer again was quite disappointing. “Well the corner shop does sell some medicines, but it doesn’t give reliable advice – the man just reads the packet. The nearest shops are nearly half a mile away in a large shopping complex – there is a pharmacy there, but I have to get the bus”. It is a multiple and, as I was told – the only guys that can afford the rent in a place like that.

How sad. The community pharmacy was the anchor store in many high streets. They supported a professional image and drove footfall which ensured the viability of other shops in the high street. It was a place that residents could visit, do some shopping, get some advice, meet neighbours and even take a small amount of pride in. Now the high street is desolate, packed with the wrong kind of shops and attracting grubbiness and bad behaviour. A source of local shame and community disintegration.

It is not as if the government did not know this. They drove the community pharmacy contract so far that it only rewards the dispensing of prescriptions. The cost efficiency saving applied (this year around 3.3%) means that there is more dispensing work and less investment in front of shop care for local people. There is a view that the cost of dispensing medicines is too high so we should expect the government to continue with its plan to pressure pharmacies to close – but which ones will it be – probably the smaller high street pharmacies.

And the current regulations hamstring pharmacists from being able to manage patients properly creating expense and pressure in the system. Examples are many. In a wealthy area a family presenting with head lice purchase treatment – whereas in a less wealth area they are sent to the GP practice nurse for a prescription. The community pharmacy may test for chlamydia, but then have to refer the patient to the GUM clinic to get a prescription for the treatment. The regulations are archaic and restrictive and must be changed to allow community pharmacists to care for their patients.

It is not as if the Local Authorities did not know this seeing the rents in small communities disappear and the costs for dealing with graffiti and antisocial behaviour increase. They also know that many communities have the greatest health risk and they watch community pharmacy move out of the high streets. They now have ‘nurse in a van’ programs where they could have given the nurse a nice professional setting right on the high street and supported by a local pharmacy team who knew most of the local residents.

And who supports NHS England as they remove the support for ‘essential small pharmacies’?

Please don’t get me wrong there as a lot of community pharmacies hanging on – providing a great service to their local community. Knowing some of these people, it is a more a sense of belonging, professional pride and community responsibility rather than a commercial view – unsung local heros.

However, a healthy community is as much about local pride as the new-fangled services that might be shipped in within a converted transit van parked in a dead high street or disused parking lot.

If anyone has a wish to see health communities then there is a clear need to think about community pharmacy again.

  • How do we get community pharmacy to move back to the high street?
  • How do we define ‘community important pharmacies’ as well as ‘essential small pharmacies’ and ensure their futures
  • How do we change the financial rewards from 100% dispensing to services for local people driving, different revenue streams?
  • How do we change regulations / laws to make it easier for community pharmacists to supply on prescription or sell the medicines that people need?
  • How can we make the community pharmacy the anchor for healthy communities again?
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Community Pharmacy on your own

So public health funding cut, NHS England strapped for cash, call to action buried and little chance of minor ailment services going national. I could continue – too many pharmacies, dispensing is uneconomic and integration difficult. On top of all this salaries for locum pharmacists are falling and the supply chain is becoming ever more fragile.

There are of course some positives – the shared care records are coming and category M is relaxing a little. There are some great examples of integration, where community pharmacies have been granted read/write access to the medical records and carry out direct patient care in their premises. And the usual plethora of fantastic individual practice that wins awards, but is rarely shared to become common place.

Am I missing anything?

Actually I forgot to mention the dispensing for health campaign from Pharmacy Voice. A ‘long term campaign’ to encourage the general public, politicians, policy makers and health professionals to think differently about how they interact with community pharmacy. It is unlikely for me to support campaigns like this, but I do – it is very timely and appropriate. They just have to progress this to make the Community Pharmacy think differently.

Community Pharmacy is a business and like every other business, it has three lines in its accounts – income, overhead and profit. I am sure that most pharmacy staff realise that it is not the employers that pay their salary, but the customers. The more customers, the more income and the more an employer can pay for quality services.

Community Pharmacy is also a people business and we all know that the success of a business depends on the relationships it creates with its customers. We all know about service and the need to deliver great service above customer expectation, but have we considered ‘value’?  What constitutes value in a patient’s mind?  I have seen attempts from the PSNC and the RPS and NHS England, but I feel that most of these reflect managerial expectations rather than the individual patient. I have seen large multiple chains offering services as a driver for footfall, but does this drive relationships?

I wonder if it is actually pointless asking customers what they want. Mostly they say- what we have, but quicker and better. How do we explore customer needs in an open and forward thinking way – and without telling them what they want? I am reminded, however, that there are many example of pharmacy teams that have increased sales and prescription numbers through interacting with their customers in an advanced manner. hey are obviously doing something right.

So, bearing in mind that relationships are key to all businesses, we have to sort out some key elements that build relationships:

Active listening – this starts with a smile, friendliness and early engagement, but what am I listening for. In order to dispense health, I must recognise the triggers that allows me to ‘sell’ health

Clear Communication – I must be able to build on the triggers and deliver very simple messages clearly and concisely and link to written aids and the products that are sold within the pharmacy. I am not sure that I can change behaviour, but I may deliver something that the patient is actually seeking a solution for.

Memory retention – I must be able to remember the discussions that I have had, the products I have sold so I can reinforce the communication and ask directed questions. I have to always show that I care.

Negotiation and Persuasion – I must be able to find neutral ground where there is a win-win situation between customer and pharmacy. Be happy to win-win very small.

Efficiency – Obviously the transaction needs to be handled quickly, accurately and professionally. But I need to develop a whole range of ‘parcels of care’ that I can deliver to a wide range of customers, their families and the community as a whole

So what are these parcels of care? They are easy, just look around your selves and think about what you sell and why you would sell it. Track it back to patient needs and identify the triggers. Then build the parcel.

The unmeasurable value of community pharmacy

Community pharmacists can make a huge impact on patient lives. I know, because a lady told me so!  It is one reason why I talk about the value of community pharmacy and the need for community pharmacists to keep their feet on the ground and think about the people who come into their pharmacies.

It is not about new-fangled super-clinical stuff – it is about understanding the basics and why the generalist pharmacist, like the generalist doctor are so important, but undervalued in our NHS. You can never really put a value on a good community pharmacist.

So a lady came in – I had seen her before, but never to talk to. No dispensed medicines before and no history to recall, but she was asking for a pain-killer. All community pharmacists know how to keep one ear open to what is happening. The counter staff was doing the right thing – they always do – but I watched the woman flex her hand during the conversation – so I joined her.

‘So how long have your hands been stiff?’ was the opening question, which naturally got an open-mouthed stare, ‘well I saw you flexing your hand and I wondered if your hand was stiff’.

With a disbelieving look she said ‘yes – been stiff for a few weeks, worse in the morning’.

‘Are your joints sore as well?’

‘Well yes, I was just asking what medicine might help. They feel swollen and I can’t actually get my rings off any more’.

So I go for the slamdunk – ‘do you mind?’. But without waiting for a response I took her hand in mine and squeezed a little.

There was my answer- sore, tender, stiff and swollen joints on the hand. And with some follow up questions, they were probably not the only joints affected.

It is funny that the moment sticks in my mind, holding the hand of a 40something lady in a busy pharmacy telling her that ‘I don’t like this much, you may have and acute inflammatory arthritis’. Fortunately she was registered at the local practice and they would see her straight away.

I bumped into her three months later and she came up to thank me. The GP did some blood tests and sent her as an urgent case to the early inflammatory arthritis clinic where she was seen and treated within a week. Now she was on a ‘mab’ thingy and already feeling much better. The consultant told her that ‘we caught it early’ and that was a great advantage.

As the community pharmacy training sessions focus more on DMARDS and biologics, I do still wonder if community pharmacy is losing the ‘touch’. To make a massive difference to someone you may need notice things, ask questions and hold their hand.

If hope that there are no pharmacists out there that do not understand ‘Stiffness, Swelling, Squeezing’ when people visit our pharmacies looking for help.

Community Services Commiunity Pharmacy

Last week I was chatting to a District Nurse. Under pressure now that district or community based nurses are at a record low. Half the number with twice the workload –  running around likes the proverbial blue XXXXX fly. Loved the Care in local communities vision for district nursing, but hardly the time to say hello my name is…. At the bottom of this there is a recruitment issue – just not enough nurses to fill the posts. It is OK to use healthcare assistants, but sometimes that is not the same.

It’s obvious, it is not the vision that is broke – far from it – it is the ability to deliver.

We talked a little about geography. She lived 8 miles away from here and the base was four miles further away. It’s outer London – so four miles doesn’t sound much, but could take 20minutes.

The first discussion was about why she uses the base. It would seem ‘not a lot’ since all of the appointments were scheduled electronically, but it was probably necessary to visit the base to pick up equipment for the day – catheters, dressings and other equipment that was required. Thinking about this list, there was very little that wasn’t stockable or orderable from the community pharmacy. You could easily use a community pharmacy an outpost of the unit – then at least you could be on patch quicker.

We chatted about the things that she and her team do on a regular basis for people who live in the streets around the community pharmacy.

Ok – I am not going to get involved in catheterisation or wound management, but I can at least ensure that the products required are available or close to the patient’s home – perhaps even delivered. LMW heparin injections, blood glucose testing, insulin injections, anticoagulant monitoring and immunisation for the housebound – well I could do all of those.

Falls assessment – tick – I do those for the elderly who can get to the pharmacy and basic health checks – BP etc – tick.

Visiting some frail elderly patients after discharge and liaison with social services. Well I bet we deliver to them weekly – why can’t our delivery driver check on them regularly then either ring me or you or their care worker when something is not right.

Setting up remote monitoring equipment – right up my street – I love gizmos.

And connect to voluntary support and help – excuse me – I work in this community – I know most people who live in those streets. My staff live in those streets.

Throughout the conversation there were many more things that were mentioned that a community pharmacist could deliver with a small amount of additional training and orienteering. At one point the nurse looked longingly at the consultation area – could we run some clinics in there?

When I mentioned that we were hoping for read/write connection to the GP clinical system of the nearby practice, she nearly fell of her chair – advanced communication between district nursing and General Practice through the Community Pharmacy – just let the thought of that sink in!

At the end of the day we must accept that district nurses are valuable commodities that need to be protected and supported, but they don’t grow on trees. There are numerous functions that a community pharmacist and their team could deliver through an integrated multispecialty community service.

And then we might think about introducing more advanced nurse practitioners and a few independent prescribing community pharmacists. Was this Simon Stevens vision?

Community Pharmacy – back to the future

I tried to explain at the Clinical Pharmacy Congress that Pharmacy ethos needs to change. We need to start with the person and work from there. A pharmacist asked me what I meant – so I visited their pharmacy and showed them what I was saying. I must say that there are others that think like me – it is clear with the dispensing health and the self-care pharmacy initiatives that some community pharmacists are on the same track.

The first prescription that I picked up was for thyroxine so I asked the question – what is this? The answer was complete and accurate as you would expect.

So what is it for? And again a perfect answer. And what are the symptoms of being hypothyroid which was also followed by an impressive list of symptoms.

Fantastic, so just as I expected this pharmacist was red hot. But the next question was the one that caused consternation. What are you going to say to the lady when she comes for her prescription?

Err – an answer of ‘ask if she has had blood tests within the last year’ may have been right or even ‘do you know how to take your tablets’, but it did not really follow after listening to a whole list of symptoms.

When the lady came in, we started from a different point. The introduction was ‘my name is’ and followed by ‘I am your pharmacist today’. I liked the personal touch and the use of the word ‘your’. The next question was slightly more leading ‘how are you getting on – are you having and problems, like tiredness, feeling cold, or dry skin’.

At first she looked a little shocked, but then started talking about her skin. She always felt cold, but she knew it was part of her condition, but the dry skin was quite a problem. She used plenty of moisturiser, but her current problems were her lips and her feet. We chatted about options and what she had been using. So she bought a lip balm with sun protection included for the day and plain Vaseline for the night. I hope that we had persuaded her to use the hydrocortisone cream a lot less often.  And a foam cream containing urea to use on her feet. We approached the subject of bowel function, but she had a diet high in fibre and constipation wasn’t an issue. She was using lots of conditioner on her hair and felt that was OK. Finally she volunteered that she had a blood test about 6 months ago and it was OK.

She left the pharmacy feeling happy. Her last comment was that she had been collecting her prescription for 12 years and nobody had asked her these questions and shown such interest.

The pharmacist asked me if I knew.  Of course not – but most people have some issues that they are managing. He understands a little bit more about what it is like living with hypothyroidism, but everybody will be different and he won’t know until he asks. Strangely, you do find these things in a text book, but you only understand when you listen to people.

The connection with people is the heart of community pharmacy. In our drive to be experts in medicines and knowledgeable about disease we may have for forgotten about the person standing in front of us. This lady may have been on a medicine (thyroxine) and may have had a medical condition (hypothyroidism), but we must always start with the person, who just happens to have a thyroid problem which is treated by thyroxine. Through engaging with the person, we were able to help.

I believe that pharmacists used these skills in the past, but we may be overlooking them now. People don’t care what we know, until they know that we care. So it is time to go back to the future. More and more people need their pharmacist for help and support.

Partnership in immunisation

A GP and a community pharmacist were sitting in the coffee shop – well sitting in the bar would sound like the start to a joke.

The GP says – “you know I hate flu immunisation. We have so many to do the practice is absolutely full; they are expanding the numbers all the time, then moan when we don’t surpass the targets. We have to put on extra clinics and are even thinking about opening at the weekend – but with all the overheads we are hardly likely to break even”.

The Pharmacist says – “Ha – I hate Saturday afternoon and Sunday. We are open and you are closed, it is hardly worth it for me, but it is part of my contract”.

A lightbulb moment!

“How about running the additional flu clinic in the pharmacy. You book patients in on a Saturday and Sunday. Double book them and your nurse and the duty pharmacist can alternate patients so we both make some money”.

“Hmm”, smiled the GP, “and I wouldn’t need to open up”.

“No, and while the patients are waiting they might get some advice on other common conditions or even buy something”.

“Sounds like a good arrangement to me”, Agreed the GP. However, last year one of the practice nurses had an accident and went sick, if it happens again could you help me out?”

“OK – I have three pharmacists that work for me, I am sure I can arrange for one to do some of your clinics if you cover their costs”.

 

Now why doesn’t it work like this everywhere?

Health vs Illness

I had an interesting discussion with a GP. How do we differentiate General Practice and Community Pharmacy in a patient’s mind? It is not easy when the services delivered in community pharmacy are variable. The politics are also variable – we are told to visit community pharmacy for common ailments and then we are warned about cancer and told to see a GP.

So I said – it all depends on whether you are healthy or ill. If you are essentially healthy you should visit the pharmacy and if you are ill, you visit the GP. In the backroom you join them together and then you create a compatible contract with elements of profit share and joined records.

So when do you visit the pharmacy and what services should they provide. Think about it – when you are essentially healthy you go to the pharmacy. This might mean:

  • Common minor conditions
  • Routine immunisation
  • Travel health
  • Obesity, smoking and exercise management
  • Emergency hormonal contraceptives and general contraceptive services
  • Child health

‘Hold on a minute – all immunisations’ – yes these patients are not ill and the whole point is to tell patient to only go to their GPs when they are ill – really ill and the GP practice will look after them. When you are not ill then you go elsewhere – to the pharmacy.

You aren’t ill when you need a contraceptive – you aren’t ill when you go on holiday and children aren’t ill.

‘But how would you deliver this’. Community pharmacy can employ nurses if that is appropriate or use pharmacists. We are well used to this mix of staff delivering good care. It would just need the contracts to force working together with some cross management of resource.

‘What do you mean – cross management of resource?’ The community pharmacy may contract nurse support from you and you may contract pharmacist support from them. When you both have access to the medical records, it matters less where you practice and operate the services.

‘But will we lose money?’ That is the whole point of shared contracts – so the delivery becomes a shared responsibility and you are jointly paid for delivering outcomes. It is not beyond us to develop something like this is it?

The whole point is that we have to simplify the message to the population in a manner that they can understand. If you are ill go to the GP, if you are generally well then see the pharmacist.

Travel Health

This was an interesting conversation with a GP.

I overheard the receptionist say to a patient “Why don’t you go to Superdrug?” Well this is not something you often hear in a GP practice. And the practice nurse jumped in with ‘ask for Jackie – she will sort you out’. This was followed by a supportive smile and a nod of agreement by both members of staff.

On the way out a patient in the waiting room joined in with ‘they are very good, I always go there’. What is going on? This is hardly the way to run general practice so it is important for everyone to be suitably quizzed!

The patient wanted advice about travelling to the Far East on holiday and rather than booking the patient into the travel health clinic, they were referring the patient to a community pharmacy. They say that this is routine now and the patients are OK with it. In fact they seem to support it. So I had to go and investigate….

I have to say that I had to push my way past shoppers and isles of cosmetics and sundries, but I arrived adjacent to the pharmacy section to a sign that said ‘Travel Health Service’. It looked professional and there were leaflets and a large map on the wall.

I asked for Jackie and was met by a nurse – ‘I know you’  – I suddenly blurted out. Yes she was an ex-practice nurse that was now working for Superdrug – who would have guessed!

Her office was small, but professional and she explained that she worked with the pharmacist to deliver a full travel service including yellow fever and rabies. They had expanded and now there were three part time nurses that run the service. They will prescribe/supply malaria treatments and administer vaccines and offer travel health advice. There was a whole section of stuff that I might need from flight socks, through mosquito repellents to nets and everything you could think of all in one place.

I left both pleasantly surprised and a little annoyed. Why didn’t I know about this service and it was probably better than the one offered in the practice.

The practice nurse was happy to admit that she saw less patients now for travel advice – “they have a better set up and can offer more than we can – it is not as if I haven’t got other things to do”. Do you still offer a travel health service – ‘yes of course we do – there are patients who want to see us – but many seem happy with the community pharmacy and there are a few that we have to refer there anyway’.

So what a learning exercise that was. An hour a week of senior practice nurse time saved and the patients actually get a better service.

Community Pharmacy – time to change?

Is it still now or never – or has the rush passed and are we still calling to action? All I know is that we have to think differently in community pharmacy. We are where we are, some might say, but it is neither where we want to be nor what the population or the NHS wants from us.

So let’s start with the negatives. We have a community pharmacy contract that is dispensing focussed. The DH believes that there are too many pharmacies and that dispensing is not economical. The provision of clinical services is hugely variable in volume and in quality and we are losing our way. There is money in the system, but it is not going to flow in a manner where it could end up in owners’ pockets. The politicians are not confused as to the role that they want community pharmacists to play in the future, but they can’t see a path.

And the positives. The government seem hell bent on driving patients to the pharmacy before booking an appointment with the GP or out of hours provider. Areas have built new services against the trend and many community pharmacists are providing services that are above and beyond our basic expectation. Community Pharmacists are engaging more, but are still a way from building integrated multi-professional services within primary care other than in PM Challenge Bid Projects. The government will invest in pharmacists to support primary care or at least in GP practices.

One sad fact always comes to mind. A procurement pharmacist in a multiple can make more money for the company in one trade than a whole team of clinical specialists over the year. Remember this as this is important.

If there is little new money, then it may be about trading and compromise, working towards a new definition of community pharmacy that suites the population, the government, the profession and the owners. Perhaps the owners are the key to change – have we understood this?

So what are we going to do about dispensing? Here is just one suggestion. We split prescriptions into acute/first or repeat – it is easy to do. We slightly increase the dispensing fee of all acute/first prescriptions and reduce significantly the fee for all repeat prescriptions. The money saved goes into two separate pots. The first is an establishment payment that supports any pharmacy to upgrade to a ‘Healthy Living Pharmacy’ or ‘Self Care Pharmacy’ – I don’t care which, but these pharmacies have additional features and additional standard services. We can bundle ‘Pharmacy First’ or MASchemes into this, along with staffing and training requirements. The second is a clinical services pot which supports the pharmacies becoming a clinical service point within the system – it might only need to be a pump-priming fund and could sit under the control of the Chief Pharmacist. No more dabbling in asthma or pain management – a fund that can support pharmacists to develop and deliver specialities in the pharmacy.

Yes it is about a choice – repeat dispensing will be less profitable and factories may take a larger role – but community pharmacies have the chance to develop and provide additional services. And yes CCGs and LAs that already invest in community pharmacies must embrace this move and we work out how their commitment is rewarded. A community pharmacy must be able to survive dispensing fewer repeat prescriptions (or sending them to a factory) and increased clinical services.

Community pharmacy also needs to think independently and locally. Joining as members of federations they can play an active role in the delivery of multi-professional providers within primary care. Through this route, community pharmacists will bid alongside GPs, Optometrists, Dentists, Community Service providers and the voluntary and charitable sectors for contracts. This is the way forward and if it doesn’t work then hospitals will take it over (whatever that will mean).

I am hearing that the multiples are split – some see that dispensing is their future and some see that clinical services hold the key. That’s fine – there is room for both views and perhaps, in the future, owners will be able to make a choice, knowing that both can thrive.

Another child dies

So another child is dead due to methadone overdose. It isn’t a rare occurrence; there is some every year and I have just seen another report. Collateral damage, I have heard it called, but it is the sad and needless loss of a life. Misadventure, the coroner often calls it, unfortunate, inadvertent, but quite predictable – and that is the sad thing.

So what was it this time? Parents who dip the dummy into the methadone to help the child sleep? A parent who leaves the dose of methadone in a cup on the table? Older children who mimic mummy/daddy when she/he leaves the methadone safe open?  A teenage methadone party? It doesn’t really matter does it?

We are talking about a child born into a family struggling with addiction. Often a child that is neglected, with one parent that is ‘away’ somewhere for some of the time. A family that is slightly flaky – or should we call them ‘troubled’ to be accurate, with some undesirable friends and contacts and not living in the best accomodation. It is hard enough for the child and it is hard enough for the parents.

So what do we do – we offer the parent methadone as part of their detoxification program. The reason – probably it is because it is cheap and can easily be administered under supervision 6 days a week. The parent might actually ask for it – always a good choice if you want to top it up or trade it. And the supervision cost is less – although the whole process of supervised administration does not fit well with a parent trying to pull their life together and look after a child. Ask any mother how long it can take to get your baby ready to go out in the morning.

We know that methadone is extremely dangerous to children. Perhaps that explains why the dose is so often a little on the low side. Perhaps we invest the savings in special methadone safes. We could always supply naloxone injections and train the parents how to use them should their children ‘inadvertently’ take an overdose on the end of their dummy. We could add on the label – do not even think of dipping the dummy in this solution.

Or perhaps we could use buprenorphine.

Nah – that would cost us more. Hmmm – it is generic now and on category M. Yes, but it takes longer to supervise.

But it is much less likely to kill a child.

If you haven’t spotted the hidden statement – here is this. Do not use methadone within your detoxification regimen if the patient is living in a home where children reside or are likely to visit.