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Future pioneers

Pharmacy white paper outlines the government's vision for the changing role of pharmacists

The future of pharmacy lies in service provision, with a greater clinical focus, and increased integration with other services. This is according to the vision for pharmacy as outlined in the recently published pharmacy white paper in England. Recommendations in the white paper include the development of pharmacies as healthy-living centres, the introduction of minor ailment schemes on a wider basis, a vascular screening programme and new services for those with long-term conditions and those introduced to new treatment courses.

Clinical care
The white paper describes an expansion of clinical care in community-based pharmacy services and signals governmentís commitment to providing more support to people with long-term conditions.

The prospective role for pharmacy is outlined on three levels - supported self care, disease management for people with multiple, complex medicine regimes and case management in conjunction with other healthcare professions. The emphasis on pharmacists providing clinical services and moving away from dispensing/profit from purchasing could, however, see the development of a 'polarised market' model for community pharmacy in the future, eg one pharmacy takes on the majority of the dispensing in the vicinity, allowing other pharmacies the chance to take on the provision of more clinical services. This polarisation could become a reality when community pharmacy funding gets to the point where a predominantly service type operation becomes feasible, which would allow those pharmacists that want to work principally as clinical service providers to do so.

Release 2 of the electronic prescription service could be a catalyst for this shift to occur, and could potentially attract other willing providers such as wholesalers, manufacturers and hospitals into the dispensing arena.

The electronic prescription service was developed to allow patient prescriptions to be sent electronically from the GP to the pharmacy. Release 2 is the second upgrade, aimed at allowing all technical, clinical and process aspects of the full-scale system while the paper system is still operational.

There is, however, a lack of information in the white paper on how the payment mechanisms will work at PCT and community pharmacy level. The government recognises that payment mechanisms are an important means of allowing PCTs to take greater ownership of the new services. Whether fees should be set nationally, which would allow equality across all PCTs, or whether decision making should be left at a local level is yet to be determined. Just how and when changes to the pharmacy contractual framework and associated funding arrangements will happen also remains unclear.

As more complex pharmacotherapies are prescribed in primary care and the need for specialist support in the management of these patients increases, the need for 'shared' or seamless care across the interface will become more important than ever before. 

On the delivery of Practice Based Commissioning (PBC), the onus for improvement is directed towards PCTs as the ultimate owners and drivers of the PBC process. The white paper recognises the difficulties pharmacists have experienced in engaging and commissioning services. In some ways this is addressed by recognising the need for community pharmacists to have greater involvement in the commissioning process. This might involve community pharmacies being clinical service providers, giving input into local pharmaceutical need assessments and in service redesign in relation to care pathways and drug delivery. Having said that, the value a pharmacy can provide as an active member of the commissioning process also needs to be recognised, at both government and PCT level.

The white paper also identifies a new category of service for pharmacy, - direct enhanced services. PCTs will have to commission services identified by the Secretary of State as direct enhanced services (DES) for pharmacy, where there is a local need or national demand. Chlamydia testing and a minor ailments service are tipped as the first two to come on board. 

In the years that I worked in hospital pharmacy, I saw the transformation of the pharmacistís role from predominantly providing a supply function, to one of providing personalised pharmaceutical care to the patient on the ward. In the latter instance the pharmacist was truly integrated into the clinical team. The success of this is underpinned by visionary leadership, a robust competency framework and a commitment to continuing professional development and practice research.

The white paper goes on to recognise that community pharmacy is on a similar path of transformation and that there are barriers that need to be overcome in order to complete this.
A number of recommendations are proposed, such as the appointment of two new clinical leaders to focus on pharmaceutical service delivery in both a community and hospital pharmacy setting, and the need for multidisciplinary working and the fostering of closer professional co-operation.

In the future it is recommended that the delivery of medicines use review (MUR) services be prioritised by PCTs according to their local health needs, with the intention of increasing the quality rather than quantity of MURs performed. A PCT could then monitor this and the services of those pharmacies that fall below the minimum requirements could be decommissioned.

Community pharmacists are ideally placed to support patient adherence and concordance of patients through MURs. Intentional and unintentional non-adherence is as a result of multifaceted issues and reasons such as patients' beliefs about their medicines, adverse effects they might feel or simply practical issues such as not being able to open the tablet container or understand the directions on how to take the medicines appropriately. Again the white paper recognises this and intends to explore further the impact that pharmacies have in patient adherence to medication. It also makes recommendations that patients on newly prescribed medicines for long-term conditions (such as high blood pressure or cholesterol), have specific support.

The access and use of information in community pharmacies and, in particular, patient information is key to the effective transformation of these pharmacies into CSPs. Work to understand and address the issues of patient consent and confidentiality and how community pharmacies will use the summary care record is on-going. Future work by the government with an early adopter PCT will consider the benefits, governance and practical arrangements of community pharmacies having access to the summary care record.  

Conclusion
Pharmacy is at a time of unprecedented change. This change offers the pharmaceutical industry an opportunity to support community pharmacy in strengthening its skills as a clinical provider of care, through constructive partnership. This could be through supporting service provision or utilising its research expertise to support pharmacies generate an evidence base for clinical outcomes, thus enabling them to demonstrate value in the commissioning process.

The white paper has indicated positive intentions and aspirations with regards to pharmacy in the future, and it is hoped that the consultation planned for this summer will provide the detail currently lacking to make this vision a reality.

The Author
Shailesh Patel
is marketing manager at Apotex UK

23rd July 2008

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