Few if any stakeholders will argue that the pharmacy sector needs to change. Recent years have seen a series of reports and proposals to that effect, but there has been little evidence of large-scale progress.
In its recent report, Now or Never: shaping pharmacy for the future, the Royal Pharmaceutical Society (RPS) has sought to summarise the sector’s problems, publicise the work being done to address them, and come up with nationally viable solutions and models of care.
Pharmacy is in some ways a victim of the times. Set against a backdrop of dwindling NHS resources and recent reforms, the sector is struggling to find a voice and a direction. The spread of technology has prompted uncertainty around the pharmacist’s role and pharmacy finds itself hampered by a public reputation that, while respectful, shows little awareness of the profession’s potential or capabilities.
So change is needed, and in a number of areas.
Time to move centre-stage
At the heart of Now or Never’s findings lies the need for pharmacy to end its traditional isolation. Now more than ever, the pharmacist needs to play a part in a multi-disciplinary team. In other words, community and primary care pharmacists need to be more like the hospital pharmacist, who works alongside medical and nursing staff.
Being part of a bigger team also fits into the ‘pharmaceutical care’ model, whereby pharmacists take on a degree of responsibility for the outcome – rather than simply dispensing medicines, the pharmacist should also be helping patients manage their conditions, providing health tests and spotting early deterioration in the patient’s condition.
As the NHS continues to shift its focus from acute to integrated care, the opportunity exists for pharmacists to play a larger part, to the extent of visiting patients in care homes or even at home. Any changes made within pharmacy need to lead to resources and professionals being used to optimum capacity, says the RPS, concluding that the best way to do so is by improving the treatment of vulnerable older people and those with long-term chronic conditions.
Better communication
The public tends to view the pharmacist as the person in the white coat who counts out their pills. The report identified a fundamental need to promote what the pharmacist can – and is authorised – to do. And this communication needs to be about more than a poster in the pharmacy window.
Rather than waiting for a doctor’s appointment and using up already stretched GP resources, members of the public need to turn to the pharmacist first for flu jabs, blood pressure tests and the like. While a significant number of pharmacies already offer these services, public awareness is low, and yet the benefits are clear – no long queues, rarely the need to make an appointment, and ease of access, with a pharmacy on every high street.
The RPS report cites studies as having shown that 18 per cent of GP consultations involve minor ailments that could be dealt with by a pharmacist.
Scotland is one step ahead when it comes to the treatment of minor ailments – some two million people there are registered with the minor ailment services, benefiting from treatments that the government has commissioned pharmacies to provide. Wales has a similar arrangement.
Technology and its opportunities
Robots have been used for dispensing in hospital pharmacies for a number of years and are becoming increasingly popular in community pharmacies. Their use means that much of the dispensing can be managed by technicians. While pharmacists must be present to ensure that the medicine prescribed is safe and appropriate for the patient in question, having dispensing taken out of their hands means that they are free to concentrate on other elements of their role.
Another example of the benefits of technology is also being seen in pharmacies and GP surgeries having shared access to patients’ records, and the RPS hopes that this will become more widespread.
Pharmacy as a career
Encouraging pharmacists to take a step back from full-time dispensing in order to work more closely with patients and other health professionals will, says the report, make pharmacy more attractive as a career option. Yet the number of qualified pharmacists already exceeds the rate at which new employment opportunities arise. The number of GP trainees, on the other hand, falls short of government targets. Could this be a chance for pharmacists to step up and play a bigger role in primary care teams?
Almost 3,000 of the 40,000 pharmacists registered in England today have been accredited as Pharmacist Independent Prescribers following extra training. They are allowed to prescribe any drug for all conditions within the pharmacist’s competence, except for certain addiction treatments – this means that there is real potential for their involvement in the ongoing treatment of the elderly and chronically ill, and therefore broader career opportunities.
A pharmacist prescriber with a specialism in pain management, for example, ran an NHS pain management clinic from a community pharmacy in Essex. Patients were referred from a local health centre, instead of been referred to a secondary care pain team.
No shortage of good ideas
The report was compiled by RPS’s independent Commission into future models of care delivered through pharmacy and one of its most encouraging findings was that there is no shortage of good ideas within the UK’s pharmacy sector – more than 100 models of care delivered through pharmacy were submitted to the Commission during the call for evidence. Examples cited include signposting service for wider determinants of health such as fuel poverty and domestic violence, monitoring and dose adjustment of anticoagulants, and end of life care.
Most of the models of care discovered by the Commission, however, are local and one-off – few “had been rolled out consistently and at scale across a district or region”.
The commissioning landscape
Commissioning remains a bone of contention for the pharmacy sector, not helped by periodic reorganisation in England, although Scotland has an effective systems. Lack of clarity over who is responsible for commissioning which services remains at the root of the problem for pharmacists in England.
Community pharmacy – its commissioning has been the responsibility of NHS England and its local teams since April 2013 – is in particular disarray. Some local services are commissioned directly through local authorities, and the RPS expects clinical commissioning groups to elect to do the same at some stage.
The commissioning of local enhanced services is suffering, having been hit by the 2010 abolition of primary care trusts, and again by the NHS reforms. The number of services commissioned is falling steadily.
How to remedy the situation? In the first instance, there needs to be clarity. The sector needs to know who is commissioning what. And there needs to be consistency. Some community pharmacies are providing certain services, while others aren’t – simply because of differences in commissioning. Regional variation in commissioning has also limited community pharmacies’ ability to deliver services on a larger scale and to invest in facilities and staff in order extend their services.
Local pharmacy services will increasingly be commissioned directly by clinical commissioning groups, creating the opportunity for them to provide services for care homes and for chronically ill patients in their own homes. The RPS stresses, however, that community pharmacy will need to be proactive to attract commissioners, for instance by working with other pharmacies to design service offers and prepare tenders. In Now or Never, the RPS also urges clinical commissioning groups to call on pharmacies to improve local services, especially urgent treatment, out of hours primary care and care for the frail.
Reaction to the report
The industry has responded well to Now or Never. Speaking of the RPS’ continued commitment, Carol Blount, NHS partnership director for the Association of the British Pharmaceutical Industry (ABPI), said: “The report quite rightly highlights the need to change the balance from dispensing and supply towards medicines optimisation and the provision of new forms of patient care.”
The Royal Society for Public Health too welcomed the development of the role of the pharmacist, said chief executive Shirley Cramer. “Pharmacy is in a unique position to help improve community health and well-being,” she said.
The General Pharmaceutical Council chief executive Duncan Rudkin echoed Blount’s sentiments regarding the role of the pharmacist. Acting on its new strategic plan, his organisation too is keen to put the patient at the centre of pharmacy.
“As the pharmacy regulator, we want to play our part in enabling innovation and promoting improvement so that a greater role for pharmacy in supporting the health and well-being of patients can be realised,” he said.
Praise for the report came from beyond the pharmacy sector. Royal College of Physicians president Sir Richard Thompson said: “We agree with the RPS that there is a greater need for joint working of professions, including pharmacists in multidisciplinary teams, in order to widen the provision of care for people in hospital and the community.”
“The RPS is right to note the need to control costs, and that therefore all professions working in or with the NHS will have to drive change using existing funding and innovation,” he added.
What next?
Now is the time for action, says the RPS. The sector needs cohesion and strong leaders, and it needs to work alongside other health professions.
Commissioning needs to be straightened out and pharmacists need to work more closely with one another, setting up groups and consortia.
There is scope, believes the RPS, for NHS trusts and foundation trusts to develop local primary care services where community pharmacies cannot.
Pharmacists should embrace, rather than shy away from, the opportunities afforded by technology, and see the increasing popularity of dispensing as facilitating a move towards working more closely with patients and overseeing a more patient outcome-based treatment.
National, rather than local, innovation and policy is needed – and the sector needs to be bolder, influencing the NHS, clinical commissioning groups and local authors to commission new services.
Ironically, in concluding Now or Never, the RPS acknowledges that there have been too many reports, stressing that now, instead, it’s time for action.