Pressure release

Community pharmacists are the newest addition to the NHS family. The new pharmacy contract, which will go live from April 2005, provides the legal framework to allow the skills, experience and expertise of pharmacists and their staff to be fully exploited in a modern NHS.

It makes clear the role of the community pharmacy and how it can contribute to the achievement of targets for the health sector, such as improving access and choice, and helping people with long-term conditions. Additionally, the new pharmacy contract will allow PCTs to develop community pharmacy services that can support GP practices in fulfilling the new GMS contract.

What has changed to make community pharmacists (CPs) integral to the NHS, and just how important are they going to be? How has the role of the CP changed in recent years and which new roles will CPs take on under the new pharmacy contract? How influential will this professional group be and how might the pharmaceutical industry identify appropriate CPs with which to engage?

What does a CP actually do?
The core role of a CP is in the safe supply of medication to customers and patients. This sounds like a fairly simple task! However, due to the many processes and responsibilities involved, it takes five years of study and training to become a CP - four years studying for a pharmacy degree at university and one year in post graduate training in a pharmacy. A registration examination must also be passed in order to practise.

In addition, CPs provide a range of other health related services from their pharmacies, which include: advice in managing minor ailments like colds and flu; smoking cessation advice; healthy eating advice and travel advice. Other, more specialised, services provided by some pharmacists include: additional support by way of monitored dosage systems for people who need assistance in managing and taking their prescribed medicines; diagnostic testing and supervised medication services.

However, until recently the NHS had not recognised the potential value of CPs as part of the NHS team and had paid them via a contract that rewards on the quantity of prescriptions dispensed, rather than on the quality of service provided. CPs have been perceived by many to be `retailers', rather than bespoke health professionals.

One of the main aims of the NHS Plan is to make better use of the skills and experience of other health professionals working in the NHS, freeing up doctors' time to deal with those patients who require it, and providing alternative and more easily-accessed care for those who do not. The CP is one health professional identified in the NHS Plan who is well qualified and well placed in the community to compliment the NHS team.

Before issuing any medicine, a CP must be satisfied that medicines are safe and effective and will not interact with any other prescribed, or purchased, medicines. For example, when a request for self medication is made, the CP, or their highly trained staff, will ask a number of questions to ensure that an appropriate treatment is selected:

• Who is the medicine for?
• What are the symptoms?
• How long have the symptoms been present?
• What age is the patient?
• Are any other medicines being taken?

Part of the NHS family
Over the last few years, many CPs have taken on challenging new roles in the development of medicines management services, working more closely with other health professionals and primary care organisations. Success in these roles can be seen in terms of quality, cost effectiveness and benefits to patients and the NHS.

The new pharmacy contract is the mechanism by which CPs can be remunerated for delivering those services that help PCTs achieve the objectives of the NHS Plan around Patient choice, Public Health and Chronic Disease Management. Accordingly, the CP is now an integral member of the NHS family and has become an important addition to the network of health professionals involved in planning and delivering local services.

Three-tier role for the CP
The new pharmacy contract divides services that can be provided by CPs into three tiers: essential services, advanced services and enhanced services.

Essential services are defined as those core services that would normally be provided by all community pharmacy contractors, including dispensing, repeat dispensing and, importantly, clinical governance. These, together with advanced services, will form the 'nationally agreed' services and these will not be open to local negotiation.

Advanced services will require accreditation of the pharmacist providing the service and/or that specific requirements are met with regard to premises. Advanced services currently include medicines-use review and prescription intervention.

Enhanced services are those which will be commissioned locally by PCTs and will also require further training and accreditation. It is these services in particular that will result in some CPs becoming important members of the NHS medicines management network. Examples of some enhanced services include: minor ailments schemes, anticoagulant monitoring, medicines assessment and compliance support, care home support, patient group direction service, full clinical medication review and supplementary prescribing.

In addition to the new pharmacy contract roles, some CPs are already becoming increasingly active in promoting the clinical and cost-effective use of medicines by undertaking medication reviews for targeted patients, and managing services such as hypertension clinics with their local GP practices. As more CPs become supplementary prescribers, and indeed further into the future, independent prescribers, they will become more involved with the practice team in decision-making about medicines use within their specialist area.

What is supplementary prescribing?
It is important to differentiate between independent prescribers, supplementary prescribers and Patient Group Directions.

Independent prescribers - historically doctors, but now also some nurses - may prescribe drugs and appliances in their own right from an approved formulary. Formulary choices vary, with doctors having access to the complete British National Formulary (BNF); however nurse prescribers must prescribe from a limited Nurse Prescribers Formulary, or Nurse Prescribers Extended Formulary, depending on the level of additional training undertaken.

Supplementary prescribing is defined by the Department of Health (DoH) as: 'A voluntary partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient's agreement'. Supplementary prescribers work in specialist areas, such as diabetes, asthma and inflammatory bowel disease, and are only able to prescribe drugs that have been agreed with their independent prescriber within the clinical management plan for their own speciality.

Patient Group Directions (PGDs) are written instructions, signed by a doctor/dentist and a pharmacist, allowing authorised healthcare professionals to supply, or administer, specific medicines, provided personnel are appropriately trained or accredited in the speciality covered. PGDs may be used by a CP to provide, for example, emergency hormonal contraception or nicotine replacement therapy.

The new pharmacy and GMS contracts mean that there will be much greater interaction between GPs and CPs. Consequently, CPs will become more influential where prescribing decisions are made. Community pharmacists are also making a valuable contribution as members of PCT professional executive committees, as well as PCT prescribing and medicines management committees.

As more pharmacy-only drugs become available, pharmacists will make clinical and therapeutic decisions in their own right in order to provide their patients with the most appropriate medicine. Similarly, CPs, as supplementary prescribers running specialist clinics from their pharmacies, will have been involved in making decisions about the appropriate medication for the condition through clinical management plans that were developed with the supervising GP.

Pharma marketing opportunities
As the number of influencers in the NHS increases, pharmaceutical companies that wish to work in partnership with the NHS must become more sophisticated in the way they engage with it. Pharma marketers must do their homework to discover where their best suited point of contact in the NHS is most likely to be, and what that contact will require.

Clearly, not all CPs will take on all the opportunities that the new pharmacy and the new GMS contracts bring; neither will all PCTs implement the new pharmacy contract at the same rate.

It is likely that PCTs that have had little engagement previously with community pharmacy will need to focus entirely on implementing the essential services in the first year, whereas the PCTs that have involved their community pharmacists in the early medicines management pilots (for example, prescription intervention schemes and practice prescribing support) will be more ready to develop advanced and enhanced services.

PCTs in the second camp will provide pharmaceutical companies with the greatest marketing opportunities. For the pharmaceutical industry, a number of steps will need to be taken to drill down to the CP influencers in a given PCT.

Three-step challenge
The first step is to identify which PCTs have been innovative in developing new pharmacy services. The second step is to identify the CPs involved in medicines management initiatives, and the third step is to identify the influencers in the local health economy.

The first step is probably the greatest challenge as it is unlikely that pharmaceutical companies will have the means to identify how effectively PCTs are working with their CPs - this is a new group of health professionals not previously targeted.

By answering the following questions, it may help to rank PCTs in terms of how quickly they are likely to implement the new pharmacy contract:

• Is there a CP on the PCT professional executive committee?
• Is there a pharmacy development group?
• Is there a community pharmacy clinical governance facilitator?
• Has the PCT developed any accreditation schemes for CPs?
• What schemes has the PCT involved its CPs in? (for example, prescription intervention, medication review, GP practice prescribing support, repeat dispensing pathfinder site, smoking cessation, minor ailments).

Engage with a pharmacist
Pharmaceutical companies should consider community pharmacists as key stakeholders in their business planning and a new target for their marketing. Communicating accurately to them - and treating them as sophisticated influencers - will generate new NHS networks through which to work.

There are several areas, related to the new pharmacy contract where the pharmaceutical industry may begin to engage with the CPs:

• Clinical governance is an essential requirement for the new contract and there are opportunities to help CPs achieve this
• Pharmacists are now rewarded for offering advanced and enhanced services, such as smoking cessation programmes, diabetes screening, palliative care or healthy living programmes. In order to provide such services, pharmacists require adequate training
• Assistance in new service development, such as a minor ailment schemes and medication review, by sharing knowledge of successful schemes in other parts of the country.

Nurture the relationship
Involving CPs in education and training initiatives will develop good relationships, provide a protected environment in which to understand what their needs and aspirations are, and identify who the key influencers are in their new role.

As far as providing clinical information, CPs must be treated with the same respect as PCT prescribing advisers. They will need access to good evidence-based information from reputable sources in order to communicate effectively and accurately with their GPs.

They will need hard facts about issues that will bolster their role as a prescribing supporter. This information can include clinical data about how a drug works, the diagnostic techniques needed to ensure that the right patients are targeted, and the cost benefits of a treatment.

It is important to note that the format in which this type of information is presented will have a major impact on the responsiveness of the pharmacist; CPs are busy people with little time to spare and, as such, expect to receive concise and accurate information in which they can have confidence.

If pharmacists cannot understand the clinical benefits of a medicine, or how a specific drug actually works, or indeed if pharmacists harbour any doubts about the effectiveness or the potential side effects associated with a drug, it is unlikely that they will recommend the medicine for patients.

However, with the right approach and by using the right market intelligence, there is now a clear window of opportunity for pharmaceutical companies to grow their revenues by providing support to community pharmacists, thereby helping them to deliver these 'added-value' products and services. Pharmaceutical companies can also help the NHS to carry out effectively its plans and directives, and that can only benefit consumers.

The Author
Sue Knox is NHS information director for Health Direction Limited and a practice support pharmacist for her local PCT. She has worked previously for the NHS as a pharmaceutical adviser