Tees Local Pharmaceutical Committee Response to Government proposals
Following a consultation meeting with contractors, pharmacists, pharmacy manager and locums across the Teesside area please find below our response to the questions raised with the recent PSNC document. This is a collaborative set of opinions based on information available at the time of writing on 11th February 2016. Overall there are issues with providing detailed opinions as the information available is not in sufficient detail to inform of the specifics of the proposal.
What are your views on the introduction of a Pharmacy Integration Fund?
Although investment is always welcome there are several issues with the suggested areas involved within this idealism. It would appear that many of the suggestions focus on digitalization and technology, there is a strong view that many of those in the every growing older population may have difficulties with internet access and the use of such technology. There is also an assumption that all individuals have access to such systems. Across Teesside the social deprivation index indicates that there is a higher than average population falling within the most deprived areas of the country where access to this would be restricted, again widening the inequalities gap for many.
There is agreement in principle but there is a need for further information on how this will affect individual pharmacies. Are we identifying payment on outcomes and what do those outcomes focus on?
What areas should the Pharmacy Integration Fund be focused on?
The is a need to integrate NHS Services into community pharmacy rather than moving pharmacists into other settings. The accessibility of community pharmacy is the reason patients chose to visit community pharmacy. The extended opening times, patient relationships and availability of support and services have all been sited as reasons for visiting community pharmacy in the area.
Asthma, COPD, Warfarin Clinics, Diabetes, Acne/Skin Conditions, Venepuncture area all services which could have an impact on GP workload but also provide a wider range of accessibility and choice for patients. Emergency supply of medication and minor ailments should be available at all times of the year in order to embed this option into the patients mindset.
How else could we facilitate further integration of pharmacists and community pharmacy and other parts of the NHS?
Integration of primary and secondary care pharmacy with effective discharge planning and referrals but this needs to be funded to ensure it is an integrated part of working practice. The integration of IT systems would be required again requiring significant investment in time, training and funding.
Within Summary Care Records the ability to have a write facility to ensure all entries are concurrent and informative. This should be available in both primary and secondary care pharmacy but also for medical staff. The ideal would be full access to NHS records with the governance being managed by existing NHS systems.
Independent prescribers have a clinical role in the community pharmacy setting but this will require funding, time and support for provision of prescription pads and referral for appropriate prescribing. There is also a need for clinical skills training to support roll out of a independent prescriber piece for pharmacists.
Further development of integrated services for example BP management and Asthma reviews. Travel clinics and vaccination services would expand the offering of the community pharmacy ensuring the public see them as a clinical service provider.
To what extent do you believe the current care system facilitates online, delivery to door and click and collect pharmacy and prescription services?
GP practices are not consistently offering online services currently to patients, where will the investment to upgrade this offering be sources from?
In addition currently there are multiple system providers both within pharmacy and GP surgeries, a huge investment in time, training and funding would be required to standardize systems and ensure compatibility offering a truly equitable service to patients.
A suggestion of pharmacy being able to directly order prescriptions, working as a patient’s advocate may reduce waste as this will allow more detailed discussions with patients about compliance and concordance as well as the need for each prescription, highlighting problems at a much earlier stage in the medicines provision process.
The removal of customer contact could impact on those people who are most vulnerable, often at a pharmacy visit the social care aspect and safety of individuals becomes a priority for them. For those suffering a mental health issue or social isolation the removal of direct contact may have an impact on their wellbeing.
An interaction on a face to face basis can never be replaced by a click of a button on a computer and the advocacy role of community pharmacy would be a loss to many patients.
There is an additional issue of competence for many medications that are given out, in the instance of emergency hormonal contraception or many other medications how will that assessment be made ahead of delivery of a pill through the letter box.
What do you think are the barriers to greater take-up?
There is a distinct lack of understanding by patients about EPS and how this can make their medication available. An online request from GPs in general would increase the opportunity for patients to obtain their medications in an efficient manner but this is currently not available.
Community pharmacy are also already carrying out a ‘click and collect’ service in effect whereby medication can be ordered and either delivered or collected from the pharmacy at a mutually convenient time. There will be an increased cost either for the patient or the NHS if deliveries to every patient are made, especially when redeliveries are commonplace. There will be issues with a patient receiving medication without seeing a health professional, what is there are interactions with other medications, underlying health conditions that are not considered. There will inevitably be an increase in waste as medication not able to be delivered may require discarding and reordering and patients only need one poor experience of a delivery being delayed and they will order significant numbers in advance to ensure they have their medication for when it is needed.
How can we ensure patients are offered the choice of home delivery or collection of their prescription?
Medications are a requirement for quality and longevity of life, there are issues with any miscommunications which could occur which means the patient receives incorrect dosage, missing or late medication. Also how is it ensured that medication is delivered in the correct state ie if it should be stored at a recommended temperature or out of sunlight how is this to be ensured and then communicated to the patient at delivery. What if the patient is not available at the time of delivery would this then be left with a neighbor or in a ‘safe place’ what are the risks posed by this. Medicines should not be seen as a commodity they are a treatment and it is vital that treatment is received in an efficient and appropriate manner.
Would patients be required to pay for delivery of prescriptions and if this is the case then would that be a universal payment or would those who obtain free prescriptions also be offered free delivery? Also what is the situation with controlled drugs and how will they be delivered safely?
There is a need for further clarity on this in order to further inform opinions.
What are your views of the extent to which the current system promotes efficiency and innovation?
Pharmacists support patients on many levels within the community pharmacy setting, there have been many innovations to reduce waste and prescription ordering especially when having detailed medicines reviews with patients. There is also an issue with competition from generic market and streamlining of medicines provision via hubs could force prices to escalate, this would need to be capped as is a current issue. With the opportunity to source products from a range of wholesalers currently the pharmacist can ensure the most cost effective product is obtained therefore reducing medicines costs.
Currently community pharmacy with a focus on patients provide a service of aids to compliance, not only does this increase the likelihood of a medicine being taken at the correct time and dose for the patient but supports the patient to be able to access their medication in a safe and efficient manner. There is currently a piece of work being undertaken across tees to determine the numbers of individuals receiving this regular service.
Many patients currently order medications they do not require as failure to order over a number of months
Inverse care law: access to healthcare tends to be greater in the least deprived areas, whereas pharmacies tend to be in the areas of most deprivation where the greatest clinical need resides.
Do you have any ideas or suggestions for efficiency and innovation in community pharmacy?
In order to further integrate community pharmacy into the NHS there needs to be a seamless service. In order for this to happen referral systems should be set up both into and from community pharmacy to facilitate appropriate and efficient access to services for patients. Reducing the impact of low acuity conditions and minor ailments would give patients a one point of contact for advice and support as well as medications which take up a significant amount of time currently within GP surgeries, out of hours and Accident departments. These appointments could and should be taken up by those with a greater need of a medical intervention which is complex or of higher impact on the individual.
Domiciliary visits by pharmacists for interventions, medication reviews and minor ailments without the need for a lengthy process for gaining agreement would have a significant impact on the care provision for patients in their own home, nursing homes and other settings. This would require pharmacies to have 2 pharmacists which would ensure existing provision was not compromised, again this would require investment in the process and funding to enable community pharmacies to do this.
Education for patients is required re requesting medication that is not required for fear of the medication being stopped, this is particularly relevant for seasonal medications for instance asthma medication may only be required during hay fever season but will be ordered all year round for fear of losing the option.
Pharmacists should be able to amend prescriptions in terms of quantity and length of prescriptions. The offering of private services promotes patient choice.
Patients could be registered at a pharmacy who have responsibility for their long term condition, this may help with reducing hospital admissions. Pharmacy could receive incentives for proven reductions in hospital admissions.
What are your views of encouraging longer prescription durations and what thoughts do you have of the means by which this could be done safely and well?
Repeat prescribing would be a safer and more efficient option to prescribing. Pharmacist could also be given the ability to change quantities of medications in order to synchronize prescription ordering, therefore reduce waste and ensure the system is more efficient for the patient.
From the viewpoint of the patient many of them are on multiple medications, giving them a significantly greater number of medications at one time would cause storage issues, may cause issues with expiry on medication and may add to confusion and waste if there are dosage changes or medication changes.
Care homes remain a big issue with stock piling of medications occurring regularly, short time ordering, running out of medications.
There remains a safety issue with this aspect, only being seen 4 times in a year would reduce the opportunity to identify and changes in a patient’s conditions, effectiveness of medication or incidence of side effects.
What are your views on the principle of having a Pharmacy Access Scheme?
We are unable to comment on the Pharmacy Access Scheme as the information provided does not give enough information to provide an informed response
What particular factors do you think we should take into account when designing the Pharmacy Access Scheme?
We are unable to comment on the Pharmacy Access Scheme as the information provided does not give enough information to provide an informed response