Health and Social Care Committee
HSC(4)-01-12 paper 3
Inquiry into the contribution of community pharmacy to health services in Wales - Written evidence from the Minister for Health and Social Services
i) This paper provides the Committee with my response to the questions posed in Mr Drakeford’s letter to me of 16 August 2011.
Introduction
ii) There are 708 community pharmacies in Wales; 64% of these are multiples, i.e., having 6 or more branches nationwide. Fifteen community pharmacies are supported by the Essential Small Pharmacies Scheme (ESPS). The ESPS aims to ensure the proper provision of pharmaceutical services for individuals in rural areas who would otherwise have difficulties accessing a community pharmacy.
iii) The number of items dispensed by community pharmacies continues to increase every year, rising from 53.1 million in 2005-06 to 65.2 million in 2010-11[1].
iv) Welsh Government investment to support the development of community pharmacy services has increased substantially since the new pharmacy contractual framework was introduced in 2005. The current budget for 2011-12 is £145m, a 51% increase on the £96m provided in 2005; this excludes funding for the costs of medicines prescribed. In addition, the Welsh Government has a separate budget to tackle substance misuse[2]; in 2010-11, £2.3m of this budget funded the provision of needle exchange and the supervised administration of substitute medication for opiate addiction. A pharmacy specific budget of £4.3m is also provided for education and the training of pharmacists (paragraphs 4.16 – 4.17 refer).
1. The effectiveness of the community pharmacy contract in enhancing the contribution of community pharmacy to health and wellbeing services.
1.1 A new community pharmacy contractual framework was introduced in 2005 and signalled a step change in the role of community pharmacists. The framework introduced important advances in community pharmacy services which included:
1.2 Key features included standardising information for the public about services offered, introducing patient satisfaction surveys, increasing opening hours to a minimum of 40 hours over 5 days, embedding self care services and signposting within the contractual framework along with mandatory monitoring and reporting of patient safety incidents. All of these have been achieved.
1.3 To underpin the aspirations of the new contract framework, the Welsh Government made significant investment in developing the Information Technology infrastructures of community pharmacies.
1.4 Since 2005 we have provided £12.1 million specifically to support health informatics within community pharmacy services. The key objectives of this investment are to facilitate the transfer of information between healthcare providers and community pharmacy and improve patient safety. Key features include:
· Secure access to the NHS network;
· Electronic prescriptions claims; and,
· Electronic governance framework to facilitate the consistent and comprehensive assessment and monitoring of services throughout Wales.
1.5 The 2005 contractual framework was effective in standardising services and raising the profile of the wider role of community pharmacists; without it, it is doubtful that any progress would have been made and community pharmacists would still be focused almost entirely upon dispensing and not recognised as a major player in the wider health agenda. However, progress has not been quick enough. To energise and prioritise the agenda for community pharmacy the previous Minister for Health and Social Services established a Strategic Delivery Group. This group comprised senior NHS staff and was chaired by the Chairman of Hywel Dda Local Health Board (LHB). The Group were tasked with identifying the key areas for change. Their recommendations have been taken forward and are reflected in the work which has commenced to review the Pharmaceutical Services Regulations and the changes to the contractual framework which came into effect on 1 November 2011. Further detail on the developments are outlined at paragraphs 3.6 – 3.9, 6.1 – 6.2.
2. The extent to which Local Health Boards have taken up the opportunities presented by the contract to extend pharmacy services through the provision of ‘enhanced’ services, and examples of successful schemes.
2.1 Enhanced services were enshrined in the 2005 contractual framework to provide an opportunity for a wide range of services to be commissioned from community pharmacists, in addition to core essential services such as dispensing. The opportunity to provide enhanced services was intended to enable LHBs to introduce services based upon an assessment of local healthcare need, and utilise community pharmacy when identified as the most appropriate provider.
2.2 Needle exchange, supervised administration of substitute medication for opiate addiction and smoking cessation are the enhanced services most commonly provided by community pharmacies. Smoking cessation services in particular are showing encouraging quit rates as demonstrated by Public Health Wales (PHW) in their evaluation of the services in North Wales, Powys and Merthyr Tydfil.
2.3 In April 2011, Welsh Government launched the first directed national enhanced service for emergency hormonal contraception. Since introduction 18,500 individuals have accessed a service which is now provided by 386 community pharmacies.
2.4 Annual data on the provision of enhanced services is collected from LHBs and published on the Welsh Government Stats Wales web-site[3].
2.5 In November 2011 NHS Wales Shared Services Partnership launched a new All Wales Pharmacy Database (AWPD) to collate information on services provided by each community pharmacy in Wales. The AWPD ensures there is a single central source of accurate information on community pharmacy services. In the future e-claims submitted by community pharmacists will be linked to this database to verify their individual accreditation status and that of the pharmacy from which the service was provided. AWPD will also provide a feed to NHS Direct to update public facing information.
2.6 In April 2011, to coincide with the launch of the national directed service for the provision of emergency hormonal contraception, the National Electronic Claim and Audit Form (NECAF) was launched. NECAF replaced existing paper based claims and simplified arrangements for community pharmacists when making claims for providing emergency hormonal contraception services. This has reduced the administrative burden on pharmacists allowing them more time to focus on patient care. Importantly, for the first time it provides comprehensive information on service provision in a timely manner and will support needs assessment and future service planning.
2.7 To support LHBs in developing enhanced services, PHW has carried out a literature review to identify the evidence base and support LHBs in the development of enhanced services. They have also worked with LHBs to complete pharmaceutical needs assessments and thereby provide further information on which to base service planning.
2.8 To further support the delivery of high quality, consistent enhanced services across Wales, we are also finalising national specifications for smoking cessation, needle exchange and supervised administration of substitute medication for opiate addiction services. These specifications will be in addition to that for the emergency hormonal contraception service which is already in place.
3. The scale and adequacy of ‘advanced’ services provided by community pharmacies
3.1 Advanced services are national schemes for which accreditation is required before the service can be provided. Until the 2011 contract settlement Medicine Use Review (MUR) was the main advanced service provided, with each community pharmacy allowed to provide up to 400 MURs per annum.
3.2 A MUR involves reviewing the patients’ use of their medicines to improve understanding of how it should be taken, identify problems that they may be experiencing and help those who may be at risk of not making effective use of their medicines. MURs have also provided pharmacists with an opportunity to formally engage with patients and provide a recognised role in supporting individuals to use their medicines in the most effective manner.
3.3 There are good examples of MURs being used to help patients manage conditions such as asthma by improving inhaler technique and asthma control.[4] Public Health Wales published a literature review on MURs in June 2011 which helped inform the direction of the 2011 changes to the contractual framework.
3.4 The level of participation has increased year on year with 88% of community pharmacies delivering MUR services in 2010-11. The number of MURs carried out has also increased with an average figure of 208 MURs undertaken per pharmacy in 2010-11.
3.5 As part of a range of changes to the contractual framework that took effect from 1st November 2011, the MUR service was revised to target specific groups of patients. Half of all MURs conducted must be carried out with the following groups:
3.6 These groups reflect the Welsh Government’s commitment, as set out in the Programme for Government, to improve health outcomes in those with circulatory disease, support the 1000 Lives Plus agenda around high risk medicines, address respiratory disease (the second most frequently reported condition from which people in Wales report suffering after circulatory disease[5]) and deliver the Welsh Governments’ manifesto commitments to work with community pharmacy. In addition the MURs will seek to:
The new focussed MURs will also provide an opportunity for the pharmacist to provide advice on self care, tackle lifestyle issues and signpost other services.
3.7 In November 2011 a new advanced service, the Discharge Medicines Review (DMR) service, was launched. The DMR service is targeted at patients discharged from hospital or other care settings into the community. It comprises a two part intervention. The first part requires the community pharmacist to check that the medicines prescribed in the care setting (e.g. hospital) match those taken by the patient when they return to their home. The second part builds on the current MUR service and provides the opportunity for the pharmacist to discuss the patient's use and understanding of their medicines.
3.8 There is evidence that discrepancies arise between the medicines an individual is prescribed on discharge from hospital and the medication they are subsequently prescribed in primary care. Typically this occurs because of problems with the flow of timely and detailed information on their medicines.
The active engagement of community pharmacists in this process should help ensure patients receive the medicines intended, and improve both patient safety and health outcomes.
3.9 The continuation of the DMR service after April 2013 will be subject to completion of an evaluation and demonstration of significant patient benefit.
4. The scope of further provision of services by community pharmacists in addition to the dispensing of NHS medicines and appliances, including the potential for minor ailments schemes
New service provision
4.1 As outlined above, from November 2011 a DMR service was introduced to complement the restructured MUR service which now places more emphasis on targeting specific groups of individuals taking medicines. These developments have followed on from the introduction of the first National Enhanced Service for the provision of emergency hormonal contraception in April 2011. It is also planned to introduce three additional specifications for new National Enhanced Services in 2012:
4.2 Going forward there is a need to recognise the increasing complexity of new medicines and the treatment regimens that patients must follow to obtain benefit from their prescribed medicines. Community pharmacists can provide a key role in supporting patients to gain maximum benefit, minimise side-effects and reduce medicines waste. With their expertise in medicines management, pharmacists need to be at the heart of new service developments in the community and take on greater responsibility and ownership for supporting patients with long term conditions and the vulnerable elderly.
4.3 At any one time[6] a typical community pharmacy can be providing medicines to:
4.4 All the above benefit from the support and intervention of a community pharmacist. NHS Wales needs a community pharmacy network that is cost effective, located in the heart of the community and supports patients, the public and carers. Community pharmacy services have developed since 2005 and now provide a much greater range of services than just dispensing – important though this is. The Welsh Government is committed to strengthening primary and community care and community pharmacists have a valuable contribution to make alongside GPs and other healthcare professionals. It is important that the contribution of community pharmacists is considered within this context and not in isolation. All options are being explored and we will be consulting widely with healthcare professionals and most importantly, patients.
Minor ailments
4.5 Each year, a large number of GP consultations are for conditions that can be diagnosed by a pharmacist and do not need the intervention of a GP or a prescription only medicine. Minor ailments such as athlete’s foot, constipation, cough, diarrhoea, thrush, warts and verrucas, sore throat, threadworm, head lice, headache, hay fever and indigestion are all conditions for which treatment can be supplied by a pharmacist.
4.6 However, research from the Proprietary Association of Great Britain (PAGB)[7] has shown that up to 40% of a GP’s time is taken up dealing with patients suffering from minor ailments. This reduces the number of appointments available to patients with more complex conditions and may increase the length of time patients, who need to see a GP, have to wait. The research also identified the patients’ own perspective of the barriers to using a community pharmacy for a minor ailment. These included privacy, the need for reassurance from their GP and the cost associated with non prescribed medication.
4.7 Advising on minor ailments is recognised as a core function of pharmacy and in many cases they are more accessible to the individual in terms of journey and waiting times than a visit to their GP. Overall, the evaluation of minor ailment schemes[8][9][10] have concluded they are a safe and effective service and generally well received by patients.
4.8 We are exploring with stakeholders from across Wales a number of issues including:
Rurality
4.9 In our Programme for Government wehave re-stated our commitment to a vibrant rural community with access to good quality health services. Rural communities benefit from a sustainable, reliable and effective community pharmacy network. There are good examples of pharmacies providing a range of health care services in our rural communities: smoking cessation (Powys), optimising treatment in heart failure (Hywel Dda) and providing cognitive behavioural therapy for depression in Gwynedd.
4.10 However, there remains a need to build new services based upon a clear understanding of pharmaceutical need that reflects good practice. We are currently exploring this further with PHW; in particular the potential impact of wider community pharmacy services such as MURs and minor ailment services could have on increasing access to services in rural areas.
Public health
4.11 The location, accessibility and foot-fall of community pharmacy puts them in a key position to promote the public health agenda. Whilst the public health contribution of pharmacists should remain focused on their contribution to medicines management, given that taking a medicine is the commonest intervention in health care, they also have roles in disease prevention, screening, monitoring, treating and supporting the population.
4.12 We have yet to realise the full potential impact of community pharmacy involvement in the public health agenda. However progress has been made this year. In June 2011, all community pharmacies in Wales had the opportunity to participate in the first, national, public health campaign. Over the two week period of the campaign, 17, 507 people were screened and 1, 478 found to be at high risk of developing diabetes. This was considered to be a successful campaign by participants and involved collaboration between Public Health Wales, Community Pharmacy Wales, Diabetes UK and Local Health Boards. We need to ensure all pharmacies participate in future national campaigns; the campaigns for 2012-13 have already been identified and will embrace cardiovascular disease, the expert patient programme and respiratory disease .
4.13 Community pharmacists will also feature in other public health roles including the programme for annual health checks, provision of lifestyle advice and support, emergency contraception, methadone supply, needle and syringe programmes, reducing medicines waste and influenza vaccination.
Influenza vaccination
4.14 The Welsh Government is committed to ensuring influenza vaccination is widely available to those who need it. The location, accessibility, training and expertise of a pharmacist in the community is ideal for the delivery of the influenza vaccination. Although many pharmacists provide vaccination to individuals as a private service outside of the NHS, to date they have not provided an NHS service. It is therefore disappointing that plans to pilot a community pharmacy based NHS influenza vaccination programme in two LHBs for the winter of 2011/12 foundered. However, the LHBs concerned needed to take account of the fact that GPs had placed orders for their vaccine several months earlier and were at risk of having unused stock on their hands. The use of community pharmacists to deliver influenza vaccination will be progressed in 2012/13 with the early engagement of all parties.
Non-medical prescribing
4.15 At the present time there is a limited amount of non medical prescribing taking place in community pharmacy although several community pharmacists are appropriately qualified. Most non-medical prescribing for chronic conditions is undertaken in GP practices and primary care centres in pharmacy led clinics and reflects the desirability of having a clear separation of prescribing and dispensing. In addition, community pharmacists routinely prescribe and supply over the counter medicines, supply medicines in accordance with a Patient Group Directive or make emergency supplies to patients who have typically run out of their medication. All require the skills of a prescriber.
Education
4.16 Workforce development is integral to the delivery of high quality, professional services. The Welsh Government has invested significantly in supporting pre and post pharmacy registration education and training. In total, £4.3m is invested each year to support a suite of education, training and resources through the Wales Centre for Pharmacy Professional Education (an operational unit of the Welsh School of Pharmacy, Cardiff University) and the National Leadership and Innovations Agency for Healthcare (NLIAH). This includes £3.2m to support students for pre registration training in both the hospital and community sectors and £1.1m to fund the development and delivery of continuing professional development to community pharmacists which is used, in part, to enable them to deliver enhanced services. The range of training available provided by the Welsh Centre for Pharmacy Professional education that is supported by Welsh Government can be accessed atwww.wcppe.org.uk
4.17 We are also in early discussions to introduce a new 5 year degree course for pharmacy which will integrate clinical and practice training alongside academic studies. This will produce pharmacists with the clinical skills and knowledge required by the NHS and the citizens of Wales.
5. The current and potential impact on demand for NHS services in primary and secondary care of an expansion of community pharmacy services, and any cost savings they may offer.
5.1 A strengthened, high quality, primary and community care service in Wales delivered by multi disciplinary teams working across sectors will have a positive impact on the secondary care sector and allow them to focus on what they do best. Community pharmacy services have an important contribution to this agenda and are well placed to help deliver this along with GPs, other health care professionals and social services.
5.2 Ensuring the effective and appropriate use of medicines, providing expert advice on self care of long term conditions and other health issues, signposting sources of healthcare support, and the early identification of health problems are just a few examples of the contribution a community pharmacist can make to reduce avoidable admissions or re-admissions to hospital, and thereby deliver cost savings to the NHS.
5.3 Community pharmacy is one of the few healthcare providers that engage with people when they are well and this can be used to target potential vulnerable groups. Community pharmacies are the accessible beacons of the NHS located in the centre of towns and cities across Wales. Moreover, when people are away from home they know they can walk into a pharmacy and get sound health advice or even, in an emergency, medication they may have left behind or lost without incurring significant further costs for the wider NHS.
5.4 There is a clear and increasing requirement for community pharmacy to provide more services in a cost-effective manner against a background of increasing prescription numbers. I am confident community pharmacy can deliver these services and in the November 2011 contractual framework settlement I asked community pharmacy to target specific areas for improvement, e.g., the restructured MUR service and the new DMR service, and made the necessary monies available. Over the next 15 months I will be closely monitoring the contribution of these new services to patient care and expect community pharmacy to demonstrate robust evidence of benefit.
6. Progress on work currently underway to develop community pharmacy services.
6.1 This paper describes the progress that the Welsh Government has made on the development of community pharmacy services and sets out our challenging work programme for the year ahead. None of the achievements so far would have been possible without the commitment of the community pharmacy family in Wales and LHBs and I would like to thank everyone for their input to this agenda. In summary, the key health care service areas we are taking forward are:
· The 2012-13 Public Health campaign which targets the Welsh Government’s health priorities of cardiovascular disease, the expert patient programme and respiratory disease;
· The introduction of targeted Medicines Use reviews and Discharge Medicines Reviews that focus on supporting our most vulnerable citizens;
· Ensuring the emergency hormonal contraception service is available in all of those community pharmacies where needed;
· Establishing a community pharmacy based NHS influenza vaccination programme for winter 2012.
6.2 In support of these developments, Welsh Government will shortly consult on changes to the pharmaceutical regulations to streamline and simplify the “Control of Entry” application, approval and appeal process. We are also looking to strengthen and integrate the planning of pharmaceutical services within the context of primary and community care planning at LHB and locality levels. In the longer term future, we will seek through legislation to make these plans the basis for LHBs to determine applications to open new pharmacies.
[1] Welsh Government Statistics: Community Pharmacy Services in Wales 2010-11 – 26 October 2011
[2] Substance Misuse Action Fund (Revenue and Capital) allocated to Community Safety Partnerships of which LHBs are a statutory partner.
[4] Price A, PCA 2009: Effectiveness of MURs in Asthma – South Wales & the South West.
[5] Welsh Health Survey 2010. Available at: http://wales.gov.uk/topics/statistics/headlines/health2011/1105191/?lang=en
[6] Remedies for success, A strategy for pharmacy in Wales. Welsh Assembly Government 2002
[7] Making the case for the self care of minor ailments – August 2009
[8] Vohra S. A community pharmacy minor ailment scheme-effective, rapid and convenient. Pharmaceutical Journal 2006; 276: 754-756.
[9] Blenkinsopp A; Noyce P. Minor illness management in primary care: a review of community pharmacy NHS schemes - Keele University 2002.
[10] Implementing a community pharmacy minor ailment scheme - National Pharmaceutical Association, 2003