Primary health care policy and vision for community pharmacy and pharmacists in England

Abstract

The United Kingdom health and care system is changing dramatically to meet the health challenges of the 21^st century. People will increasingly have multiple morbidities. The focus of service delivery is changing from hospital to community, patient to population and curative to preventive. This paper describes the NHS and primary care and community pharmacy in England at the start of 2020, a time of great change. The 10-year vison for the NHS is that everyone gets the best start in life, world class care for major health problems supporting people to age well. It has over 40 mentions of pharmacists and pharmacy. The key aims of the plan are to improve ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health service in England. All of England is covered by integrated care systems and the newly formed primary care networks which will form the foundation of these new systems. Pharmacy is involved at multiple levels. There are 11,569 community pharmacies and most of their total income comes from the NHS (range 68-85%). Around 60% pharmacies are part of multiple chains, with the remaining 40% independents or small chains of less than six outlets. The new five-year community pharmacy contract provides an opportunity to develop community pharmacy and move towards service delivery away from dispensing volume. The new services are described under medicines optimisation, prevention and urgent care. The pharmacy quality scheme is also described. The new deal will help many community pharmacies to plan their future, particularly for those pharmacies who are ready and able to change and work closely with pharmacists and other health professionals in collaboration with Primary Care Networks. There will be specific challenges around: dispensing efficiencies, freeing up pharmacists’ time, wider use of clinical skills of community pharmacists, community pharmacy viability and consolidations.

INTRODUCTION

The United Kingdom (UK) health and care system is changing dramatically to meet the health challenges of the 21^st century. Twenty five per cent of the population have more than two chronic diseases, 18% of the population is over 65. The focus of service delivery is changing from hospital to community, patient to population and curative to preventive. The UK has a size of 93,628 m² and a population in October 2019 of 67,630,324. UK gross domestic product (GDP) in second quarter of 2019 was USD 553,563 million. England has a population of around 56 million and the largest share of GDP. In 2018 the UK spent 9.8 per cent of GDP on health. GBP 18.2 billion was spent on medicines in England, a significant contribution to UK economy. This paper focusses on England as the National Health Service (NHS) is devolved in the UK.

The NHS is the Government funded health care services that everyone living in the UK can use without being asked to pay the full cost of the service. The costs are covered by taxation. These services include: being treated at general practice surgery, pharmacy services, prescriptions, there is a fee per item cost of GBP 9 per prescription (many people are exempt from charges), getting treatment at a hospital if unwell or injured, seeing a midwife if pregnant, calling an ambulance and being transported to hospital and some dental and optometrist services.

The NHS 10 year plan

The NHS 10 year plan was launched in January 2019. This 10-year vison for the NHS is: everyone gets the best start in life, world class care for major health problems supporting people to age well.1 It has 40 mentions of pharmacists and pharmacy, the largest number of mention a key policy document from the NHS has ever seen. The key aims of the plan are to improve ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health service in England. The NHS will redesign and reduce pressure on emergency hospital services. People will get more control over their own health, and more personalised care when they need it. Digitally enabled primary and outpatient care will go mainstream across the NHS. Local NHS organisations will increasingly focus on population health and local partnerships with local authority-funded services, through new Integrated Care Systems (ICSs). The highlights are a GBP 20.5 billion budget settlement, GBP 4.5 billion for primary and community care and Primary Care Networks are the foundation for Integrated Care Systems.

Primary care context

Primary care services continue to face unprecedented and growing demand. This reflects widely recognised system pressures associated with an ageing population, multimorbidity and inappropriate polypharmacy. Between 1996 and 2008, GP consultations increased by an estimated 11%, and nurse consultations by 150%.2 At the same time spending on the NHS, and in particular, in general practice in Great Britain has declined.3 Furthermore, there are significant reductions in the numbers entering general practice as a career, and a high rate of turnover of those working in the profession.4 The 2016 General Practice Forward View recognised some of the key issues in efficiently and effectively managing the frontline demand and supply of healthcare in the UK.5

The Royal College of General Practitioners (RCGP) suggested one potential solution is to develop a more diverse skill mix in primary care workforce and outlines the fact that community pharmacy is a ‘significant unexploited potential’.6 In 2013, the Royal Pharmaceutical Society’s ‘Now or Never’ report proposed a significant rethink of the models of care through which pharmacy is delivered, towards a model utilising the full professional expertise and potential of pharmacists.7 The Murray review of community pharmacy clinical services was commissioned by the Chief Pharmaceutical Officer for England in 2016.8 The review made several recommendations to make the most of the clinical services that community pharmacies can provide including development of repeat dispensing, management of people with long term conditions and clinical medication reviews, a common minor ailment service and a national smoking cessation service. It recommended using the pharmacy integration fund to develop new models of care. Murray identified a number of barriers including poor integration with other parts of the NHS which is hindered by the lack of interoperability of digital clinical systems, issues around behaviours and cultures including sometimes weak relationships between GPs and pharmacy, which in turn inhibit better integration and system design issues including the existing contractual mechanisms for pharmacy that are complex and poorly understood.

The NHS long term plan gave an additional GBP 4.5 billion to primary medical and community health services to improve out of hospital care. In January 2019, NHS England and the British Medical Association’s GP Committee England agreed a five year GP contract framework aiming to alleviate workforce pressures on general practice, secure enhanced investment into primary medical care, and roll out new service models in collaboration with community services and other providers and to improve proactive and preventative care for patients.9 There are around 1,250 primary care networks and they have a mandatory requirement to work with other providers like community pharmacy.

All of England is covered by integrated care systems that bring together NHS, local authority, voluntary and community organisations to take responsibility for the resources and health of the population of a defined area by April 2021 and key contractual responsibilities will be with placed with primary care networks. Integrated care systems work on three levels 1) system: focusses on partners working together to set strategy, finance, workforce planning, and agree overall levels of integration. 2) Place: based around towns within a system, work at ‘place’ level centres on the planning of localised services and the delivery of secondary and community care. 3) Neighbourhood: this level is based around Primary care Networks), groups of GP practices and other providers covering populations of 30,000 to 50,000 people. Multi-disciplinary teams will be central to Primary Care Networks, with clinicians and health and care professionals from a wide range of services including pharmacists working together to provide primary and community care. This approach reinforces the strategic direction toward place based, population health.

A group of clinical priorities have been chosen for their impact on the population’s health: cancer, cardiovascular disease, maternity and neonatal health, mental health, stroke, diabetes and respiratory care. There is also a focus on people’s entire lives from birth to endo of life.

Alongside primary care networks, the plan commits to developing ‘fully integrated community-based health care’. This will involve developing multidisciplinary teams, including GPs, pharmacists, district nurses, and allied health professionals working across primary care and hospital sites.

The GP contract framework set out seven national services specifications that will be added to the Network Contract Directed Enhanced Services, five starting from April 2020, and a further two from April 2021. The seven proposed services are: structured medication reviews and optimisation, enhanced health in care homes (jointly with community services providers), Anticipatory care (jointly with community services providers), personalised care and supporting early cancer diagnoses. The first five were planned to be implemented from April 2020 With CVD and tackling neighbour inequalities supposedly coming in from April 2021 subject to agreement over contracts.

There is also a move to support more digital engagement with patients, over the next five years every patient will get the right to telephone or online consultations, usually with their own practice, with the emphasis on digital access. For outpatients, technology will be used to redesign services to avoid up to a third of outpatient visits (30 million visits a year).

Primary Care Networks (PCNs) will be guaranteed funding for an up to estimated 26,000 additional staff by 2023/24. This funds new roles for which there is both credible supply and demand. The NHS is making a financial contribution toward the recruitment and employment of pharmacists, physician associates, first contact physiotherapists, and first contact community paramedics; and 100% of the costs of additional social prescribing link workers.

Under the 2019 GP contract framework by 2023/24, a typical network of 30,000-50,000 patients could choose to have its own team of approximately six whole time equivalent pharmacists. A dedicated team makes it possible to create varied and tailored roles: undertaking structured medication reviews, improving medicine optimisation and safety, supporting care homes, as well as running practice clinics. Pharmacists will be supported with an education/training programme alongside supervision by other pharmacists/healthcare professionals across the PCN. It is suggested that this will make it easier to support pharmacists’ professional and career development at network rather than practice level. Some of these pharmacists will come from the existing pharmacists in general practice and pharmacists on care homes schemes. There are some pharmacy technicians working in general practice complimenting the pharmacists work, and there maybe considerations how such posts could be funded through the NHS schemes soon.

Overview of community pharmacy in England

NHS England currently spends nearly GBP 2.6 billion a year on a network of 11,569 community pharmacies. Most of their total income comes from the NHS (range 68-85%). Around 60% pharmacies are part of multiple chains, with the remaining 40% independents or small chains of less than six outlets. Following Government liberalisation of market entry, there are nearly 2,000 more pharmacies than 15 years ago. 40% of pharmacies are located within a ten-minute walk of two of more other pharmacies. There are an estimated 1.6millioin visits to community pharmacy every day, this equates to the entire population of England in six weeks.

National responsibility for community pharmacy is shared with NHS England and the Department of Health and Social Care. The Pharmaceutical Services Negotiating Committee (PSNC) negotiates the contract on behalf of the profession in England. The system is governed by statutory arrangements, known as the Community Pharmacy Contractual Framework, which provides remuneration. The budget was reduced from GBP 2.8 billion in 2015/16, to GBP 2.687 billion in 2016/17, and GBP 2.592 in 2017/18. In 2018/19 the budget remained at GBP 2.592 billion. A new NHS England community pharmacy contract10was agreed and launched in 2019. This is an unprecedented five year deal. It takes into account the need for pharmacies to engage with local Primary Care Networks (PCNs).

All pharmacies will have to be healthy living pharmacies. The Healthy Living Pharmacy framework is a tiered commissioning framework aimed at achieving consistent delivery of a broad range of high quality services through community pharmacies to meet local need, improving the health and wellbeing of the local population and helping to reduce health inequalities.11

NHS England wants to make efficiency savings through the transformation and reform of dispensing using automation, online, and changing supervision laws we are yet to see what the proposed approaches will be. Pharmacy services are divided into essential, locally commissioned and advanced services. Essential services include dispensing, promotion of healthy lifestyles, disposal of unwanted medicines and signposting to other services. Examples of locally commissioned services include smoking cessation, sexual health and minor ailments services. Advanced services include the New Medicines Service, the Community Pharmacy Consultation Service and the Flu vaccination service. The new services are discussed below under the flowing headings, medicines optimisation and safety, prevention, urgent care and the pharmacy quality scheme.

MEDICINES OPTIMISATION AND SAFETY

The New Medicines service

The New Medicine Service (NMS) started in 2011. The service provides support for people with long-term conditions, newly prescribed a medicine, to help improve medicines adherence; it currently focusses on asthma and COPD, type two diabetes, antiplatelet/anticoagulant therapy and hypertension. It is likely to be expanded in the future. Following a patient‘s written consent the pharmacist discusses the new medicine with the patient at the initial consultation then books a further consultation 7-14 days after their initial presentation with a prescription for a new medicine. The patient will have a third appointment about two weeks later. The main aim of the follow up consultations (which can be face-to-face or telephone-based) is the patient-centred identification of any problems either with the treatment and any support or action needed.

Since the introduction of the NMS, more than 90% of community pharmacies in England have provided it to their patients. To inform the longer-term commissioning decision, researchers at the University of Nottingham evaluated the service the researchers concluded that as the NMS delivered better patient outcomes for a reduced cost to the NHS, it should be continued.12 Pharmacists are paid Community pharmacy contractors earn between GBP 20 and GBP 28 for each completed New Medicines Service they provide depending on the total number of patients who receive the service in the month. The structure rewards each complete NMS provided whilst also encouraging the provision of the service to the greatest number of patients.

To free up capacity and funding for the new Community Pharmacy Consultation Service, and also in recognition that the NHS does not consider MURs to be offering good value for money, MURs will be decommissioned in phased way. In 2020/21, a Medicines Reconciliation service will be introduced, to ensure that changes in medicines made in secondary care are implemented appropriately when the patient is discharged back into the community. Further work is required to finalise the details of this service. Models of such a service have been successfully piloted and some predicted economic benefits and reductions in hospital admissions have been seen.

Structured medication reviews

Structured medication review as defined by NICE is a critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste. As mentioned above they are being funded under the new GP contract. At present pharmacists who are based in GP surgeries will carry this out along with GPs and nurse prescribers. Based on the primary care networks flexibility of working, community pharmacists and hospital pharmacists may also be involved in the delivery of these going forward.

Further proposed services include the routine monitoring of patients, for example those taking oral contraception, being supplied under an electronic repeat dispensing arrangement and the testing of a new service to improve access to palliative care medicines. If PCN enhanced services free up local commissioning, then this money could be invested in other services that involve community pharmacy providers to support local population needs and could leads to future services/opportunities.

PREVENTION

Flu vaccination service

Community pharmacists in England have provided flu vaccination services since 2015. These services are in addition to the nationally commissioned GP vaccination service, giving patients another choice of venue for their vaccination and helping commissioners to meet their national NHS vaccination targets. The service demonstrates high levels of patient satisfaction and evidence that pharmacy vaccination is accessible, often capturing ‘hard to reach’ patients who would not otherwise take up the offer of vaccination. Community pharmacies. Uptake of NHS funded flu vaccinations in pharmacies has increased by 90.1% from 2015/16 to 2018/19, 595,467 to 1,433,095 vaccinations.13 We would hope to see more vaccinations delivered through community pharmacy in the future e.g. MMR or childhood vaccinations.

Further prevention services

A Hepatitis C testing service will be introduced in pharmacies that provide a needle exchange service in 2019/20. A model for detecting undiagnosed cardiovascular disease will be developed. Other proposed services include; smoking cessation support referrals from secondary care, point of care testing around minor illness, to support efforts to tackle antimicrobial resistance, The routine monitoring of patients, for example those taking oral contraception, being supplied under an electronic repeat dispensing arrangement; Activity complementing the content of forthcoming PCN service specifications, for example on early cancer diagnosis and in tackling health inequalities.

URGENT CARE

Community Pharmacist Consultation Service

Following pilots the new Community Pharmacist Consultation Service was launched in October 2019.14 The service refers patients to community pharmacy from NHS 111, the NHS telephone triage service, and is currently being piloted from GP surgeries, urgent care and accident and emergency services It improves access and educes demand on integrated urgent care services, urgent treatment centres, emergency Departments, walk in centres, other primary care urgent care services and GP Out of Hours (OOH) services, and free up capacity for the treatment of patients with higher acuity conditions. To provide the service, pharmacies must have access to the NHS summary care record and a consultation room, which must be clearly designated as an area for confidential consultations, it must be distinct from the general public areas of the pharmacy premises, it must be a room where both the person receiving services and the pharmacist providing those services are able to sit down together and talk at normal speaking volumes without being overheard, it must have IT equipment accessible within the consultation room to allow contemporaneous records of the consultations provided as part of this service to be made. A Consultation fee of GBP 14 is paid for each completed referral (urgent medicines supply or minor illness). Pharmacists may also sell the patient any appropriate medicines, but not all consultations will end in supply, as some will be supported with just health advice.

THE PHARMACY QUALITY SCHEME

From 2019/20, the Pharmacy Quality Scheme came into effect.15 There is GBP 75 million associated with this scheme and it demonstrates the shift form volume to quality. It has clear links with the quality improvement module in the GP contract to hopefully allow greater collaboration between GPs and community pharmacists especially within PCNs It includes a number of new requirements for pharmacies, including: preparation for engagement with Primary Care Networks, doing audits on prescribing safety around lithium, advice on pregnancy prevention for women taking valproate and a re-audit of use of non-steroidal anti-inflammatory drugs (NSAIDs); checking with all patients with diabetes whether they have had annual foot and eye checks; a reduction in the total volume of sugar sweetened beverages sold by the pharmacy to 10% or less; completion of training and assessment on look-alike, sound-alike (LASA) errors, including an update of the pharmacy’s patient safety report and evidence of action; completion of sepsis online training and assessment with risk mitigation and completion of a dementia friendly environment standards checklist.

CHALLENGES

The new contract secures a future for community pharmacies and sets out a clear vision for community pharmacy services. It starts to put pharmacy at the heart of primary care, and builds some leverage for the future. But there is flat funding until 2024 and no recognition of costs and inflation and this all comes against a backdrop of pressure and stress within community pharmacy.

The new deal guarantees a future for those pharmacies that are ready and able to change. There will be specific challenges around: dispensing efficiencies, freeing up pharmacists’ time, wider use of clinical skills of community pharmacists, community pharmacy viability and consolidations. Pharmacists will need to effectively record and use data to demonstrate value. There will need to be additional funding to train community pharmacists as independent prescribers. International evidence shows that collaboration in primary care takes time; strong relationships, a shared vision and effective leadership are all crucial.

Delivery of the NHS plan relies on increasing workforce capacity, especially in primary care. There also needs to be investment in diagnostic equipment and IT infrastructure, interoperability and access. There is also the question about how an agenda focussed on single diseases can be implemented in to meet the needs of people living with frailty and multiple long term conditions. Workforce shortages are currently the largest challenge facing the NHS where there is a large shortage of GPs and nurses. Moving pharmacists into primary care is already causing shortages in hospital and community sectors in some parts of England. There needs to be a proper, joined up workforce strategy for pharmacy from undergraduate through to consultant level, with appropriate training and competency development at every stage. New services will also need being evaluated properly and proper rather than piecemeal and funding made available to do this.