Report of the Health and Social Care Committee Inquiry (2012) into the Contribution of Community Pharmacy to Health Services in Wales
Progress Report by the Welsh Government
September 2014
1. The seven recommendations contained in the 2012 report of the Health and Social Care Committee inquiry were accepted by my predecessor. At the time I had the privilege of chairing the committee so I am fully aware of the breadth and complexity of the issues raised in evidence and considered by the Committee.
2. A recent publication in the BMJ[1] has once again highlighted that community pharmacies have the potential to offer convenient and equitable access to health care, in particular to individuals living in our most deprived areas. This reflects established Welsh Government policy which recognises and supports community pharmacy as a key contributor in the primary and community healthcare team whether giving healthcare advice, supporting individuals with long term conditions, providing influenza vaccination or using their reach to promote the wider public health agenda. No longer is it appropriate to consider community pharmacy’s role is solely that of dispensing prescriptions, although this remains an important function; rather it is as a member of the multidisciplinary team focussed on delivering prudent healthcare.
3. At the time of the Committee’s scrutiny in 2011, work was already underway to optimise the reach of community pharmacy and maximise their potential as a healthcare provider. All of the seven recommendations made by the Committee are embedded in current Welsh Government policies for community pharmacy and recognise the contribution the pharmaceutical profession can make to improve the health and well-being of Welsh citizens.
Service Planning and Pharmaceutical Needs Assessment
4. Welsh Government policies for health, including Setting the Direction: Primary and Community Services Strategic Delivery Programme in 2010 and our more recent policy on Prudent Healthcare promote multi-disciplinary working and place the individual at the centre of all services. The easy and ready accessibility of community pharmacy for the public and their proximity to General Practitioner (GP) surgeries present opportunities to develop ever stronger, collaborative arrangements for the benefit of patients.
5. To support the role of community pharmacy in the delivery of wider health services, the Public Health white paper contains a proposal that will require Local Health Boards (LHBs) to undertake a pharmaceutical needs assessment. This proposal has received widespread support and, subject to the white paper receiving the support of the National Assembly, pharmaceutical needs assessment will be embedded in Welsh Government planning guidance from 2016 as part of the overall health needs assessment of the local population.
6. In the intervening period, LHBs will be expected to develop their systems to assess pharmaceutical needs as part of their planning at locality level centred around GP practice clusters. The planning guidance for three year integrated medium term plans will be issued later this year to support planning for 2015-16 and beyond. This will require LHBs to demonstrate the actions being taken to rebalance their healthcare systems to strengthen primary and community care and establish multi-disciplinary care teams with the different health professionals utilising all their skills and operating at the top of their clinical licence. The Welsh Government will be issuing a plan for a preventative primary and community care led NHS in Wales in October to guide and direct this planning process and set national service improvement priorities and milestones to drive delivery across Wales.
Collaborative Working
7. Effective multi-disciplinary working was highlighted in the 2012 Committee report with the need for closer collaboration between health professionals, particularly GPs and community pharmacists emphasised. The Welsh Government response agreed with the Committee’s conclusion that the responsibility for achieving collaboration through mutual understanding and respect lies with the professions and LHBs. In July 2011, the Royal College of General Practitioners and the Royal Pharmaceutical Society issued a joint statement on working together for the benefit of patients. Whilst this is a welcome step in the right direction, I continue to look to LHBs and health professionals at locality cluster level to translate the national collaborative agreement into reality through the planning cycle.
Funding
8. In the Welsh Government evidence paper to the Committee in 2012, detail was provided of the budget to support the community pharmacy framework. This showed an increase from £96m in 2005 to £145m in 2011-12; representing a 51% increase. Since 2011-12, the funding to support this area has increased further to £156m, representing an additional £11m investment (8% increase). This includes the £3.6m recurrent funding transferred from the HCHS & Prescribing budget in 2012-13 for the Discharge Medicine Review Service. This funding should be viewed as an integral part of the overall envelope of funding provided to LHBs to deliver services across the range of priority areas, including for example, the contribution made by community pharmacies to the delivery of services to patients with chronic disease and targeted public health messages.
IT Infrastructure
9. Since 2005, the Welsh Government has invested £12.1 million to develop the Information Technology infrastructures of community pharmacies. All pharmacists now have appropriate hardware and software, e-mail function, secure access to the NHS network and an electronic system to make service claims.
10. Since the Committee reported, the Medicines Transcribing and E-Discharge project (commonly known as MTeD) has been evaluated successfully in the Cardiff and Vale Health Board by the NHS Wales Informatics Service (NWIS). This project provides a patient’s hospital discharge information, including the medication regime, in electronic form to the GP. NWIS are now progressing roll-out with LHBs.
11. The independent evaluation of the Discharge Medicines Review (DMR) service was published earlier this year and analysed 14,649 interventions undertaken by community pharmacies. The analysis identified the lack of access by community pharmacists to discharge information, and electronic discharge information in particular, was proving a considerable barrier to full implementation of the service. Overall the evaluation showed a substantial saving of circa £3.5m in avoidable costs to the NHS as a result of DMR interventions. As a consequence, I was pleased to announce the incorporation of the DMR service into the Community Pharmacy Contractual Framework for 2014-15 onwards.
12. The priority now is to move to a secure IT platform that supports the delivery of national services within community pharmacy and enables the sharing of relevant patient information between GPs, hospitals and community pharmacists; this is a key element of achieving an integrated primary and community health care service.
13. The Choose Pharmacy pathfinder service has provided the opportunity to develop and successfully test, a patient registration model and supporting IT platform that enables relevant patient information to be stored electronically. An additional, new project “Improving Connectivity” will build on this work and that of the MTeD project to further develop the IT platform and test the provision of secure and real time sharing of patient information between primary and secondary care. It also contributes to realising the longer term ambition of moving towards a fully integrated healthcare system that allows information to be shared between secondary care clinicians, GPs and community pharmacists at the point of patient discharge from hospital. The new project is being supported by a £280,000 award from the Welsh Government’s Health Technology and Innovation fund. The project is one of a suite of three primary care focussed projects supported by this fund representing a total investment of £2.33m; all designed to improve connectivity between primary and secondary care within community pharmacy, dentistry and optometry.
Community Pharmacy Service Developments
14. There have been four key pharmacy developments since 2012:
· Establishment of the DMR service as an integral element of the community pharmacy contract;
· Creation of two Choose Pharmacy (common ailments) pathfinder sites;
· Provision of influenza vaccination; and,
· Revision of the pharmaceutical regulations.
The DMR Service
15. A national workshop was held in July 2014 to discuss and disseminate the evaluation findings. A key outcome of the evaluation report is the need to set the service within the overall context of improving discharge information and I expect this to feature in forthcoming LHB plans. The DMR service has helped address a problem which is internationally recognised; the avoidance of serious and potentially fatal prescribing errors when patients are transitioning between care settings. It is a service which is associated with considerable patient benefit and must be expanded and developed further by Health Boards.
Choose Pharmacy
16. The Choose Pharmacy pathfinder projects in North Wales and Cwm Taf are progressing well and showing a steady increase in the number of patients using the service. To date, over 1300 patients have registered with and accessed the service with 6% receiving solely advice and information on self care, whilst 94% have also received medication to treat the presenting condition. In the first eleven months of the service one in seven patients has returned at least once for further advice and treatment. An independent evaluation was built into the project from the outset and is exploring the clinical and cost effectiveness of the service; in particular, the impact of the service on promoting self care and the extent to which it releases GP time to deal with more complex matters. The final report is due in Spring 2015 and will inform the decision on national roll-out of the service.
Influenza Vaccination Service
17. In 2012-13, 81 pharmacies across Wales participated in the UK’s first and only national community pharmacy seasonal influenza vaccination service. The number of vaccinations administered was small, around 1600, and uptake was variable across Wales reflecting differing eligibility and service criteria in each of LHBs. However, a relatively high proportion (31%) of those vaccinated by community pharmacists reported not having been vaccinated in 2011-12. This supports the view that the accessibility of community pharmacies can make an important contribution to improving vaccine uptake.
18. Building on the experience of 2012-13, we standardised the eligibility and service criteria for the winter season of 2013-14. We also required LHBs to ensure as a minimum, influenza vaccinations were provided by 25% of all pharmacies. Across Wales 195 pharmacies participated in 2013-14, delivering 7851 vaccinations; one in four vaccinations were for people not vaccinated in 2012-13. This confirms the reach community pharmacies can have into the community and the contribution they can make to the wider health agenda.
19. LHBs have begun planning for this year’s winter season and I expect to see community pharmacies featuring as a key contributor to this important agenda.
Revision of the Pharmaceutical Regulations
209. During 2012, we worked closely with Health Boards and community pharmacy on a comprehensive review of the NHS Pharmaceutical Services Regulations (1992). This resulted in new consolidated regulations which came into force in May last year.
21. The new regulations have been simplified to improve the robustness and speed of decisions by Health Boards on applications to the pharmaceutical list (Control of Entry). The changes were also intended to reduce the number of appeals, consequently shortening the time from application to the opening of premises.
22. In addition, the regulations introduced a charge levied by Health Boards for making an application and this has already reduced significantly the number of speculative applications. Overall, the intended effect of the regulations described above is helping to create a more stable environment for community pharmacies to develop their services. Introducing pharmaceutical needs assessment into the health planning regime will reinforce that stability for those pharmacies that continue to provide a comprehensive range of services that meet the needs of the community they serve.
Education and Workforce Development
23. Education, training and continuing professional development are essential components to help us achieve the vision for pharmacy as set out in Together for Health. Since my predecessor reported to the Committee we have commissioned Workforce, Education and Development Services to undertake a review of the pharmacy workforce in Wales. The review, which is due to complete by next spring, will inform the development and implementation of a pharmacy workforce development plan that will deliver a robust, sustainable, affordable and agile workforce for Wales.
24. We currently invest £4.3m in educating and training pharmacists and I am clear we must move to an integrated academic/practice undergraduate curriculum. This in conjunction with a standardised approach to the accreditation of community pharmacy services will support our vision of a national integrated health service that fully utilises the clinical skills of pharmacists whether they are working in the managed sector or in primary care.
25. The desire to strengthen clinical leadership was also reflected in my announcement earlier this year regarding the establishment of Consultant Pharmacist status. This step change enhances the career for pharmacy practitioners by creating senior posts for our leading edge practitioners, helping to retain them in patient facing roles rather than losing them to management posts as they progress their careers.
26. The direction of travel for the pharmacy workforce will bring additional benefits to patients by delivering high quality and safe healthcare through increased clinical and pharmaceutical input at the point of delivery, for example in the treatment of long term conditions, the care of the elderly at home or in care homes.
27. I set out below my update to the Committee’s recommendations:
Recommendation 1
The Welsh Government improves the communication mechanisms it uses to inform the general public about the services available at any individual community pharmacy. To this end, we recommend that the Welsh Government makes it an obligation for all community pharmacies to place a prominent notice in their premises identifying the range of services available in that pharmacy
The community pharmacy contractual framework already places an obligation upon community pharmacists to provide information to the general public on the NHS services that are provided. An audit tool introduced in 2013 requires Community Pharmacists to report compliance on a range of contractual matters to Health Boards. The data shows a steady improvement with 86% of pharmacies reporting they display clear publicity indicating the NHS funded services they provide.
We have been working with Community Pharmacy Wales (CPW) to take this a step further and develop guidance for pharmacies on how they can publicise their services and utilise the NHS Wales brand, including the use of standardised, bilingual service names and descriptions, recognisable across Wales. We envisage this being established within community pharmacies early in 2015 and I am grateful to the support of CPW in progressing this area.
Recommendation 2
The Welsh Government provides a clear national lead for the future development of community pharmacy services to ensure that the necessary policies and structures are in place to secure its delivery. This should include nationally agreed priorities for the service and a centrally driven direction for its development.
The Welsh Government’s response to the 2012 report and this particular recommendation describe how the Community Pharmacy Contractual Framework provides the mechanism to introduce new community pharmacy services. These services support the Welsh Government’s health policies and priorities and have national specifications and fees and include:
All of the nationally specified services have unified training and accreditation procedures to support consistency of approach across Wales. The one service for which it has proved difficult to agree a single specification has been smoking cessation. However, work is progressing with Community Pharmacy Wales and Health Boards and it is envisaged a national specification will be established next year.
The summary above describes Welsh Government’s policies and support for a strengthened primary care service with the patient at the centre of a multi-disciplinary team. Welsh Government expects Health Boards to ensure the full range of national services are available, as appropriate, in community pharmacies across Wales. The expectation upon Health Boards is to ensure the range of national community pharmacy services are available as part of a comprehensive package of planned primary and community care services. This is underpinned by the requirement upon Health Boards to incorporate pharmaceutical needs assessment as an integral element of the service planning cycle and will help overcome any unnecessary barriers to the implementation of service implementation. (Paragraphs 4 – 6 provide further detail).
Recommendation 3
The Committee recommends that the Welsh Government should take the opportunity afforded by the recently announced national minor ailments scheme to consider changes to the way in which community pharmacies are remunerated, including a transition to capitation-based payments, underpinned by a patient registration system.
When my predecessor attended the Committee in January 2012, she advised that the establishment of the common ailments scheme provided a mechanism to test and introduce patient registration and capitation based payments. The service, launched as Choose Pharmacy in September 2013, remunerates participating pharmacies on the basis of the number of patients who have registered and used the service i.e. on a capitation basis.
It is important we take a measured approach towards introducing capitation based payments for other services. It is a novel concept within pharmacy but I believe it has the potential to be a component of an efficient and more stable financial and professional environment for our community pharmacy contractors, in which they can invest in developing additional services to promote and protect health. The Choose Pharmacy service is being independently evaluated and the results of that evaluation will help to inform future decisions on the introduction of a capitation based payment and patient registration system.
A form of patient registration or pharmacy nomination is required to secure electronic information flows between health care sectors. Whilst there is broad consensus amongst professionals about the basic principles of sharing information, the challenge is to achieve a system that balances the need for information sharing with patient confidentiality and patient choice. Models for patient registration and/or pharmacy nomination are being explored as part of the brief for the new Health Technology and Innovation Fund project “Improving Connectivity” (described at paragraph 13 above). The Welsh Board of the Royal Pharmaceutical Society and Community Pharmacy Wales are members of the Project Board and have agreed to work with us on designing an appropriate model that supports the sharing of appropriate patient information between community pharmacy, GPs and hospitals and underpins a capitation based payment system.
Recommendation 4
The Welsh Government promotes further enhanced services with a national specification for community pharmacy, including a national Chronic Conditions Service, and follows the incremental model proposed for the introduction of the National Minor Ailments Scheme to ensure robust monitoring, evaluation and improvement of services. The Committee recommends that where there are clearly national health conditions, the service should be nationally specified, but that some continuing scope should be allowed for the volume and location of such services to be determined locally.
The summary describes our intended approach to strengthening the role of community pharmacy within the primary and community care team. In particular, I will be expecting Health Board plans to reflect a robust assessment of need around the management of long term and/or chronic conditions accompanied by explicit reference to the service delivery options available; this should include the use of community pharmacy national services such as I have described at recommendations two and three above.
In particular the targeted Medicines Use Review and the Discharge Medicines Review services focus on individuals with long term or chronic conditions. Specifically, the Medicine Use Review service requires pharmacists to undertake half of all reviews with patients in nationally specified target groups which include patients who suffer from hypertension or respiratory illness. The two most frequently reported conditions in Wales[2]. Officials are now in discussion with Community Pharmacy Wales to increase the proportion of Medicine Use Reviews undertaken with target groups.
Recommendation 5
The Committee recommends the consistent participation of community pharmacies across Wales is secured for the next round of public health campaigns, whether national or local. Close monitoring of community pharmacy‘s participation is required by Local Health Boards to ensure that those failing to deliver on their contractual obligations are called to account for their non-compliance.
Since the publication of the committee’s report there have been five national pharmacy public health campaigns helping to raise awareness of important public health issues such as stroke risk reduction, eye health, keeping well during the winter, sun safety and bowel screening. As the committee pointed out in its 2012 report, the involvement of the third sector in these campaigns adds considerably to their impact and I am very pleased with the collaborative working between pharmacies and the Stroke Association, Royal National Institute for Blind People, Age Cymru and Tenovus on recent campaigns. These campaigns have a positive impact on the lives of Welsh citizens:
· The stroke awareness campaign resulted in over 10,000 Medicines Use Reviews being carried out by pharmacists with people who were at increased risk of stroke. A new stroke awareness campaign is being developed by Public Health Wales for January – March 2015 with community pharmacies at the heart of the campaign.
· The look after your eyes health campaign achieved UK wide recognition and received the Multidisciplinary Innovation Award at the UK community pharmacy awards ceremony earlier this year. Results showed the scheme had a significant and positive impact on the identification and referral of individuals to the Welsh Eye Care Service.
· The here comes the sun campaign which ran in May 2014 resulted in approximately 6,000 people seeking advice from pharmacists on how to reduce their risk of skin cancer.
These examples of public health services underline the positive contributions of community pharmacies in delivering public health messages and building resilience within our communities to support the co-production agenda by helping people to make positive decisions about their health.
It is the responsibility of Health Boards to ensure an appropriate level of community pharmacy participation in public health campaigns. Community Pharmacy Wales also play a key role in facilitating participation at the local level and generating media interest. Officials have regular dialogue with both Community Pharmacy Wales and Health Boards to discuss and plan public health campaigns including tackling issues such as increasing community pharmacy participation levels.
It is clearly Welsh Government’s role to ensure that Health Boards have the tools they require to effectively and proportionately manage under-performance. Committee members may have noted the proposals for pharmaceutical needs assessment set out in the recent public health white paper also include proposals to strengthen the sanctions available to Health Boards to address under-performance issues; this would include failure to participate in public health campaigns. I believe the collaborative approach works most effectively in improving participation levels. However, the introduction of pharmaceutical needs assessment and sanctions will enable Health Boards to make decisions on applications to the pharmaceutical list based upon the applicant’s stated commitment to deliver the range of services required to meet assessed need
Recommendation 6
The Committee recommends that the Welsh Government and Local Health Boards prioritise taking proactive action to address issues of cooperation and joint working between community pharmacists and GPs, both in rural and urban areas. We believe that better leadership from within the professions in this context is vital to securing the stronger relationships between key health professionals which are needed for the successful integration of community pharmacy services and the delivery of the Government‘s ambitions for primary care in Wales.
At paragraph 7, I have highlighted the responsibility for achieving collaboration through mutual understanding and respect lies with the professions and Health Boards. The joint statement on working together between the Royal College of General Practitioners and the Royal Pharmaceutical Society issued in July 2011 is the platform for Health Boards and health professionals to integrate collaboration for the benefit of patients at the local level.
In some services, collaboration is much more explicit such as the Choose Pharmacy service and the influenza vaccination programme. The emerging evidence from the ongoing evaluation of Choose Pharmacy is showing that a stronger working partnership is emerging between GPs and community pharmacists driven by the need to develop effective referral pathways. This is most notable where relationships were already established and provided a foundation to enable further integration.
In December last year, the Welsh NHS Confederation facilitated a discussion on collaborative working between representatives from community pharmacy and GPs. They identified a number of immediate areas for collaboration that would result in positive benefits and included: antibiotic resistance, improved medicine adherence and care of individuals in residential homes or housebound patients.
This supports the Welsh Government’s strategic aim for as much healthcare to be planned and delivered at, or as close to, home as possible through highly organised multi disciplinary primary and community care services designed around the individual, integrated with secondary care and social care. In January 2014, I reiterated to the NHS that it must embark on a sustained shift in leadership focus and resources invested in primary and community care. The development of the 64 “clusters” of GP practices offers a real opportunity for a breakthrough in locally led service planning and delivery and I was pleased to note the discussion within the group identified a need to extend locality groups to include community pharmacy. I expect to see this aspiration reflected in Health Board plans for 2015.
To support Health Boards in securing a sustainable re-balance of resources between primary and secondary care I announced in July the provision of an additional £3.5m for primary and community care in 2014-15. This funding is focused on tackling the inverse care law and building the skills of multi disciplinary primary and community care teams. The provision of pharmaceutical medicines management support to GP practices is one of the areas I am keen to see developed using this fund.
Recommendation 7
The Committee recommends access by community pharmacists to summary patient records where patients are registered with a community pharmacy.
The patient registration model and IT infrastructure developed to support the Choose Pharmacy service were designed to serve as a test bed for community pharmacy access to the NHS Wales IT platform that stores patient information. This represents an important step which we are building on through the new “Improving Connectivity” project described at paragraph 13 and in the progress update for recommendation three.
The Committee’s report noted that the key barrier to exchanging essential information on patients between health professionals is a professional one. I welcome the positive steps being taken by GPs and the pharmacy profession to work more collaboratively and I expect to see tangible evidence of real progress towards information sharing in the short term. As a final point I re-iterate my predecessor’s comment, our long term goal has to be an individual patient record shared appropriately with health and social care professionals.