Community pharmacy is firmly on the agenda with decision-makers says Dr Bruce Warner. And in his position at NHS England, he should know. P3 finds out more about his perception of where pharmacy is currently “at”.
“There is interest in pharmacy at the minute – it’s easy to say it’s never felt like this before, but it genuinely hasn’t. This is for all sorts of reasons, and I think that lends huge opportunities for pharmacy and some huge challenges as well.” We’ve never been in an environment quite like the one we’re in now, he says.
He describes a “perfect storm” in the NHS that is helping to create further interest in pharmacy. “We have a crisis, for want of a better word, in recruiting general practitioners, and practice nurses as well. We have major problems with urgent and emergency care, and we also have the financial challenges that we’re all facing in the NHS. We can’t cope with all those things by tinkering around the edges – things have got to change, and change quite dramatically. That presents pharmacy with some great opportunities.” His view is that more people are “waking up to the possibility that community pharmacy could have something to offer in facing these challenges,” he says.
While the climate is a positive one, with a wealth of potential opportunities for pharmacy, a huge amount of work is needed to be done to achieve this, says Dr Warner. “We have a once in a lifetime opportunity to grasp this, and if we don’t, it may pass us by. We can’t sit back and expect it all to be handed to pharmacy on a plate.”
In his role at NHS England, and in various other roles, he works towards putting pharmacy in the best position to move forward. But he asks for the involvement of all pharmacists in moving forward the current agenda. Pharmacists have already been involved in the process of the emergency care review, for example, he says.
“In terms of emergency care, so far – what the system looks like at a local level will be determined by local system resilience groups. We’re starting to see pharmacists getting involved in those system resilience groups to help shape what that offer is at a local level.
“I think this is something that individuals can help shape. They need to find out who are the key local decision makers who sit on these groups and who to influence.” Pharmacists can also work locally, for example, to ensure that the NHS 111 directory of service is accurate and includes details of local pharmacy services, he says.
“We need to make sure that is up to date, reflects reality and is comprehensive, and the system needs to be confident that if it’s directing people towards pharmacy, they know what they’re going to get.” This will help to build local confidence in pharmacy, he says.
“It’s down to people at a local level to make sure the lists up to date, and to make sure they’re doing what they say they’re doing. One of the things that we need to promote is the consistency of service, so if people are going for a certain service, they know what they’re going to get.”
The roll out of the summary care record is “a great move forward,” he says. But future write access, and the addition of more information on the record, would both be important steps. This will improve awareness and knowledge of the work and effectiveness of pharmacy, and help to raise awareness of the role.
“We need to make sure that community pharmacy has write access to that record and I really think that would be a game changer. Once we get to that point, what pharmacy does becomes visible. It becomes visible to patients, it becomes visible to other healthcare professionals, and they then suddenly they see what value pharmacy is adding.”
“Once a GP can log on and say ‘oh, this patient has been to the pharmacy, this was the advice they were given, this is what they’ve tried and this why they’ve now sent them to me,’ it changes the way that pharmacy is perceived.” He will be campaigning for write access, he says, but knows that this might take some time. “I’ll be pushing for write access as soon as we can, but I know how long it took for us to get read access. We are fundamentally changing the way that pharmacy is viewed.”
In the meantime, it will be useful to record how pharmacy makes use of the summary care record, suggests Dr Warner, to help communicate the benefits. “I will be asking people to make full use of summary care records, and keep some kind of record of when they’re using them, what they’re using them for and how they are using them. We’ve already seen some great examples, where patients arrive in pharmacy looking for an emergency supply.”
The pharmacist can log on to the summary care record and see what a patient is taking and can make a huge difference in giving the patient what they actually need.” “We need to make sure these are recorded, and build that confidence with the patients to show that we can make use of that kind of information.” Use of the summary care record, brings greater responsibility for pharmacy.
This is something that Dr Warner wants to help with. “Access to greater information comes accountability and responsibility. When you have access to that information it become incumbent on you to use it. I think people need to recognise that. We are the only profession that doesn’t keep clinical notes on what we do and I think we have a lot of work to do in gearing the profession up.”
About half of medicines are not taken as intended and between five and eight per cent of all unplanned hospital admissions are due to medication issues. Dr Bruce Warner says: “Medicine is the biggest intervention that the NHS makes towards a patient and quite often the medicine they’re taking isn’t the one they think they want, so it’s about working with patients to make sure they get the best possible outcomes from the medicines they take.” Earlier this year, NHS England launched a Medicines Optimisation Dashboard – bringing together data in themes such as patient safety, diabetes and community pharmacy – for the use of CCGs and trusts.
Changing the perceptions of pharmacy relies on building a clinical role for pharmacists, and moving the pharmacist role away from the supply function, he says. “If community pharmacy is just seen as a supply function primarily, then I don’t think it will be in the right place. It has to be, and needs to be, clinical first.”
Pharmacists themselves can accelerate this process, he suggests. “So I think pharmacists need to make sure they have the right training and knowledge. They need to be upfront and perhaps leave the technical side of dispensing to those better placed to do it. They should make sure they have that patient contact.”
Wider use of the pharmacy team will help this, he adds. “I think that now we have a wider range of support staff, technicians are playing a much greater role, we’re getting more towards a time where that will free the pharmacist to do more clinical work and spend less time tied down in the dispensary with prescriptions.” But he is more than aware of the day-to-day challenges that are involved.
“I still do one morning a month in pharmacy myself – under supervision these days – and one of the things it does remind of is all the pressure pharmacists are under. It’s not an easy job.” He says that it’s no secret that he would like to see a pharmacy contract that rewards clinical work, but says, “I’m astonished by the fantastic work that pharmacy’s do with the current contract. The innovative ways that people are going about things is tremendous to see”.
So, in conclusion, what does he feel that can pharmacists be doing themselves to help move things forward more swiftly? “I think they should be looking at how they can add that clinical value to what they do, about the four elements and principles of medicines optimisation, and about how they can build that in on a day to day basis, and really put the patient at the front of that. And they should get out there and bang the drum locally about what pharmacy should be doing. There’s only so much that can be done nationally.”
“The climate we’re in at the moment and the changes we’re seeing in the way that prescriptions are handled, mean that pharmacy does need to change, and it is changing. Pharmacy needs to think more about that added clinical value, because if it stays as a supply function, it will be overtaken.”
…a future minor ailments scheme for England: “I’m not convinced a national minor ailments scheme is needed. Most regions have one that fits their local need, so I understand why people feel it would be advantageous, but I don’t think we should get too hung up on it. If it happens it happens, if it doesn’t, it’s not a disaster.”
…automated dispensing: “I’m in favour of anything that increases the clinical role the pharmacist can take, automation frees them up to spend more time with the patients and to have those conversations, rather than being tied down accuracy checking because we’ll never be as accurate as the automation. However, this can mean many things – it doesn’t just mean you have to have a huge robot in your dispensary.”
…general practice pharmacists:
“It’s a good thing, but it’s nothing new – pharmacists have been working in general practice for the past 25 years plus. I think it’s going to help in relation to helping general practitioners and I think it’s going to show them what pharmacists can do. There is more than enough work to go round and this is a genuine additional career path for pharmacists.”