No one can say that the Scottish Government’s vision for the future of pharmacy isn’t groundbreaking. But can it work?

The Scottish Government’s 10-year vision for pharmacy is a groundbreaking document that has inspired awe and admiration from many quarters, and consternation from others. The ‘Prescription for Excellence’ document explains how all patients in Scotland could receive high quality pharmaceutical care from independent pharmacist prescribers working in collaboration with other pharmacists and health and social care professionals in the near future.

‘It is no understatement to say that Prescription for Excellence is quite possibly the most visionary and challenging document ever to set out a government’s aspirations for pharmacy and pharmacists,’ says Jonathan Burton, co-owner of the Right Medicine Pharmacy Group. ‘It’s no exaggeration to say it kicks ass in terms of vision and potential impact.’ Many aspects of the document will seem like a ‘quantum leap of practice and infrastructure’ for grassroots pharmacists.

Professor John Cromarty, chairman of the Scottish Pharmacy Board, describes the vision as ‘almost unheralded territory’. It makes pharmacy an important and integral component of the wider Scottish Government’s 2020 Vision for Health and Social Care, he says. ‘Prescription for Excellence puts pharmacists and pharmacy services at the very core of direct healthcare delivery through establishing a framework, within which further innovative pharmacy practice and integrated partnerships can flourish to deliver pharmaceutical care.’

Mark Koziol, chairman of the Pharmacists’ Defence Association, is ‘delighted’ that the Scottish Government has pursued the principle of individual pharmacists providing pharmaceutical care services directly to patients with long term conditions from caseloads previously handled by GPs – a concept outlined in the PDA’s own ‘Road Map’ proposals for community pharmacy.

‘The view has always been that pharmacy represents an underutilised resource within primary care and this has continued to be the position, probably because of the almost exclusive focus on a pharmacy premises centric model of pharmacy,’ says Mr Koziol. ‘What is different about this development is that whilst it recognises the vital role played by the community pharmacy, it also recognises the value and the importance of the unique professional and intellectual investment of the individual pharmacist and it will put it to a much better use than has previously been the case.’

Prescription for Excellence has inspired students and academics, too. Alison Strath, professor of community pharmacy practice at Robert Gordon University, says it presents the entire profession with a ‘fantastic and exciting opportunity to evolve’. And her students see it as setting out a vision of the practice of pharmaceutical care that inspires them because it delivers on their ambitions. ‘The only hurdle I can see to implementation is that we don't rise to the challenge or that we aim too low.’

Contractors’ views

Recognition of the value of the pharmacy network as well as the skills of pharmacists and their teams operating in community settings has been welcomed by the National Pharmacy Association. It supports the increased partnerships between healthcare professionals and the aim to extend access to patient information systems and enable the sharing of information between pharmacists, GPs and other healthcare and social care practitioners, says chief executive Mike Holden. The NPA also supports the aim to prioritise a national framework and NHS standards for the pharmaceutical care of residents of care homes and people receiving care and support at home.

But not all pharmacy owners are so happy with the idea that patients may register with individual pharmacists, who will become contractors in their own right, rather than with pharmacy premises or businesses. Managing director of Lloydspharmacy Cormac Tobin has already spoken out on this issue, saying it is unacceptable to control how patients receive their pharmaceutical care and that patients should be free to choose.

And although a spokesperson for Celesio UK, Lloyds’ parent company, says the proposals, which offer much to be excited, ‘energised and optimistic’ about, will help to realise the pharmacist workforce’s full potential, it has concerns about several areas and is working to understand their impact on Lloydspharmacy. ‘One primary concern is the concept of separating the supply of medicines from the delivery of clinical services, as this may lead to the fragmented pharmaceutical care of patients. However, there is no reason why the overarching Prescription for Excellence vision cannot be achieved, using the well-positioned network of community pharmacies in Scotland and continuing to promote patient choice and access.’

The vision contains much to be commended, says Rob Darracott, chief executive of Pharmacy Voice, since in many ways it continues a direction of travel of ‘The Right Medicine’ that has seen the implementation of new models of pharmaceutical care in Scotland. He recommends working with the grain of developments over the past 10 to 15 years, which has seen considerable investment by pharmacy owners in pharmacies and new models of provision.

Proposals should not necessarily be viewed as ‘either/or’, says Mr Darracott. For example, he does not think it is either desirable or intended that current providers, who have shown themselves able to adapt to new requirements effectively in the past, are gated out because the model changes. ‘This could prove an expensive way of delivering enhancements in service, when working together to evolve services could deliver more, cost- effectively.’

Pharmacy Voice has recently identified how community pharmacists add value, in keeping patients safe, as part of the dispensing process. It has also argued that pharmacists need access to more clinical information in order to provide the best support they can to patients, particularly with long term conditions. ‘It would be unfortunate if new risks were introduced into the system as a result of fragmenting care unnecessarily and we would suggest that, from the perspective of patients, access and convenience and an ability to choose the provider of their pharmaceutical care will continue to be important in the future.’

Scotland the brave: points from the plan

  • Better use of technicians and automation to manage the dispensing process
  • Pharmaceutical care will not be delivered solely through high street pharmacies, but through a ‘distributed model’ of GP practices, domiciliary settings or via remote consultations using telehealth
  • By 2023 all pharmacists will be required to be NHS accredited clinical pharmacist
  • independent prescribers – they will be referred to as general practice clinical pharmacists
  • Post-diagnosis caseloads from GPs will be allocated so that pharmacists can manage long-term conditions in partnership with doctors
  • Pharmacists in primary and secondary care to work together in an integrated way that would be supported by a common clinical pharmacy career structure
  • Patients to register with individual named pharmacists to ensure greater continuity of care
  • NHS Boards to have a direct relationship with individual pharmacists providing services in their areas, regardless of setting
  • Pharmacists to work in groups to deliver NHS pharmaceutical care to patients in all care settings
  • A national framework and nationally determined NHS standards for pharmaceutical care
  • NHS Board pharmaceutical care services plans with needs assessments to enhance local healthcare planning.

Don’t be a dinosaur!

As co-owner of 15 pharmacies himself, Mr Burton admits to being cautious about patients registering with named pharmacists, but is willing to discuss the concept. ‘Forget the old rules – protect your territory before all other considerations, etc – the world is moving on, don’t be a dinosaur!’ Pharmacists need to think beyond their current sectorial boundaries and ways of working, he says.

The vision can be a success if the profession works together. ‘If we respect each other’s hopes and fears and work through the various aspects of the vision with an open mind we can find a way of making it work for us all, and importantly for patients.’

The only hurdle I can see to implementation is that we don’t rise to the challenge or that we aim too low - Alison Strath

Mr Burton calls on pharmacy owners to engage wholeheartedly with the process. ‘We are not bigger than the profession and need to start thinking harder about our relationships with individual pharmacists, other health professionals and health boards.’

Although generally positive about the document, Mr Burton’s main area of concern lies around the patient journey and continuity of care. Continuity and patient trust is one of the key ingredients of effective pharmaceutical care, he says. The document refers to ‘general practice clinical pharmacists’; ‘primary care pharmacists’; ‘clinical pharmacist independent prescribers’ and ‘clinical pharmacists’ – a lot of different pharmacists that a patient might see, making their journey unnecessarily complicated. George Romanes, proprietor of five pharmacies in Scotland, is also concerned about the potential fragmentation and loss of continuity that could result from separating supply and services. He believes that continuity is important, and has not had locums working at his pharmacies for 10 years. ‘Continuity pleases patients and lack of continuity annoys patients,’ he says.

Patients will not want to visit a pharmacy to collect their prescription and then have to go somewhere else for their pharmaceutical care, says Mr Romanes. Supply and care are closely linked, and if the supply element of remuneration is taken away it risks breaking up the pharmacy network. ‘If you don’t do the supply you don’t know what you’re talking about unless you have a heck of a good record.’

Some parts of the document are ‘anti-contractor’, he suggests, and it also contains contradictory elements. For example, while it says the pharmacy network is vital, it also talks about separating supply and services. And patient registration with individual pharmacists is a backward step. Patients used to register with individual GPs ten years ago, but now register with a practice instead. Multiple pharmacists at the same pharmacy, high pharmacist turnover and locum pharmacists all make this idea ‘unworkable and fraught with difficulties’.

Ambition required

The requirement for all pharmacists to be independent prescribers by 2023 will encourage a lot of older pharmacists to leave the register, rather than have to undertake the additional training. Mr Romanes suggests that this might be the intention, and he also points out that a lot of already qualified independent prescribers are unable to find posts.

A number of the vision’s aims are particularly ambitious; giving every patient access to a pharmacist is one of them. This could be particularly difficult in rural areas, some of which remain the preserve of dispensing doctors. GPs may be reluctant to share their caseloads with pharmacists. ‘I don’t think people realise what an uphill struggle it will be. Doctors like to control their own workload.’

Mr Romanes highlights the Pharmore pilot studies as a ‘very exciting development’, which offered access to services such as a pharmacist-led minor illness clinic and nurse-led minor injury clinics. Some of these included out-of-hours periods and reduced the need to access out-of-hours doctors. This model would be particularly relevant in his area, as out-of-hours doctors are in short supply.

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