With 90 per cent of all care being provided in primary care, there are numerous references in national guidance on the emerging healthcare systems to the need to integrate community pharmacy into local
primary care plans.
Pharmacists are well placed to meet the challenges this brings – if the conditions are set to allow them to do so. And with general practice under severe pressure, Local Pharmaceutical Committees (LPCs) continue to work with commissioners to try to achieve this integration and ensure community pharmacy can be used to its full potential to help patients and the NHS.
However, in December 2016 the Community Pharmacy Integration survey of LPCs – carried out by PSNC, Pharmacy Voice and the Royal Pharmaceutical Society – found that community pharmacy had little or no involvement in many initiatives, and that the contribution of the community pharmacy sector had not been fully explored during the development of the 44 sustainability and transformation partnerships (STPs) across the country. What’s more, 50 per cent of LPCs said community pharmacy had no involvement in plans for health and social care devolution, and 55 per cent had no involvement with the Prime Minister’s GP Access Fund, with the most common remark made by respondents being that community pharmacy often felt overlooked by leaders of the various programmes.
Any hope that this situation would improve over the intervening months may have been dashed by England’s chief pharmaceutical officer. In October Keith Ridge admitted in an all-party parliamentary group meeting that NHS England would not be publishing a formal response to the Murray review into pharmacy services, which aimed to “make the most of the existing clinical services that community pharmacy can provide” because, he said, “we do feel that it’s by and large been taken into account”.
If this feels like a gaping chasm of disconnect between what NHSE appears to think has happened and what community pharmacy reports from the coalface, what can be done – and by whom – to bridge that gap?
“Those leading pharmacy need to properly wake up to the changes that have happened to the system following the Health & Social Care Act 2012 and the publication of the Five Year Forward View in October 2015,” says Professor Rob Darracott, director of McIntosh Health Partners.
In particular, he says, the experiment in new models of care and the emergence of STPs, and now the push for some of the more organised STPs to evolve into accountable care systems/organisations, has been “largely ignored by key elements of community pharmacy”.
He suggests there is much to be learned from innovators in some of the other primary care professions who have taken a different approach.
He points to the National Association of Primary Care’s Primary Care Home (PCH) initiative, which has tried to get doctors to think differently about their locality, and put population health, provision and outcomes first by exploring how a multidisciplinary workforce might be better integrated to deliver those outcomes, and how financial incentives might be realigned to support the health needs of that population.
The programme was launched in October 2015 by NHS England chief executive Simon Stevens, bringing together a range of health and social care professionals to work together to provide enhanced personalised and preventive care focused on local population needs and to provide care in the community, closer to patients’ homes.
Fifteen rapid test sites were chosen in December 2015 and since then the programme has expanded to a current total of more than 200 sites across England, which serve eight million patients and 14 per cent of the population. The number continues to grow, with all the sites developing and testing the model as part of a community of practice.
When it comes to the involvement of community pharmacy, an NAPC spokeswoman says the organisation is “looking to drive forward further integration”, building on the Healthy Living Pharmacy model.
“We envisage the new environment will be one where community pharmacy is an integrated partner working seamlessly within pathways alongside other health and care partners, and in fact, NAPC is currently working on a paper on community pharmacy and the Primary Care Home,” she says.
Outside the health and social care professions involved in the PCH initiative, Professor Darracott also points to the work that optometrists have been doing for some years now to encourage local commissioning of novel optical care pathways designed to address patient needs within primary care – either directly through optical practices or through shared care protocols with general practice – reducing the need for relatively expensive secondary care referral or management.
“To take one example,” he says, “optometrists have argued that their Minor Eye Conditions Service (MECS) should be commissioned nationally. And it probably should be. However, optometrists have also recognised that the value of the service, implemented well, will accrue to local commissioners in reduced referral to the acute sector. Get MECS commissioned to a single standard, driven nationally, in enough places and you can create what appears to be a national service delivered locally.”
If pharmacy is lagging behind in these shared care initiatives, what is making engagement complex?
Andrew McCracken from National Voices, the coalition of 160 health and care charities, says if community pharmacy is to realise its potential, it needs to shift decades of public perception. In a recent workshop of charities hosted by National Voices and the Royal Pharmaceutical Society, misconceptions about the skills of pharmacists was identified as a barrier to greater use of community pharmacy.
“If these misconceptions exist among the general population, there is every reason to believe they also exist among primary care professionals,” says Mr McCracken.
Building relationships means finding common ground with the other primary care professions, and some of this might be more obvious than it appears.
Consultant community paediatrician Dr Renu Jainer says community pharmacy can forge this path with other healthcare providers through “improving compliance and reducing medicines wastage”, and communicating directly with colleagues in primary and secondary care “to avoid duplication and improve outcomes for patients”.
Dr Chris Moulton, vice-president of The Royal College of Emergency Medicine (RCEM), suggests another collaborative approach would be to have two types of pharmacist working in the A&E department. “Coming from either hospital or community practice, one would be a pharmacist who utilises the unique skills of pharmacy in order to support A&E work and improve the care and pathways for A&E patients, whether admitted or sent home,” he says.
“The credentialling of this pharmacist would not be under the auspices of RCEM. The other is a pharmacist who has followed a prescribed pathway to become an advanced care practitioner. In this case, pharmacy would be a route into the ACP role, much in the same way as nursing or physiotherapy. The pharmacist would, however, be working in a standardised non-pharmacy role for most of the time, with credentialling of this ACP pharmacist under the auspices of RCEM, as is the case with other ACPs.”
This would fit well within RCEM’s hub model of collocated urgent and emergency services, within which A&E becomes a hub rather than a department and includes an on-site community pharmacy at all major (type one) A&E departments. The RCEM is urging the NHS, throughout the UK, to adopt the model.
While this kind of vocal support for pharmacy from outside the profession is encouraging, it doesn’t take away from the fact that leaders within community pharmacy feel overlooked by those who head up various other programmes. So how can they gain the necessary access to people and groups responsible for, or influential in, planning and decision-making?
Professor Darracott says it’s not too late to get involved. “It’s good to talk, and everyone is in the same boat in many ways in having to think differently,” he says.
“When you make the leap you can find yourself having some very different conversations. And when those conversations are informed by primary care professionals from across the spectrum, and not just GPs, then you might find yourselves coming up with better solutions, as different professional perspectives are brought to bear on what might be possible.
“You might also avoid the kind of unintended consequences that come from the ill-informed assumptions of what other professions actually know, do or get paid.”
Mr McCracken says these kinds of assumptions have led to misconceptions about the clinical knowledge of pharmacists, scepticism about pharmacists’ connectivity with the wider system and some concern about the suitability of community pharmacy premises for sensitive discussions.
However, he agrees that communication and working together can help to change that. “Pharmacists are embedded in communities and can bring continuity and aid co-ordination,” he says. “They are also one of the few health professionals to see people when they are feeling well. If we can more closely connect pharmacy to other health and care services and be proactive and assertive in promoting the skills and services of pharmacists, then I suspect we would start to realise the potential of community pharmacy.”