Redesign puts care front and centre
By Rob Darracott
It’s been a strange few weeks for Rose Marie Parr. I’d approached Scotland’s chief pharmaceutical officer to talk about the fifth anniversary of her taking on the role after the retirement of Bill Scott. By the time we met in St Andrew’s House on Calton Hill in Edinburgh, Rose Marie had announced her own retirement, then reversed that decision for the time being to oversee the pharmacy response to coronavirus, at first from her office on the first floor, and now from home.
We met in the middle of a busy week. That morning, Rose Marie had accompanied the cabinet secretary for health in an appearance before the Scottish Parliament’s Health & Sport Committee. The following evening, Community Pharmacy Scotland were hosting a dinner to celebrate the launch of the new Pharmacy First service. Both activities are rooted in the strategy Rose Marie put in place in 2017, Achieving Excellence in Pharmaceutical Care – A Strategy for Scotland.
“I spoke to the Health & Sport Committee today about Achieving Excellence,” she says. “About pharmacists being at the front line, how we want to use them differently, make them a bit more clinically patient-focused, and use their social capital. Why would you not do that?
“We’ve not got it all right yet, that’s for sure. We’ve not got the workforce model right, not got the pharmacotherapy [GP practice pharmacist] model right. But it’s early days. The potential is there, which is good.”
Big step with Pharmacy First
The Pharmacy First service will see people directed to pharmacies as the first port of call for common conditions, with additional self-limiting conditions such as uncomplicated urinary tract infections and impetigo, for starters, being added to what was the Minor Ailments Service. It was a key deliverable for ‘improved and increased use of community pharmacy services’ - the first of the nine commitments in Achieving Excellence.
“Working with Community Pharmacy Scotland (CPS) has been something I’ve always wanted to do,” Rose Marie says. “They are on a good trajectory, and Pharmacy First has helped all of that. The CPS vision, which they brought out at the same time as Achieving Excellence, aligns really well. There are differences, and rightly so, but it’s aligned, and they’ve been brave in what they’ve said about supervision and rebalancing.
“They understand that pharmacies can’t stay the same. One of the questions we had today was about the threat of online pharmacies. The future will be quite different, but the current building blocks will help with the redesign. Pharmacy First is not the Minor Ailments Service.”
Going to the whole population will be challenging for community pharmacy. It is a bit of a leap of faith, but it’s needed as well.
Rose Marie says the inclusion of prescription medicines in Pharmacy First is important. The UTI service was piloted in Inverclyde, west of Glasgow. “It worked so well, that’s what we will roll out nationally, along with impetigo. Get it right and it works, it doesn’t just stay at those two things.
“Going to the whole population will be challenging for community pharmacy. It is a bit of a leap of faith, but it’s needed as well. We need to redesign our heads around what community pharmacy is going to do. It’s not about minor ailments, it’s not about a product. It’s actually about care and advice, and self care first. That’s the big thing.”
Rose Marie pays tribute to CPS chief executive Harry McQuillan. “Harry has been absolutely crucial to this,” she says. “Community Pharmacy Scotland had roadshows across Scotland in January and February. I think they’ve had two thousand people. Sell outs – thank god they did it before the virus. The system’s different, the name’s different, the remuneration’s different, services will be different – and the eligibility is almost everyone.”
NHS Education Scotland (NES) will follow up with educational roadshows in due course, at dates to be arranged. “It’s behind the service, supporting it, not in front of it. The service has to lead,” Rose Marie says. “The other thing that has made a big difference is the faith of our cabinet secretary. She has been so supportive of community pharmacy particularly. She really gets it. She understands that primary care needs to be redesigned, and that that’s difficult.”
I suggest that prescribing is an important part of the picture for the future of community pharmacy in Scotland – perhaps more so than down south at this stage. “It needs to come,” Rose Marie says. “We need to sort out what that service looks like, but we are bogged down with patient group directions. That’s so bureaucratic. For Pharmacy First, we have had to do national ones, which is fine, but you don’t want to continue that way.
We’ve got pharmacies that do public health, that are vital to their community, and we won’t know what we’ve lost till it’s gone
“We’ve models of prescribers working in GP practices and in community pharmacies and it works really well. We need to build on that. There needs to be a career framework – two years foundation with prescribing at the end of it. Going into community pharmacy to deliver a clinical service is what we want people to do. And it will make it more attractive as a place to work.”
Like Pharmacy First, the shift into prescribing is a key part of that first commitment in Achieving Excellence. “We have 1,257 community pharmacies,” Rose Marie says. “That social capital is really important for Scotland. We have remote and rural practices, we’ve got pockets of huge deprivation. We’ve got pharmacies that do public health, like needle exchange and methadone, that are vital to their community, and we won’t know what we’ve lost till it’s gone.
“We need to hang onto that. But it’s not about community pharmacy doing the same old, same old, either. We need to make community pharmacy more responsive to local populations. We want to put community pharmacies where the service needs them. We want them to do things that the service needs. That might involve quite tough decisions in the future. But that’s still the vision in Achieving Excellence.
“Hospital pharmacy just needs to change. We have a thousand hospital pharmacists in our hospitals, absolutely run ragged. We need to have a radical look at what care means in hospital pharmacy. I don’t know the answer, but I know the problem. When I was in hospital pharmacy, you’d come in, go on a ward round, you’d see the patients and 10 days later you’d probably have a discharge plan. Now they’re in and out in one, two, three days. There is no time to care, so it’s medicines reconciliation and discharge planning. I don’t see how we can not redesign that.”
Building leadership capacity for the future
Rose Marie sees a big role for primary care in any transformation. “There’s been some good, mostly pilot work. Making that mainstream is going to be difficult.”
As well as focusing the strategy, Rose Marie has also changed the delivery process internally, with internal programme managers replaced by implementation led by health board directors of pharmacy (DoPs) and others, including CPS. She has also followed the lead of her English counterpart, Keith Ridge, in building future leadership capacity with clinical fellows embedded around the system.
“Keith has worked a blinder for the profession; I wish we could do as much,” she says. “We’re on our second cohort of five or six – it depends on how you count them – and hopefully about to get our third. It’s about succession planning for me; they deliver a piece of work and also a way of achieving some of the aims of Achieving Excellence. The care homes fellow will look at what we can do nationally. We have a fellow looking at hospital electronic prescribing management and administration (HEPMA) across Scotland.
“DoPs have been really supportive and tried to help them with some of the strategic stuff, then they’re just thrown in at the deep end. They are never the same again, because they’ve been altered [laughs] – in a good way. They can knock on my door, ‘can I have some time?’ Absolutely, of course you can. You are part of what we want to see in the future. It’s great.
Scotland’s health board model has included DoP roles for many years. Might chief pharmacists at the integrated care service level soon be a parallel in England? Rose Marie thinks there is potential there. “They are really important. Scotland has an advantage because of its size. Everyone knows each other. They meet the Scottish Government regularly. And in Scotland they are integrated. They have a locus for community pharmacies – that’s good for us. They have been absolutely key to the pharmacotherapy work.”
In Scotland, the money for pharmacists in general practices has been routed through the DoPs too, rather than being handed to practices or primary care. “We made sure the funding came through as a governance line to DoPs,” Rose Marie says. “Possibly not forever, but certainly for the first three to five years. That’s good because professionally these people have a route back up to the pharmacy director. Primary care is a tough place just now, so to have that governance line is really important. I wouldn’t want to be isolated in a different professional grouping.”
Until the coronavirus, workforce was Rose Marie’s biggest worry. “There’s a perfect storm because pharmacy is the new black. People want the workforce to grow quickly and that can be difficult to do. We have working groups around an integrated five-year course, but we’ve been talking about this for 15 years. The writing is on the wall. We need pharmacists who are more clinically experienced, so we need experiential learning and time in practice, understanding what the patient needs. And we need them now. It’s not to say the schools of pharmacy are not doing a good job. They are, but they are not future proofing it enough.
“We are looking at values-based recruitment, and the programme development and quality management groups are looking at what the curriculum looks like. But it has proven difficult to get transparency around funding.”
Rose Marie believes all the groups will report eventually. “We will probably not have co-terminus registration and graduation, but we will have a much more integrated five-year programme [she stresses the word], with much more experiential learning and a lot more clinical placements. The GPhC’s policy on initial education and training has made a difference, but it has taken a lot longer than I thought. It will get there.”
Out of her comfort zone
The chief pharmaceutical officer role in Scotland comprises three jobs, Rose Marie says. The community pharmacy agreement is one of them. Looking back to 2015, she says there was only one way things could go – up. “It got better, I think. We started talking to Community Pharmacy Scotland incessantly. Even when we had nothing to say, and even when times were difficult, we continued to have that collaboration. CPS, Harry and the negotiating team have done the same. We are very close in a way, but we also understand each other’s remits. I give them the credit for that.
“The second policy job is access to new medicines – the devolved aspects of health technology assessment, sponsorship of the Scottish Medicines Consortium (SMC) and the Area Drug & Therapeutics Collaborative. Increasing access to medicines is a very political issue, and it’s a difficult balance. Access versus affordability, with the big unknown being outcomes. This morning was the last evidence session in the Supply and Demand into Medicines Inquiry. The Health & Sport Committee have looked at purchasing, distribution, dispensing, prescribing, and social prescribing. It’s a really interesting area, but Scotland’s not cracked it in many ways. We have really good prescribing data in primary care, but not in secondary care because we don’t have HEPMA. The chief scientist used to say ‘prescribing some of the most expensive and most difficult medicines to the most sick people is like driving without your headlights on at night’. That’s been an interesting area for me, outside my comfort zone.
When you explain that it’s about taking responsibility for outcomes, it is just so positive
“The third bit of my job is the professional part. That’s by far the best bit. I’ve loved going out and speaking to people, meeting pharmacists at the coal face. One of the first things someone said in here was that we needed visibility of the CPO post. That’s permission, and I’d have liked to have done more of it. You see issues you don’t see coming any other way. Last year, EU exit was in our heads the whole time; we’ve had a lot of media around cannabis-based medicinal products, and had some issues with the service around whistle-blowing. That can distract you completely. I was talking about Achieving Excellence, but I couldn’t do any of it. You want to keep the professional agenda strong, while still doing what you are here for, to serve ministers. I don’t think people understand the three elements; I don’t think I did when I started.”
That professional element has been built, in Scotland at least, very firmly around the concept of pharmaceutical care. Rose Marie says you need a hook. “The Right Medicine, Bill’s first strategy in 2002, was about care. I think the words are really important. Now it’s about health and social care integration, bringing care closer to the individual, shared decision making. It hooks into everything policy-wise. That’s important here. It also supersedes settings – it’s not about hospital or community, but the patient. When you explain that it’s about taking responsibility for outcomes, it is just so positive. Hopefully, that direction of policy will be maintained. It’s been a nice framework for us to work with.”
A bright future in public health
There is work still to do, particularly with GPs. “We still have to make the case of what it means for you as a medic, and how we can support some of your patients,” says Rose Marie. But community pharmacy has a bright future. “I’m really positive about this. There are lots of circling sharks – workforce, finance, a small virus – but I think community pharmacy will be sustainable, I absolutely do. It needs to change, but it can make its mark around primary care.
“Medicines will be part of that, but it will be about public health too. Not health promotion, not things that other people are quite good at. But methadone, needle exchange, blood-borne viruses. We see good examples of that in community pharmacy, including for people who wouldn’t normally have access to health care provision.”
Rose Marie cites a Glasgow pharmacist working with the homeless, and pharmacists working with a heroin treatment base funded by the local alcohol team. “Deaths on the street are one of the biggest problems. Catherine Calderwood, the chief medical officer, and I visited the centre recently. Pharmacists are crucial to that.”
I say we can’t stop without talking about supervision. “It’s been an interesting, bumpy journey,” she says. “I think supervision and automation are going to be important, and we need flexibility, for sure. We need to make sure it’s safe, that pharmacists and technicians are doing the right thing, but we do need to embrace it. I thought CPS put it beautifully in their vision – if it’s a technical task, technicians should be doing it. If robots can do it, let them do it. Let pharmacists do what they need to do. It’s hard right now to bring that forward. The UK CPOs are still pushing that forward because it’s about flexibility. And there couldn’t be a better time for it. We all think that new policy is really easy, ‘just go and implement it’. But it’s quite a difficult thing.
Having postponed her retirement for the time being, the only policy issues Rose Marie is likely to be dealing with in the short term will be the challenges arising from Covid-19. “There’s no other show in town right now, other than fighting the virus and its effects on the NHS,” she tells me on 27 March. “We’re all working in very different ways, including knocking down barriers that would have seemed unthinkable. We’ve been trying to get access to emergency care summaries for a long time; we got it really quickly because of need.
“We’re trying to get the message over that the UK medicines supply route will stay open if people don’t over order. And we’re trying to stabilise the pharmacy workforce as much as possible,” she says.
As well as flexibility in opening hours, including for down time and decontamination time, Rose Marie says DoPs will be looking at moving pharmacists and technicians in general practice, who are all directly employed by the NHS, into community pharmacy.
So her retirement plan – to “do nothing”, apart from spending more time with long-term partner Archie, will have to wait for now. The pair married last October after 24 years together; they haven’t yet found time to have a honeymoon, and plans for that are obviously now on hold.
When we met, Rose Marie promised not to go far. “I’m staying on the register,” she said. “I’ve never had a career gap, I’ve never had a gap year and, touch wood, I’ve never been off sick. I’ve only ever known work, and I’ve had that conversation with myself. It definitely defines me, so I will have to do something. It’ll be interesting to see how I cope with it.”
She has recently been appointed as a registrant member of the General Pharmaceutical Council. Given the conflict of interest with her job, her delayed retirement means she will now ease more gradually into it.
Many will be grateful she’s still going to be around if the comments on social media after her retirement announcement are anything to go by. “It was lovely, which is why I’m coming off social media immediately I leave here,” says Rose Marie. “I was told ‘you’ve got to have a presence, get on with it’. There’s always plusses and negatives in that.”
Major career highlights?
I loved my time in education and training at SCPPE (the Scottish Centre for Pharmacy Postgraduate Education) and NHS Education Scotland (NES). It was my first time in a national post, and education and training has always been at my heart. The director general here, Malcolm Wright, was my boss at NES and we were having a conversation the other day about some of the fun times there. This is a wee bit less fun; no one died for want of a course.
If you weren’t doing this, what would you be doing?
I would still want to be part of the profession; that’s important to me. It’s been a fantastic career. And that’s what I’d say to young people as well. You have such autonomy. It’s going to be great to see what’s in the next stage.
How do you relax?
I run. I’m a really bad jogger. I’ve done a couple of marathons, lots of half marathons, lots of 10Ks. Badly. I’ve got a small house quite close to the Crinan canal and we go up and down it. There’s a run – the Crinan Puffer – that runs the length of it (eight miles). We’ve done that lots of times.
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