Pharmacy Complete

Pharmacy consultancy

HLP

Collaboration, integration and transformation

As we all move forward into a reset, reform and recover phase, it is critical that we learn from and build on community pharmacy’s excellent and dynamic response to the COVID-19 pandemic.

Collaboration

If there is one of the many hashtags doing the social media rounds over the last two months that best fits the Coronavirus response it is undoubtedly #allinthistogether 

We have complete admiration for pharmacy teams who are putting outstanding and safe patient care, often ahead of personal safety, at the heart of their communities. This is against a backdrop of current underfunding, major cash flow and workload challenges, late and limited supplies of personal protection equipment and poor recognition, beyond a few words of thanks from politicians and NHS England, of the critical role we play in the current pandemic crisis.

One of the many objectives of the Healthy Living Pharmacy programme when we created the concept, was and remains to collaborate better for the greater good of pharmacy and the health and wellbeing of our communities. If there is any silver lining to this dark COVID-19 cloud, then it is the way in which pharmacy teams, other healthcare providers and local volunteer groups have all worked together for the benefit of the population.

Integration

This could be a defining moment for pharmacy. What we are doing now will cement in the minds of the public, other health professionals and, one would hope, NHS commissioners, the role of bricks ‘n’ mortar community pharmacy at the frontline of healthcare in the heart of our communities.

What we must all ensure is that this intra and inter-professional collaborative approach continues beyond the pandemic and drives the need and opportunity for pharmacy in the community to be fully integrated into the local health and care systems. To be sustainable, this must also extend beyond (yet still include) the important safe supply of medicines to a broader role in clinical care and prevention.

Before COVID-19, which seems an age ago now, the NHS long term plan, the GP contract and the community pharmacy contractual framework began to align behind this integrated approach. Once this is all over, we must go back to the key objectives which are and should still be to focus on:

  • the prevention of illness;
  • personalised care;
  • utilising data and technology; and
  • making the best use of collective resources across all local health and care providers.

The only way these objectives will be achieved is through effective collaboration and integration. How we achieve that to support the delivery of the objectives requires individual, organisational and system transformation.

Transformation

We are going to experience a radical and rapid evolution in what community pharmacy looks like and does in the next five years, those who adapt will continue to successfully operate as healthcare providers.

Healthy Living Pharmacy was never just about brief advice and interventions on healthy lifestyles, although that is an important output. The HLP model was, and remains for those who fully embrace it, an organisational development framework to transform pharmacy in preparation for what was to come. One based on workforce and premises development plus effective engagement with the local population and other providers of health and care.

What we see now is a shift from a contractual framework almost totally reliant on procurement and supply of medicines to one which is increasingly more service-led and quality based, driven by financial, population health and consumer demand.

Digital healthcare is now moving at such a pace with web-based information, consultations, algorithms and ‘health-bots’ now common place. Distance selling pharmacies now provide around 3% of prescriptions and growing fast, so transacting product alone is no longer a unique option nor a sustainable model for bricks ‘n’ mortar pharmacy.

We need to find a new model which can only be provided face-to-face. Turkish barbers and coffee shops are everywhere. Why? – because you cannot get a haircut or a cup of coffee online! So, what is our new unique face-to-face offer?

The fixed funding in the contractual framework is insufficient to support the existing community pharmacy estate. This means that new skills and skill-mix must be developed; operational efficiencies must be found; technology must be embraced; we must develop new services and products that people and commissioners want to buy; consistent high quality consumer experience must be delivered; community pharmacy must collaborate and be fully integrated into local health and care systems; and we must effectively promote what we do.

All this change needs to be actively led at all levels but, as with most effective change, it must start at an individual level.

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A new year, a new Government, a new NHS… what’s new for community pharmacy?

The Secretary of State for Health and Social Care, Matt Hancock, recently gave a speech on the newly elected Government’s priorities for the NHS:

  • Prevention: because prevention is better than cure
  • People: because we need more people working smarter
  • Technology: because patients and clinicians demand better
  • Infrastructure: because buildings matter too.

The following extract from the speech relates to Community Pharmacy and the prevention priority building on the Healthy Living Pharmacy foundations:

And we will also “unleash the potential” of our pharmacies because there really is so much more they are capable of doing.

Over the next 5 years, they will become the first port of call for patients with minor illnesses. More than 10,000 pharmacies are ready to receive referrals from other parts of the health service – and that number will grow.

The prevention agenda is incredibly important because prevention is better than cure. We also know the challenges the NHS faces: demand is rising faster than at any point in history. Baby-boomers are reaching the age where they need more and more healthcare.

So, as well as investing in infrastructure, we need to make the 2020s a decade of prevention of ill health:

  • Support everyone to take more care of their own health. I don’t believe in the worried well – I want healthy people to be concerned about their own health so they stay healthy.
  • Vaccinate against preventable diseases.
  • Redouble our efforts to be smoke-free, redouble our efforts on obesity, and embed a more proactive, predictive and personalised approach across the NHS.

So what does this mean for community pharmacy? Whatever the colour of your politics, the fact that there is continued mention of the role that community pharmacy can play within an integrated NHS must be a positive. That focus has carried over from the NHS Plan, the Prevention Green Paper and the new CPCF into the newly elected Government’s plans for the next 5-years.

At a national level, building on the platform that the new CPCF provides, the first step is to deliver what is now in place whilst continuing negotiations to embed new services. This would mean that the currently unallocated funding (around £250 million) is accessible to all contractors and we must sort out the reimbursement mechanism following the recent consultation to make it more equitable for all.

At a local level, contractors, supported by their LPC, must engage more than ever before – firstly with each other and then with PCNs to ensure that they understand their needs and priorities. PCN Clinical Directors and all other health and care providers must also understand what pharmacy could offer to address their needs, particularly their real pain points. The skills of the identified PCN Community Pharmacy Leads will be crucial. This is why we created our award-winning portfolio of HLP support and launched our new Effective Engagement and Communication leadership programme which a number of LPCs have already embraced.

Apologies for plagiarising an over-used political phrase – Let’s get it done!

Community Pharmacy in a new NHS

The NHS Long Term Plan sets out its ambitions for transformation over the next decade to ensure the NHS is fit for purpose in the future.

The plan’s key aims are to:

  • ensure everyone gets the best start in life;
  • deliver world class care for major health problems; and
  • support people to age well.

So where does Pharmacy fit into the plan? Key areas that will impact on pharmacy include:

  • make greater use of community pharmacy’s accessibility and skills
  • establishment of Primary Care Networks with £4.5 billion investment
  • out-of-hospital and urgent care
  • supporting self care and self management
  • promoting good health
  • prevention and treatment of cardiovascular disease, stroke, diabetes, cancer and respiratory conditions
  • greater involvement in provision of Health Checks and their outcomes
  • support to improve mental health and wellbeing
  • involvement in social prescribing
  • expansion of digital healthcare and use of technology including automation
  • reducing waste and exploring alternative reimbursement and supply arrangements for medicines

Inevitably there are both risks and opportunities for community pharmacy so planning and executing the next steps are critical for a successful future.

Whilst we now have a new contractual framework, PSNC’s negotiations with NHS England and DHSC on how this evolve are ongoing. Within these conversations, understanding how community pharmacy can be part of the implementation and delivery of the plan’s ambitions is key to our future.

A sustainable future model must be developed at national and local levels and support provided for its implementation and delivery against NHS and public health needs. In addition, the reimbursement model must change to become fair and equitable, and drive the right behaviours.

Integrated Care Systems (ICS) are due to be in place everywhere by April 2021. As they are to be central to delivery of the plan, there is a major influencing and leadership role for Local Pharmaceutical Committees (LPCs) by working with ICSs and CCGs to ensure that community pharmacy is firmly embedded, supported and active within the Primary Care Networks (PCNs).

Over the coming years there will be additional roles employed in these PCNs including an increasing team of Pharmacists and Pharmacy Technicians as well as other healthcare professions such as Social Prescribing Link workers, Physiotherapists, Paramedics and Physician Associates. This multidisciplinary team will work across GP practices and with other health and social care providers including, assuming we proactively embrace the opportunity, community pharmacies.

This is where any new money will flow through so critical for a sustainable future.

Individual pharmacies must start to work together now and engage with their emerging local Primary Care Network to understand who the key stakeholders are and hence who to build effective relationships with, develop an understanding of priority needs and influence pharmacy’s opportunity to be embedded (and funded) in the solutions.

Ask not what the NHS can do for community pharmacy but what can community pharmacy do for the NHS. 

It is now ten years since the Healthy Living Pharmacy initiative was developed in anticipation that community pharmacy could play a bigger and better role in improving the health and wellbeing of the communities we serve and support. It was predictable then that a supply-based contract could not be sustainable in the long term and a shift to a quality-led, service-based contract including pharmaceutical care, supply and prevention would come. Hence the then, and continued focus on organisational development.

The Chief Pharmaceutical Officer, Dr Keith Ridge, has now communicated his vision for pharmacy’s role in the new NHS. That includes opportunities for community pharmacies to support medicines optimisation and patient safety, acute and urgent care, and the prevention agenda.

We have developed an online and on-demand webinar on this topic which can be accessed here.

New Community Pharmacy Contractual Framework 2019-2024

The English community pharmacy funding settlement for the next five years has been announced the first time that we have agreed a multi-year settlement. The agreement, set out in the new Community Pharmacy Contractual Framework (CPCF) which commences on 1st October 2019, aims to build on the clinical skills of community pharmacists and their teams which must be seen as a positive step.

The Headlines

Funding:

  • The contract sum will remain unchanged at £2.592 billion until the end of 2023/24, £1.792bn for fees and £800m in retained margin.
  • The Single Activity Fee (SAF) will be £1.27 from August 2019 (currently £1.26).
  • Category M prices will increase by £15m a month from August 2019 to recognise that there was predicted to be a shortfall in margin in the current year.
  • Pharmacies will receive monthly transitional payments in the second half of 2019/20 and in 2020/21 to meet costs associated with changes such as integration into Primary Care Networks (PCNs), preparation for Serious Shortage Protocols (SSPs) and implementation of the Falsified Medicines Directive (FMD).
  • Establishment Payments will be phased out by 2020/21.
  • The Pharmacy Access Scheme (PhAS) remains at £24m a year.

Services:

  • A new NHS Community Pharmacist Consultation Service (CPCS) is introduced nationally as an Advanced service in October 2019. This will replace the current NHS Urgent Medicine Supply Advanced Service (NUMSAS) and local pilots of the Digital Minor Illness Referral Service (DMIRS). The new service will operate with a fee of £14 per consultation. Initially using referrals from NHS111, but piloting referrals from GP practices with an intent to implement nationally in 2020/21.
  • Medicines Use Reviews (MURs) will be phased out over the next two years with pharmacists working in PCNs undertaking Structured Medication Reviews (SMRs). Contractors will be able to deliver 250 MURs in 2019/20 and 100 in 2020/21.
  • New Medicine Service is retained with potential extension of therapeutic areas and funding.
  • Medicines reconciliation service as part of transfer of care.
  • Being a Healthy Living Pharmacy will become an essential requirement within the new framework from April 2020 to support the prevention agenda and will include:
    • Mandatory health campaigns aligned with equivalent campaigns in general practice under an integrated programme
    • Hepatitis C testing for people using needle exchange services
    • A testbed programme for:
      • detection of undiagnosed cardiovascular disease (hypertension, atrial fibrillation)
      • stop smoking support from secondary care referrals
      • point of care testing for minor illnesses to support AMR
      • vaccination and immunisation services
      • routine monitoring of patients, e.g. those taking oral contraception
      • activity complementing future PCN service specifications, e.g. early cancer diagnosis and health inequalities.

Pharmacy Quality Scheme (PQS) 

  • This replaces the Quality Payments Scheme (QPS) and pharmacies can earn additional payments for meeting quality criteria. Funding for the scheme will continue at £75m a year.
  • Some elements of the former QPS will become Terms of Service requirements from April 2020, e.g. Healthy Living Pharmacy.
  • The criteria include:
    • A collaborative approach to engage with PCNs
    • Activity complementing the GP QOF Quality Improvement module on safe prescribing, e.g. lithium safety audit, valproate in pregnancy, NSAIDs
    • Checking whether patients with diabetes have had their annual foot and eye checks with appropriate referrals
    • Reduction in sales of sugar sweetened beverages (SSB)
    • Training and assessment of look-alike, sound-alike (LASA) medicines with evidenced safety reporting action
    • Update previous risk review with recorded mitigations
    • Sepsis training with risk mitigation
    • All patient-facing staff are Dementia Friends and a Dementia Friendly environment standards checklist completed.
  • The 2020/21 PQS may include:
    • Suicide prevention training
    • Inhaler technique audit
    • Anticoagulation audit.

Transformation and Technology:

  • A range of reviews with the aim to free up capacity:
    • Legislation to permit wider hub and spoke dispensing
    • Original pack dispensing review
    • Better use of skill-mix
    • Different terms of service for online pharmacies.

The Commentary

Firstly, we should recognise that this will undoubtedly been a big task for PSNC to achieve and remains so as negotiations are ongoing.

It should be no surprise, but will be disappointing to contractors that the contract sum has been fixed at the current level for the five year deal which is less than in previous years against a backdrop of rising operating costs. With prescription numbers set to fall due to various deprescribing initiatives, the proportion of income associated with dispensing will also drop. Hence, those relying on volume alone and not adapting to a service-led contract will struggle to survive. One can only hope that new and sustainable funding will come through on the back of some of conceptual and testbed service opportunities and that the sector is ready, willing and able to deliver.

Unfortunately, the continued use of retained margin to deliver around 30% of funding will perpetuate an unfair averaging system where not all contractors can realise their full funding, and, in some cases, drive the wrong focus and behaviours. In addition, a consultation on a review of reimbursement was announced by DHSC which will impact on this.

The eventual loss of MURs is also disappointing. Yes, they needed reform (Murray Review), but a good consultation on safe medicines use adds enormous value to patients (see our previous Viewpoint article). Not to acknowledge and fund this provision of pharmaceutical care as an adjunct to medicine supply and support medicines optimisation is a lost opportunity for patients, the NHS and pharmacy. Structured Medication Reviews by pharmacists working in a PCN will add value, but will only reach a proportion of patients and misses the opportunistic interventions on adherence and healthy lifestyles which can improve patient outcomes. On a positive note, the New Medicine Service, that also adds value to patients and the health system, is retained and a medicines reconciliation service is to be added to support transfer of care.

The arrival of a national minor illness consultation service (CPCS) should be welcomed and quickly embraced, particularly when GP referrals are included; certainly all GPs we know welcome its coming. This is likely to be a big stream of work and funding in the future and pharmacy teams will need to be ready to deliver against expectations.

Embedding HLP in the contractual framework, rather than just in the quality scheme, should  be celebrated. Many contractors have fully adopted the organisational development, health promoting ethos and criteria which are the foundation of HLP; however, some have undoubtedly just ticked the box. The opportunity to develop the right knowledge and skills within the pharmacy team and deliver a healthy living environment and enhanced customer experience will pay dividends. There will also be new services to build on these foundations. Given the launch of the Prevention Green Paper with which the pharmacy contract is aligned, the opportunities for community pharmacy to be at the forefront of prevention are significant.

One comment I saw on Twitter called it a Curate’s egg, good in parts, less so in others. Undoubtedly true, but it’s what we’ve got and we will have to make the most of it whilst building relationships with PCNs to tap into the funding that will flow through there. Contractors will also need to develop their own business plan around non-NHS services to meet local needs.

We have developed a short animation which illustrates what the new contract means through the eyes of patients that use community pharmacy.

Pharmacy Complete is here to support contractors in ensuring they meet the HLP criteria and optimise the benefits that brings. We are also here to support the engagement with PCNs and development of a business plan for a sustainable future.

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