Pharmacy

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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