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Our reflections on the latest changes in the pharmacy and healthcare landscape.

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23/07/2019 By Michael Holden Leave a Comment

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.

Helping you to help others

Filed Under: Healthy Living Pharmacy News, Media, Pharmacy Complete News, Viewpoint Tagged With: Contract, Healthy Living Pharmacy, HLP, Leadership, PCN, Pharmacy

16/07/2019 By Deborah Evans Leave a Comment

Are MURs worth it?

With the community pharmacy contractual framework under negotiation, one key question being asked will be about the future of Medicines Use Reviews (MURs). They are 14 years old (where has that time gone?) and as they reach adolescence, it is fair to say they have had a difficult infancy and childhood. It took a considerable amount of time and effort to get them off the ground and the sector is only delivering around three-quarters of MUR potential. There have been mumblings that pharmacists, under pressure to deliver the numbers, are choosing simple patients to review rather than the ones that really need help.

On a more positive note, the Murray Review of Community Pharmacy Services published in December 2016 and commissioned by NHS England, said that “ultimately MURs should evolve into full clinical medication reviews utilising independent prescribing as part of the care pathway”. There is hope for the humble MUR!

If you are looking from the outside in (i.e. as NHS England or as a taxpayer), you will be asking what difference do MURs make? What value are we getting from the £97 million (2018/19) spent on this activity? How else could we spend this money to get potentially better outcomes?

Of course, we can’t answer these questions but they are important when deciding what is included in a new contract and what is not.

At the end of this article, I’ll share with you my two most recent MURs to illustrate why I believe MURs can be worth every single penny.  I don’t believe the discussions I had with these patients were extraordinary but the individuals think otherwise.

I know that every MUR I have done has made a difference. But who else knows? Well the patient does; they are always very grateful for the time we have spent together and they may even tell their family and friends. And in some situations, the GPs I work with know because I ensure they are fully engaged in a change that’s required. But aside from a small handful of individuals, the impact of these 15-20 minute conversations is unknown to the system.

Of course, I’m not alone in making the most of MURs. Many pharmacists across the country will be having similar conversations to mine, with unknown impact and outcomes. The current MUR form tells us a little bit about what goes on in the consultation but tells us nothing about the patient experience and what happens to them next.

The NHS will never know about the harm that now won’t happen nor the improved health gain from taking their medicine correctly, and it’s impossible to know what impact a lifestyle behavioural change will have on preventing further disease progression.

We are not measuring the right things and as such, I’m fearful that an excellent service could become history before it comes of age. Of course, not everyone wants MURs to remain. With huge funding pressures in community pharmacy, the pressures to deliver the numbers get ever greater. However, every one of the 400 MURs per pharmacy, is an opportunity to make a huge difference to someone’s life, prevent harm and improve value for the NHS. But if we lose MURs, will they be replaced with something or will the opportunity be lost forever?

MURs are not perfect but with a few tweaks, such as combining it with the New Medicine Service (NMS) to create a holistic medicines optimisation service, and measuring patient reported outcomes and actions, we will have something that will continue to make a difference and can demonstrate real value. The service can be better integrated into the GP contractual framework and Long Term Plan priorities, maybe with jointly held objectives. Formalising pharmacy medicines optimisation within a long-term condition pathway, working alongside clinical pharmacists in the Primary Care Network (PCN), would be the icing on the cake. Particularly for high risk patients. Providing more flexibility around the 400 per year would help, to allow those who are engaged to make even more of a difference. Finally, let’s think carefully about the measures we put in place to ensure we can evaluate the difference made and to ensure we support the right behaviours.

So here are my stories ….

Patient 1

Middle-aged male on a range of medicines including a diuretic, beta blocker, statin, anti-arrhythmic and an oral anticoagulant. He has a complicated cardiac history including several ablations for arrythymia, a pacemaker and two episodes of defibrillation following arrest. He was under the cardiologist.

We quickly established a rapport and going through his medicines, most of which he was taking as intended. He revealed he was taking his edoxaban five days out of 7. This was because he had developed IBS symptoms which he felt were due to the edoxaban and so was modifying how often he took it, without understanding the impact. Listening further, he explained that he had been on warfarin and ‘a bright young GP’ had switched him and he hadn’t really settled on edoxaban since. I explained how his medicine worked and together we explored what it was for and his fears around taking and not taking the drug. As the conversation progressed, he trusted me enough to disclose he was only taking it ‘maybe 2 days a week’. Following, an honest conversation about his higher risk of stroke, we agreed I would write a note to his GP, and he would follow-up with his consultant. We agreed that it was important for him to take an anticoagulant but other options could be explored.

The outcome? He came back into the pharmacy shortly afterwards, hugely grateful. Following my note to the GP, she called him a couple of days later and they had agreed he would fully comply with his edoxaban for six weeks after which they would review again. His tummy issues remained about the same and more likely to be down to the number of high protein shakes he was drinking as part of his fitness regime. This patient is now a partner in how he reduces his stroke risk, and much better informed about his options.

More so, he feels more in control.

Patient 2

80 year old male with COPD receiving a Rx for Salbutamol and Beclometasone inhalers and oral prednisolone. It was the double batch (168 tablets) of  rescue oral steroids on his prescription that set off the alarm bells and my curiosity to find out more.

The gentleman was more than happy to spend a few minutes in the consultation room and thought it was marvellous that pharmacists were able to support the NHS in this way. He happily consented to the MUR and off we went. I started with understanding a little bit more about his medical history. He had recently been to an outpatient appointment with the elderly care consultant as Parkinson’s Disease was suspected and he had been given the all clear. His COPD had worsened over the last six months and he was advised by the consultant that his tremors were likely to be caused by the salbutamol inhaler. As a result my patient stopped using it completely.

I asked him to show me how he used his inhaler. His technique was one of the worse I have seen and without going into all the issues here, the result was that he was swallowing rather than inhaling most of the drug. He had been using it every 1-2 hours and so almost certainly experiencing tremor as a result of oropharynx absorption and not getting the drug into the airways to help with his breathing. His inhaled steroid technique was similarly incorrect and he had never been given a spacer. No surprise that he was struggling with his breathing and experiencing side effects. When we went through it together, he was so relieved that he could do something practical for himself that could potentially give him more control over his symptoms. We discussed that his COPD could be getting worse but in the short-term he could get to grips (literally) with his inhaler technique to make the most of the medicines he did have. Truly his technique was so bad, that there must be an improvement!

And then we came onto his oral steroids. He admitted he was confused about these and did not really understand what he should be doing with them. He therefore took them continuously. No break. No steroid card, No protection for osteoporosis. The GPs continued to prescribe, no questions asked. We had a conversation about how this medicine should be taken in the future but how important it was for him to stick with it until he could review with his GP and possibly taper off, without an abrupt stop. He was taking 20mg a day.

And the outcome? On paper, one MUR. In reality, I wrote a note to the GP, the patient has an appointment the following week and instructions to review and potentially decrease oral prednisolone (reserving for exacerbations), a Rx for a spacer and a regular review of inhaler technique. He has promised to come back and see me in a few weeks so I can find how he is doing and to check his inhaler use.

If someone had done this before his referral, he may not have needed to go.

Are MURs worth it?  Ask my patients.

Filed Under: Viewpoint

03/01/2019 By Michael Holden Leave a Comment

Planning for a sustainable 2019 and beyond

Everyone who owns or works in a community pharmacy in England is experiencing a very challenging time, both professionally and commercially. The current funding settlement together with reinstatement of the temporarily postponed Category M overspend recovery, creates further cashflow and profitability issues for many owners, particularly independents.

This is on the back of almost three lost years whilst the judicial review of the previously imposed funding settlement was pursued when we were not asking the right questions of the right people to understand where pharmacy could support the struggling NHS and public health systems.

We have written many times about the need to change the contractual framework and the funding formula to incentivise the right behaviours and reward quality delivery through a fairer system that benefits a few and penalises many. However, this will take time as PSNC seeks to rebuild relationships and trust with the NHS and DHSC.

To support pharmacy contractors, Pharmacy Complete has developed a unique Business Development Programme. Planning for Growth enables owners and their managers to take control of their future by developing and then implementing a robust business development plan.

This course, which builds on our Leadership development programmes and the platform of Healthy Living Pharmacy, provides essential business knowledge, skills and tools at a time when community pharmacy can no longer wait for someone else to create their future business model nor be so dependent on the NHS for profitable income.

We have already successfully run workshops for some forward thinking small groups. Whether you are an independent owner, a small or medium sized group, or an LPC looking to support your contractors, the time to act is here and now.

Connect with us.

Pharmacy Complete – enabling pharmacy for a healthier future

Filed Under: Pharmacy Complete News, Viewpoint Tagged With: Community pharmacy, Future of pharmacy, Healthier future, independent pharmacy, Pharmacy Cuts, Planning, Planning for Growth, Strategic planning

05/11/2018 By Michael Holden Leave a Comment

Prevention better than cure

The Secretary of State for Health and Social Care, Matt Hancock MP, has launched the Government’s vision to help the population live longer. Perhaps the strapline should be ‘live well for longer’, but this is nonetheless very welcomed as is the recognition of the important role of community pharmacy, in particular Healthy Living Pharmacies (HLP), in the plans.

The Mission is to ensure that people can enjoy at least five extra healthy, independent years of life by 2035, while narrowing the gap between the experience of the richest and poorest. This is supported by the long-term funding settlement for the NHS with an extra £20.5 billion a year by the end of the next five years giving the opportunity to radically change the focus of health and social care onto prevention.

The Minister acknowledges that we cannot continue to invest in the same service models of the past and we will not achieve that ambition with ‘business as usual‘. The vision sets out a greater focus, and spending, is needed on prevention, not just cure. With an ageing society and people living with multiple complex conditions it is imperative that this rebalancing happens – to keeping people well, living in the community, and out of hospital for longer. This means services which target the root causes of poor health and promote the health of the whole individual, not just treating single acute illnesses. In practice this requires greater funding for pre-primary, primary and community care – primary care includes community pharmacy.

Healthy Living Pharmacy was designed from the start to change the way a pharmacy operates from a focus on medicines supply and pharmaceutical care to that PLUS proactive health promotion, prevention and protection services. This we have demonstrated can be achieved by those who fully embrace the enablers of an engaged and developed workforce, the right environment, and engaging with, even leading on health and wellbeing in their community. Its a basic business development model – get the right people doing the right things that the market needs (and will pay for) at the right time. HLP is NOT a tick-box exercise to achieve a quality payment, it is that model.

Just as the Government cannot continue to do business as usual, neither can community pharmacy. We must unite behind this opportunity, demonstrate strong and effective leadership, ask the right questions of the right people in health and social care and public health, co-develop solutions, then, once commissioned, deliver consistently high quality and evidenced services across the sector.

Filed Under: Healthy Living Pharmacy News, Media, Pharmacy Complete News, Viewpoint

22/10/2018 By Michael Holden Leave a Comment

Planning for a sustainable future

The announcement of the funding settlement for the remainder of the 2018/19 financial year will not be well received by pharmacy owners in England. That, together with reinstatement of the temporarily postponed Category M overspend recovery, will create further cashflow and sustainability challenges for many owners, particularly independents.

Unfortunately, this was predictable on the back of almost three lost years whilst the judicial review of the previously imposed and poorly implemented funding settlement was pursued rather than asking the right questions of the right people to understand where pharmacy could support the very challenged NHS and public health systems.

We have written many times about the need to change the contractual framework and the funding formula to incentivise the right behaviours and reward quality delivery through a fairer system that is not based on a non-existent average pharmacy that benefits a few and penalises many.

To support pharmacy contractors, Pharmacy Complete has developed a unique Business Development Programme. Planning for Growth enables owners and their managers to take control of their future by developing a robust business plan.

This course, which builds on our Leadership development programmes and the platform of Healthy Living Pharmacy, provides essential business knowledge, skills and tools at a time when community pharmacy can no longer wait for someone else to create their future business model nor be so dependent on the NHS for profitable income.

Pharmacy Complete – enabling pharmacy for a healthier future

Filed Under: Pharmacy Complete News, Viewpoint Tagged With: Business planning, Community pharmacy, Healthy Living Pharmacy, HLP, Leadership, Strategic planning, sustainable

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