Ross Carroll, Mike Hewitson and Stuart Carroll: Don’t forget pharmacists Mr. Lansley – your “new NHS” needs them

Ross Carroll is a member of the Bow Group Health Policy Committee and a public policy manager.  Mike Hewitson is a member of the Bow Group Health Policy Committee and a qualified pharmacist and community pharmacist contractor. Stuart Carroll is a senior health economist and chairman of the Bow Group Health Committee. Here they summarise the research paper they have written for the Bow Group looking at the role of enhanced pharmacy services in the “new NHS”, which is published today and can be downloaded from the Bow Group website.

Despite the Coalition Government’s pledge to ring-fence the healthcare budget, the NHS is facing sustained financial retrenchment and increased user demand.  Against the backdrop of the UK’s parlous public finances, it is vital all aspects of healthcare are examined to assess where increased value and quality can be delivered with greater cost-effectiveness.  This is especially critical since Andrew Lansley has rightfully placed patient health outcomes at the heart of Government reforms; a pressing imperative given rising public health challenges and an aging population predisposed to long-term conditions (LTCs).

The conclusions drawn from our research paper show that Enhanced Pharmacy Services, which include smoking cessation, sexual health and weight loss programmes, are an under-utilised resource that can deliver innovative, cost-effective services to patients in a highly accessible manner.  Moreover, such services can help the NHS achieve its Quality, Innovation, Productivity and Prevention (QIPP) objectives.

For example, it is estimated annually that 57 million GP consultations concern minor ailments, which in large could be dealt with at a pharmacy.  The average cost of a pharmacy consultation (£17.75) versus an average GP consultation (£32) is £14.25 less expensive.  If all patients with minor ailments received pharmacy consultations, then over £812 million could potentially be saved from the NHS budget equating to over 4% of the Government’s pledged £20 billion efficiency savings target. 

Of course, pharmacy services must complement General Practice, but with GPs confronting increased workloads – something set to intensify given GP commissioning – and patients experiencing appointment delays, policymakers need to find new and innovative ways to unburden GPs to free-up time to treat patients with more critical and complex medical conditions.

Accessibility to healthcare is now evermore important with people leading increasingly busy and time-pressured lives.  Furthermore, over the last 10 years health inequalities – now worse than in Victorian times and something the Prime Minister has personally described as “unacceptable” – have significantly increased, with many “hard to reach groups” experiencing declining health outcomes. 

Pharmacies are at the heart of local communities and, importantly, do not require formal appointments to access professional expertise.  99% of the population can reach a pharmacy within 20 minutes by car; 96% can do so by walking or using public transport.  Consistent with Government priorities, this great accessibility offers major advantages for implementing patient-centred services around the needs of local populations.  It is also an imperative as the Government seeks a more preventative NHS, predicated on an “information revolution” to better inform and empower patients regarding healthcare choices, as most notably exemplified by its commitment to introduce a new Public Health Service by 2012.  Pharmacists have a key role in delivering this policy imperative.

Whilst enhanced services continue to evolve and develop, medicines management remains a more traditional role of pharmacy. However, its importance is likely to increase with population ageing.  Also, as LTC prevalence appreciates medication use will increase. It is reported that 30-50% of patients fail to take their medications correctly, whilst hospital admissions costs resulting from incorrect medicine usage could be up to nearly £200 million a year; an increasing cost as medicinal demands intensify.  The Government’s policy that hospitals will be charged for related patient readmissions occurring within 30 days of discharge means Medicine Use Reviews (MURs) should be regularly conducted before and after planned hospital admissions, particularly for patients with LTCs, to limit the effects of modifications to patient medication regimens at the care interface.

Despite some excellent outcomes from Pharmacy Enhanced Services in parts of the country, commissioning of Enhanced Services is patchy and lacks universality.  There are a number of possible reasons: 1) poor measurement and capture of outcomes from pharmacy contractors; 2) a lack of understanding from commissioners; 3) uncompetitive reimbursement rates; and 4) a perception that GPs influence/preferences dominate local decisions. The profession itself therefore needs to improve its ability to capture and measure service outcomes as commissioners are unlikely to commission services where outcomes data are minimal. Sustained efforts to improve GP/pharmacist relationships is also critical to foster opportunities for closer joint working. To this extent, local pharmacists should have representation within local GP consortia and local Health and Wellbeing Boards to help optimise the integration of patient care.

Policymakers also need to analyse current reimbursement and pricing mechanisms for Enhanced Services.  The current funding mechanism encourages pharmacy contractors to obtain the best price for the purchased NHS medicines, and in return contractors can retain some of these savings.  Anything in excess of the agreed cap goes to the Department of Health (DH).  In essence, these are additional windfall savings to the taxpayer generated through the hard work of pharmacy contractors. Given the persistence of sub-optimal Enhanced Services commissioning, we propose an innovative solution – all these savings are retained within pharmacy through the establishment of an “Enhanced Pharmacy Service Innovation Fund”.  This fund would sit with an expert/professional body outside of the DH – free from political interference – serving to enable easier, evidenced-based commissioning of Pharmacy Enhanced Services.

A pharmacy Quality and Outcomes Framework (QOF) is something the Government should develop.  Despite important issues on the implementation side, not least handling transitory patient populations, there is strong rationale for a pharmacy QOF complementing the existing GP framework.  This would help incentivise local pharmacies to improve quality per patient needs, demanding a focus on outcomes that would necessitate improved measurement and data capture to optimise service deliverability.

If the Government is to achieve its stated objectives of a genuinely patient-centric service; a community-orientated health service; improved health outcomes; and a more affordable NHS, it is imperative the skills and expertise of all healthcare professionals are fully optimised and utilised.  For too long, politicians on all sides have caricatured the NHS as being a service of “doctors and nurses”.  Virtually all major political speeches on the NHS since 1948 show as much.  Despite the excellent work of most doctors and nurses, the NHS is a multi-disciplinary service spanning beyond two professions.  All other professions must be valued and optimised if the NHS is to maximise its lot.

As our research shows, in some areas pharmacists – as accessible frontline healthcare professionals – are making a valuable and telling contribution to achieving these objectives. By addressing the above issues, there is significant scope for this contribution to be further enhanced, which would in turn help to improve accessibility, patient choice and health outcomes.  We hope in the “new era of politics” with a “new kind of Government”, our health representatives take note.