Pharmacy in 2020: Director s View

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1 In 2020: Grampian now has fewer community pharmacies than in The move to capitation based payments allied to the transfer of planning responsibility for pharmacy contracts to NHS Boards has led to a reduction in urban pharmacies which have amalgamated into multi pharmacist practices, sharing premises and support staff. This amalgamation has seen further investment in premises to support new models of working. Pharmacy services are now designed around the clinical care pathways and the historical separation of secondary care and community pharmacy services have been completely blurred. Community pharmacy services are now fully integrated into the cluster planning and operational management that was introduced in Almost all patients in Grampian now have a single pharmacy to which they are registered for services. Whilst patients are still free to move registration between pharmacies, registration for pharmacy services has helped to build stronger relationships between patients and their pharmacies. All patients with chronic diseases, requiring repeat prescription, are now registered with a pharmacy of their choice for the Chronic Medication Service (CMS). The vast majority of patients with stable chronic disease now receive their repeat prescriptions via the serial dispensing service. This has freed up time for GPs and is more convenient for patients with chronic diseases. Community pharmacy has retaken its role as the primary source of medicines information to the general public. Callers to NHS 24 are now directed to their registered pharmacy for medicines related advice, and treatment about minor ailments and self limiting illnesses. The community pharmacist role has become increasingly clinically focussed with a much greater emphasis on supporting patients to get the best from their medicines through counselling, support and medicines review. Multi pharmacist practice has allowed some pharmacy services to be delivered away from the pharmacy premises to support those patients who are housebound or in supported care environments. The integration of health and social care has led to community pharmacy taking a greater role in supporting medicines taking through the use of carers (formal and informal) and pharmacy outreach services. The majority of community pharmacists are now trained, qualified and registered as independent prescribers. This has led to a model of practice of CMS Plus whereby the pharmacist working in partnership with the general practitioner prescribes for selected patients. These pharmacists can also prescribe prescription only medicines for minor ailments and self limiting illness. In some areas of Grampian the growth in independent prescribing within community pharmacy has been used to enhance general medical services and specialist services provision. CHP clusters have developed and commissioned local models of pharmacist led clinics in sexual health, substance misuse, COPD, diabetes and travel health. Community pharmacists are now seen as a core part of the care team; i.e. are part of the multidisciplinary team that plans, delivers and reviews care for patients.

2 Community pharmacies and their services are now fully integrated into local health and social care provision with established signposting and referral pathways both to and from community pharmacy. This integration has been facilitated by shared access to an integrated electronic health record. Community pharmacists now work much more closely with their specialist pharmacist colleagues. Historically these acute service clinical pharmacists worked solely within the hospital setting but since 2012 they have increasingly followed the patient in their use of complex therapies and in support of transfer of care provision between settings in the community and hospital. Community pharmacists are now responsible for the planning and facilitation of the medication aspects of admission and discharge for planned care. Electronic transfer of information between settings now allows real time medicines information to be shared and virtual case planning meetings to take place between health professionals in different settings. Specialist pharmacist s roles in the hospital service have now changed to support more complex care and to provide the population level actions needed to safely provide care within the new models of care that have emerged. This has been facilitated by the restructuring of the then hospital pharmacy service that started in 2012/13 which saw enhanced roles for technical and support staff and the wider use of technology within Grampian hospitals. Community pharmacy has embraced new technology. Supporting patients medicine taking has been helped by the use of mobile application technology to remind patients on when to take medicines, visual reminders of what medicines look like, bar code recognition to reduce the risk of taking the wrong medicine and on line videos of how best to take them. Patients with chronic diseases have become much more expert in their own self care. As part of this they have embraced the availability of mobile monitoring equipment. Patients now routinely download electronic monitoring information such as blood glucose, lung function, blood pressure and their medicine compliance and discuss the results of these with their pharmacists. At a population level dispensing volumes in primary care have continued to grow, although at an individual patient level they have begun to stabilise. Growth has been driven by population growth and demographic change, technological advance and the explicit policy of moving care appropriately from secondary care to primary care. Following on from the early work in community supply of imatinib in 2012 Grampian was at the forefront of a new model of shared care with specialist prescription and community supply. Up until 2012 this supply, was in the main, provided by third party homecare providers but since 2012 there has been a move to use community pharmacies. This move has helped the maintenance of single patient pharmacy medication records for patients, facilitated the clinical activity undertaken by community pharmacists and provided greater assurance in terms of governance arrangements and sustainability over the homecare model previously relied upon. Dispensing functions are now largely automated with extensive use of robots. Community pharmacies have formed dispensing cooperatives whereby remote, robotised dispensing of repeat prescriptions at dispensing hubs for just in time delivery to patient s homes and pharmacies are the norm. Manual dispensing within pharmacies is now limited to acute prescriptions from a local acute formulary. This dispensing is managed by trained, accredited checking technicians.

3 Telemedicine has also made out of hours consultations possible with access to medicines via automated cabinets (originally trialled in ARI in 2012) from a number of pharmacies across Grampian. This has eased pressure on other unscheduled care services whilst improving access for patients. The pharmacy based minor injuries clinic, first piloted in Aberdeen City, has now been rolled out across Grampian to a number of sites in line with local primary care plans. As registration for community pharmacy services has become the norm there has been a greater focus on the use of community pharmacies as sites for other health services and interventions. The ability to profile the population of the community pharmacy, through its registration database, has meant that the needs of people who use the pharmacy are much better understood than in Most pharmacies now have a dedicated space for other members of the health and social care team to use following the continued move away from retail activity in favour of an increased focus on clinical and health improvement activity. In 2020 the Pharmacy Assistant role is focused on provision of advice on minor ailments and general health and medicines advice. Most assistants are also now trained practitioners in health promotion. This training provided and recognised by Grampian means that in each pharmacy there are staff accredited to provide advice and ongoing support for lifestyle behaviour change. This role change, stimulated by the successes in smoking cessation, fuelled by the ability to profile a pharmacy population health needs was realised through the recognition that step change was needed in health behaviour in Grampian to prevent ill health in the future. Pharmacy is now a key element of the obesity and alcohol pathways. The role change has been a success and the role of these peer educators is valued as they operate within the pharmacy and the wider community in which they work and live. By 2020 the Pharmacy Technician role has developed in scope and depth. On the supply side the separation of the clinical check and supply function means technicians are now able to manage the entire dispensing process including accuracy checking. On the clinical side the number of technicians with clinical qualifications and working within clinical roles has increased dramatically since In hospital and community they are now routinely involved in supported care settings, community hospitals and in acute wards where they undertake clinical roles in support of the pharmacist role. They have also taken on some of the traditional Practice Pharmacist role supporting efficient prescribing. The concept of a light touch hospital pharmacy service was introduced in 2012 and adopted in In essence light touch meant that within the hospital itself the focus was on managing the presenting condition that meant the patient was in hospital and managing any significant (harmful) pharmaceutical care issues. Other issues were dealt with through discussion and dialogue with the primary care colleagues. In 2020 the term light touch is no longer used as the principles of care that it espoused are integrated within clinical pathway design. Following successful pilots of new shared care arrangements between hospital prescribers and community pharmacists in 2012 Grampian moved much of its hospital outpatient and discharge dispensing to the community.

4 The introduction of HEPMA in 2014 and the integration of the Grampian HEPMA with primary care prescribing systems in 2016 meant that hospital prescriptions can be electronically transferred to primary care, along with supporting records and summaries in real time. HEPMA allied to the use of short range radio frequency tagging of all medicines within the hospital environment has improved efficiency and safety. HEPMA, allied to universal application of medicines reconciliation on admission, has allowed all patients within secondary care to be categorised on the basis of pharmaceutical risk. This categorisation, trialled in Ayrshire and Arran in 2012, has been used to help identify patients most at risk of pharmaceutical harm and ensure that these patients are prioritised in terms of receiving support and intervention. In 2020 treatments seen as complex and novel in 2012 are now delivered within the community, by community pharmacy with support and direct input from hospital specialist pharmacist colleagues. Community pharmacy now provides not only simple supply of medicines but also services to support the administration of medicines. Distribution of medicines from hospital is now automated. In 2015 Grampian took the decision to automate pharmacy stores introducing an Amazon style picking system that allows distribution to operate 24 hours a day. By 2020 a regional review of Pharmacy Technical Services has been completed. Whilst outsourcing has been maximised the NOSPG needs assessment demonstrated that a single regional centre was still required. Plans are at a late stage for a new regional Radiopharmacy and Aseptic Manufacturing Unit to be built at Foresterhill serving the North of Scotland. In 2020, the use of technology means that validated medicines reconciliation information is available for almost all patients. HEPMA provides initial decision support function for junior doctors and new prescribers. Review and amendment to clinical management plans can be completed just as easily remotely as at the bedside. The efficiencies provided by new technology have allowed the clinical pharmacists of 2012 to develop to be the pharmacotherapists of These pharmacists recognised as advanced practitioners within their speciality and awarded Consultant grade in Scotland, work alongside medical colleagues to plan the pharmaceutical treatment of patients. Whilst all are prescribers themselves they mainly lead the pharmacotherapy delivered by other staff, be they medical, physicians assistants, and nursing or basic grade pharmacists. Medicines use in hospital in 2020 has continued to become more complex, both in terms of the treatments available, conditions treatable and risk of adverse events related to concomitant use of other medicines. Use of genetic markers to offer more individually targeted treatments is now much more common. The electronic health record allied to easy and dependable access to secure IT communications has revolutionised joint working within pharmacy and across the professions. Virtual care planning meetings have become the norm for more complex care and patient review. This has been facilitated by all community pharmacies using a single IT system interfacing with NHS systems and widespread access to secure mobile computing via the Grampian Cloud.

5 As community pharmacist roles have developed, the need for the role performed by the practice pharmacist in 2012 has changed. In 2020 they are more focussed on working with GPs to support patients with unstable clinical conditions and in the community hospitals and intermediate care settings. A number have also been transferred to work in the ECC with a focus on A&E and short stay, where their generalist pharmaceutical knowledge and intimate understanding of primary and social care has been beneficial in ensuring that the ECC has operated as planned from its opening in In 2020 Pharmacy is fulfilling its potential. Patients know what their pharmacy service can do for them and how to make the most of the service; patients know the name of their pharmacist and recognise the roles of other staff in the service; patients value Pharmacy s input to their chronic care and the support provided to improve their health.

6 Pharmacy 2020 Vignettes 1. Planned Care at the interface Anne Jones has had a hip replacement and has just come out of hospital. Before going in for her operation Anne met with her community pharmacist with whom she is registered for services. Her pharmacist, Jane, did a full medicines review as part of her pre-admission assessment and even spoke to her hospital pharmacist to discuss whether one of her medicines should be stopped before the operation. The operation went well and Jane knew exactly when Anne was to be discharged and what medicines she needed. When Anne had her other hip done she left hospital with a bag of medicines but this time her medicines are waiting for her at home. Anne really appreciated the call from her pharmacist Jane to make sure she had everything she needed and understood how to take her medicines. Anne really appreciated the call a few days later to make sure her pain was controlled. Anne reflected on how things had changed over the years. Her mother, 93, had recently had a spell in the local community hospital where she was receiving chemotherapy for her oesophageal cancer. It was wonderful that the treatment could be given so close to home and even better that her GP and Jane the pharmacist were still looking after her. It was really good to see the hospital specialists coming to the local hospital instead of the other way around. Jane and the oncology pharmacist, Judith, had made sure that Anne s mother s treatment went well and that her side effects were controlled. When her mother was discharged it was all managed so smoothly, everyone really knew what they were doing and best of all Anne s mother was dealing with familiar faces. 2. Chronic Disease Tom was diagnosed with COPD a few months ago and once his disease was deemed stable he was moved into the chronic medication service at his local pharmacy. Tom s doctor had explained that now that his condition was stable the local pharmacy would take over the repeat dispensing of his medicines. He also said that as Malcolm was one of the new breed of community pharmacists who could also prescribe, that it would be Malcolm who would manage Tom s care from now on. The Doctor reassured Tom that Malcolm and he had worked closely for some time, that the doctor trusted Malcolm and often worked together to help patients. Malcolm would work within the local guidance for managing COPD and that He and Malcolm would have regular case reviews to make sure everything was progressing as planned. Tom wasn t sure at first as he d grown up thinking of the chemist as somewhere just to get your pills and the toiletries you d forgotten to buy at the supermarket. Tom s view changed at his first meeting with Malcolm, his community pharmacist. When he got there he asked to see the pharmacist and was asked which one. Even the local pharmacy now had more than one pharmacist. Tom was ushered into the consultation room where Malcolm introduced himself and explained how care for Tom would be provided. He made sure Tom knew how

7 to use his inhalers and other medicines which was just as well as Tom wasn t quite getting one of his inhalers right. A few months on and Tom is very happy with the care he is receiving. He appreciates the convenience of the serial dispensing service, has been surprised at just how much Malcolm, his pharmacist, knows about the medicines and COPD treatment and really likes the way the roles of the GP and the pharmacist are complementing each other. Best of all Tom s COPD is still stable, he feels in control of his condition and he knows who to turn to if he needs help or his condition changes.

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