Improving access to NHS care by investing in community pharmacy

Transcription

1 Improving access to NHS care by investing in community pharmacy Join in the debate at :

2 2

3 Introduction The NHS has a chronic access problem, linked to ever increasing demand for healthcare. This means that patients sometimes have to wait a long time for advice and treatment. Long waits run counter to modern consumer expectations and can have adverse clinical consequences. Community pharmacy a walk in service located close to where people live, work and shop - must surely be part of the solution. Most people believe that access to care has eroded over recent years i. Average waiting times are going up in primary care ii, meanwhile the nationwide A&E four-hour waiting time target has been missed every year since 2013/14. This is something of a barometer for overall performance of the NHS and social care system, because A&E waiting times can be affected by changing activity and pressures in other services including communitybased care iii. General practitioners have a pivotal position in the health and social care system, performing many vital functions. The Royal College of GPs wants to increase average consultation times in order to give more holistic advice iv. At the same time, many doctors are planning to retire v. Therefore, more capacity for primary care needs to be created than is currently being achieved. One cost effective way to release more capacity into the system would be to develop community pharmacies as neighbourhood health & wellbeing centres vi offering support which encompasses prevention, treatment for common ailments, health surveillance and the routine medicines management of long term conditions, in collaboration with patients GP practices. This in turn would have a positive, unblocking, effect elsewhere in the health and social care system, with each provider and professional group playing to their strengths. This document highlights how, by making more of their clinical skills, community pharmacists can be engaged to transform access to health care. By putting into practice the ideas outlined in this document, the NHS can help to ensure that people get the face to face support they need, when and where they need it, at less overall cost while at the same time reducing pressure on GPs and hospitals. Research commissioned by the National Pharmacy Association vii shows that there will be a considerable knock-on effect to other parts of the health system if access to pharmacies diminishes, under pressure from government funding cuts. Two in five people (41%) said they would go their GP if it became more difficult to access their local pharmacy for the treatment of common conditions. 28% would go to an NHS walk-in centre, call 111 or 999 or visit A&E, putting even more pressure on stretched NHS services. Properly supported, community pharmacy can dramatically improve access to healthcare, face to face and close to home. 3

4 The current level of access to health and wellbeing services in pharmacies Pharmacies already provide a range of NHS and self care services, ensuring that people can get face to face care without an appointment, and taking pressure off GPs and hospitals. Community pharmacies are a highly accessible part of the healthcare system. 89% of the population are within a 20 minute walk of a community pharmacy and opening hours are generally longer than many other settings. There are 1.6 million visits to a community pharmacy every day. That adds up to 14 visits per person per year. Community pharmacists are used to delivering a walk-in service and patients generally have access to the pharmacist within minutes of entering the pharmacy, usually without an appointment. Seven in 10 people (66%) regard face to face advice from a pharmacist or other member of the pharmacy team as very important to them; the importance of face to face advice increases significantly amongst certain key groups of pharmacy users, including carers, older people and parents of young children viii. Community pharmacists are specialists in medicines, but also have a broad training in disease and its prevention and treatment. Pharmacists undergo a minimum five years training before registering as a healthcare professional and then undergo continuing professional development throughout their careers. They operate from conveniently located premises across the UK and are more concentrated in areas of deprivation where the health needs are greatest. Access in deprived areas In 1971, academic Julian Tudor Hart described the inverse relationship between deprivation and healthcare provision, i.e. that those with the highest need for healthcare suffer from the worst access. Deprived areas tend to have a lower ratio of GPs and nurses to patients, and where the ratio is lower it is harder for patients to get appointments ix. In contrast, Todd et al, writing for the British Medical Journal, were able to demonstrate that there are more pharmacies in the most deprived decile x. Distribution of pharmacies by deprivation decile 16% 14% 90% 80% 83% 12% 70% 10% 60% 50% 8% 40% 6% 30% 20% 4% 10% 9% 8% 2% 0% Yes No Do not know 0% 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th It is important to me that a pharmacist is on the premises of my local pharmacy throughout opening hours (Survey of 1003 UK adults, RWB, March 2018) England wide data, 2016 xi 4

5 Improving access to care through community pharmacy: the proposition in a nutshell Only by mobilising the entire healthcare workforce, including community pharmacists and their teams, can there be any prospect of addressing the NHS access challenge on a sustainable basis. The NHS must think more imaginatively about how and where care is delivered, and consider local pharmacies to be people s front door to health. As well as providing convenient, face to face care in the pharmacy setting, a major benefit will be to reduce pressure in general practice, thus increasing the appointment times available to those with the most complex problems and the greatest need in turn addressing congestion elsewhere in the health and social care system. Many general practice appointments concerning minor ailments could be treated effectively elsewhere in NHS primary care. Meanwhile, 8% of emergency department consultations are for minor ailments xii, which would be better suited to self care supported by local pharmacies. In addition, many more medicines-related interventions to manage long term medical conditions could be carried out by community pharmacists in pharmacy consultation rooms xiii. So, these are our aspirations: Our proposition is to dramatically improve access to healthcare, face to face and close to home. We will be able to say to patients: Local pharmacies are your front door to healthy living and the first place to come for healthcare. Come first to pharmacy and you will get advice and support to help yourself, treatment at the pharmacy, or prompt access to treatment elsewhere, by referral from the pharmacist. This is not just about self care and the treatment of minor ailments, vitally important though that is. The idea is to release more capacity into a NHS system that is under very severe strain, by developing community pharmacies as neighbourhood health & wellbeing centres offering support which encompasses prevention, treatment for common ailments, health surveillance and the routine medicines management of long term conditions. 60% 50% 40% 30% 35% 56% For the treatment of minor ailments such as coughs and colds, no-one should have to wait to see a doctor. Instead there should be fewer limitations on the range of NHS treatments that local pharmacists are able to supply, without the patient needing to go to a GP for a prescription. 20% 10% 0% Strongly agree 8% 1% Agree Disagree Strongly disagree For the routine management of their medicines for stable long term conditions, no-one should have to wait to see a doctor. Instead, people should be fully supported in their local pharmacy to understand, review and if necessary modify medicines (within protocols agreed with the wider local healthcare team) NHS medicines review services in pharmacies should be expanded, to help people with long term medical conditions to manage their medicines and to take pressure off GPs. (Survey of 1003 UK adults, RWB, March 2018) For routine health checks such as blood pressure, people in all parts of the country should have an option to access these at local pharmacies. Currently there is only patchy commissioning of health checks in community pharmacies xiv. 5

6 The journey from where we are now to where we need to be It is not an impossible leap to get from the current situation to a situation where it can truly be said that people are able to get the community based care they need, when and where they need it. The community pharmacy infrastructure and skills are fundamentally in place. In some places, these are already being brought into play, as the case studies in this document show. Start using what you have in better ways... 6

7 Accessible medicines management in the community, Sheffield Jaunty Springs Medical Centre is situated in the middle of a post war housing estate in the suburbs of Sheffield. A community pharmacy in the neighbourhood is connected to the GP practice via smart card and N3 connection, enabling the pharmacy to provide a range of co-ordinated services from the pharmacy s consultation room. This includes management & review of repeat prescriptions, delivering structured medication reviews, and professionally led medicines triage. The scheme has saved GP time and significantly improved access to care. Pharmacy First minor ailments scheme, Scotland Nationwide in Scotland there is a Pharmacy First scheme, specifically aimed at reducing unnecessary trips to A&E as well as GPs. Community pharmacists carry out a consultation in the pharmacy with the patient and provide advice and treatment under a locally agreed protocol. The service is available from local community pharmacies both within GP opening hours and out of hours. It allows patients access to treatment for uncomplicated urinary tract infections and impetigo from a community pharmacy. Due to the success of the Pharmacy First Service, Forth Valley has extended the service to include additional common clinical conditions so patients can now access treatment for bacterial conjunctivitis, recurrent vaginal candidas and minor skin conditions. 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 17% 28% 41% 11% How long is it reasonable to have to wait for a non-urgent appointment with a GP to discuss concerns about long-term medicines? (Survey of 1003 UK adults, RWB, March 2018) 2% 24 hours 48 hours 1 week 2 weeks A month Acute triage, Fife Bernadette Brown, owner of Cadham Pharmacy, explains that the episodes of care in her pharmacy can usually be described as consult and complete, rather than the visit to the pharmacy being a staging post to another episode of care. The acute triage offered in our pharmacy is very rewarding it is a great feeling when you can reassure someone they do not need antibiotics, or you treat an asthma exacerbation, UTI, ear infection or psoriasis, for example, without the need to refer to the GP practice. Direct referrals into the NHS, Bristol Old School Pharmacy in Bristol would recognize many of the See You Sooner features in their own pharmacy practice, including independent prescribing, direct referrals into the NHS, and triage for the local surgery when its appointments are almost full. The Superintendent Pharmacist, Jonathan Campbell, has made it his mission to develop a close partnership with the adjoining GPs surgery, beginning in 2011 when the pharmacy gained full access to the EMIS patient medication records. Referrals from NHS111, North East England The North East Urgent Care Community Pharmacy Referral Scheme is a trial which enables NHS111 to refer set groups of patients to community pharmacies in an area covered by 10 clinical commissioning groups and a population of nearly 3 million. Over 300 pharmacies in the region have thereby been brought into the urgent care pathway, bringing into play an extensive network for the assessment, advice and treatment of patients for arrange of low acuity conditions, such as coughs and colds. Patients are clinically assessed in pharmacy consultation rooms rather than urgent care centres. The pharmacy receives electronic notification that a patient has been referred and will follow up with the patient if they do not attend the pharmacy within 12 hours of referral. As of December 31, 2017, around 60 per cent of callers who were referred attended pharmacies and of these: 39 per cent received advice and an over the counter medicine, 22 per cent received advice only, 18 per cent were escalated for in hours GP appointments and 11 per cent were escalated to attend outof-hours appointment/walk-in centres. Independent prescribing, Barrow-in-Furness As part of the Minor Ailments Scheme commissioned by Cumbria CCG, community pharmacist Paul Blake has been trained as an independent prescriber and given a prescribing budget, allowing him to improve access to health care in his community. Referrals usually come from the adjacent surgery, with whom Paul has worked closely for over 15 years, but can come from other local surgeries and even the out of hours GP service. Access to both his own prescription pad and the patient s full medical records means Paul can make sure his patients can get the treatment they need for a whole host of symptoms there and then. 7

8 Lewisham Community Pharmacy Health Checks The London Borough of Lewisham started using pharmacies to deliver NHS Health Checks from the start of their programme in By March 2015, a quarter of all the checks carried out were delivered via the 17 pharmacies signed up to the programme. Pharmacy staff have direct access to a secure webbased recording system which allows them to check eligibility and transfer the results securely to the patient s GP practice. An evaluation showed that the pharmacy service was effective at engaging people from deprived communities. According to the local Cardiovascular Prevention Programme Manager, it is about giving people greater access. One of the great benefits of the pharmacy is that people can have the NHS Health Checks done in the evenings and at weekends. The ability to assess, consult and complete By more treatments and other interventions being available in pharmacies, pharmacy would less often be a staging post, and more often the one stop shop for support, thereby being more convenient for service users. Therefore, minor ailments schemes (MAS) should be in place across the country, so that people can get NHS treatments for coughs and colds and other self limiting conditions from pharmacies without the need for a doctor to issue a prescription. Data collected from nearly two million patient consultations in local schemes showed that 87% of patients would have gone to their GP if MAS was not available. In 98% of consultations no onward referral to other NHS providers was necessary xv. Thinking more radically, we should move much further on pharmacist independent prescribing, to create a more convenient service for patients and make fuller use of the clinical skills of the pharmacist. In addition, diagnostic tests such as blood pressure monitoring should become common place in pharmacies. Based on the results, the pharmacy would either make the necessary intervention themselves, or refer appropriately. This happens routinely in Canada, where community pharmacists in Alberta province are able to optimise their clinical skills. A Summary Care Record pilot that ended in March 2015 showed that in 92% of encounters where the SCR was accessed, the pharmacist avoided the need to signpost the patient to other NHS care settings. In 82% of encounters where SCR was accessed, the pharmacist indicated that overall waiting time was reduced and 90% of patient respondents agree that treatment is quicker if pharmacists have access to SCR xvi. Public awareness In line with the developments in pharmacy practice, there will need to be an evolution in public understanding of how and where care is delivered. Patients will need to feel certain that if they go first to pharmacy their needs will be addressed in every instance in the form of advice, treatment and/or prompt onward referral. Funding Ultimately, this approach has the potential to create huge cost savings by moving more episodes of care closer to home and encouraging appropriate use of NHS services. Nevertheless, it must be clearly understood that community pharmacy requires a sustainable funding settlement now, if it is to make the necessary investments for the long term. Initially, monies from the Pharmacy Integration Programme should be used to develop accessible care in the community pharmacy setting. Since NHS England has invested heavily in the general practice pharmacist scheme, there is surely a strong justification for investment in community pharmacy based schemes which deliver similar benefits but can cater for many more patients, conveniently and probably at lower cost xvii. Better integration including formal referrals People would be encouraged to come first to pharmacy if signposting from pharmacies more frequently took the form of a formal referral, embedded in NHS care pathways. Other mechanisms for communication between all parts of the system also need to be optimized, in particular pharmacists having read & write access to patient care records. 8

9 Canada an example of a journey to more accessible healthcare With the success of an effective, pharmacy led hypertension service, the general acceptance in Canada of pharmacy undertaking clinical services has increased. In only a decade, clinical services across a wide range of conditions are finding a home in community pharmacy and patients are benefiting greatly as a result PHARMACISTS SCOPE OF PRACTICE IN CANADA Not completed Renew/extend prescriptions BC AB SK MB ON QC NB NS PEI NL NWT YT NU Change drug dosage/formulation Make therapeutic substitution Prescribe for minor ailments/conditions Initiate drug therapy independently Order and interpret lab tests Administer a drug injection 2017 PHARMACISTS SCOPE OF PRACTICE IN CANADA Implemented in jurisdiction Pending legislation, regulation or policy for implementation Implemented with limitations Not completed Renew/extend prescriptions BC AB SK MB ON QC NB NS PEI NL NWT YT NU Change drug dosage/formulation Make therapeutic substitution Prescribe for minor ailments/conditions Initiate drug therapy independently Order and interpret lab tests Administer a drug injection 9

10 Policy and practice proposals what are your views? We invite the views of patients, pharmacists, GPs and other healthcare professionals on our access proposition in general and the following specific proposals: 1. Pharmacist independent prescribing should become common place in community pharmacies, so that people can enjoy a more convenient service in respect of health maintenance and the management of long term conditions, as well as acute care. 2. More NHS services and interventions should be available in community pharmacies, to provide choice and convenience and reach parts of the population that may otherwise go without the support they need. For example: The NHS Health Check (which includes a test for high blood pressure) should be widely available in pharmacies. Currently about 30% of local authorities in England commission community pharmacies to provide the NHS Health Check xviii. NHS medicines optimisation services in pharmacies should be expanded, to help people with long term medical conditions to manage their medicines and to take pressure off GPs 3. Initiatives to allow pharmacists read and write access to patient records (with the patient s permission) should be stepped up - to give people the assurance that wherever they access primary care, their experience will be safe and seamless. 5. People in all parts of the UK should be able to get NHS treatments for coughs and colds and other common ailments from pharmacies, without the need to visit a GP for a prescription. England is currently the only part of the UK without a nationwide scheme. 6. Community pharmacy requires a sustainable funding settlement, if it is to make the long term investments necessary to improve access to NHS care. 7. The NHS Constitution should be updated to include guarantees of timely face to face access in primary care. Currently, the access pledges in the Constitution relate to emergency care or interventions that follow referral to hospital specialists it currently has little to say about timely access to healthcare provided in the community. Please send your remarks to independentsvoice@npa.co.uk 4. Regulations should continue to guarantee that a pharmacist is available at all times on the registered pharmacy premises, to oversee safe supply of medicines and provide clinical advice. 10

11 i Survey of 1003 adults, commissioned by the National Pharmacy Association, RWB, March 2018 ii NHS England (2017) GP Patient Survey. The number waiting at least a week to see their GP has risen by a half in five years, with one in five now waiting this long; while most people say that their appointments are convenient, that proportion has been dropping since at least In 2017, 29% of people were unable to see a doctor or nurse in primary care at a time they wanted or sooner. iii What s going on with A&E waiting times? The King s Fund, iv v In her opening speech at the 11th RCGP annual primary care conference Prof. Helen Stokes-Lampard called for holistic consultations with patients and not the current tick-box consultation. An investigation by Pulse Magazine Feb per cent of GPs who retired in 2016/17 did so before the age of 60 - having made up just 33 per cent of cases in 2011/12. vi Community Pharmacy Forward View, Pharmacy Voice 2015 vi Establishing the value of Community Pharmacy, base of 2001 consumers, Quadrangle, February 2016 vii Establishing the value of Community Pharmacy, base of 2001 consumers, Quadrangle Feb 2016 viii Stocktake of access to general practice in England, National Audit Office 2015 x xi The positive pharmacy care law: an area-level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ, Todd et al. Analysis conducted by EBI Solutions (University of Warwick) for the National Pharmacy Association, based on an England side dataset 2016 xii Community Pharmacy Management of Long Term Conditions (MINA Study), Pharmacy Research UK 2014 xiii xiv xv xvi xvii Draft report of medicines management pilot at Jaunty Springs Medical Centre Sheffield, April 2017, Garry Myers and James Roach A cross-sectional study using FOI requests to evaluate variation in local authority commissioning of community pharmacy public health services in England. BMJ Open July 2017 PSNC Briefing 044/17, Jan Based on PharmOutcomes data from 74 schemes including 1,722,230 patient consultations Draft report of medicines management pilot at Jaunty Springs Medical Centre Sheffield, April 2017, Garry Myers and James Roach xviii Tackling High Blood Pressure Through Community Pharmacy, Pharmacy Voice

12 Join in the debate at : 12