1.1 This written submission is provided by the Suffolk and North East Essex Integrated Care Board (SNEE ICB) to inform the Health and Social Care Committee’s Independent Expert Panel in their evaluation of the Government’s commitments in the area of pharmacy in England.
1.2 For each of the five policy areas, the response is provided mindful of the following key questions set by the Panel:
- Was the commitment met overall? or (in the case of a commitment whose deadline has not yet been reached)
- Is the commitment on track to be met?
- Was the commitment effectively funded (or resourced)?
- Did the commitment achieve a positive impact for patients and service users?
- Was it an appropriate commitment?
1.3 The SNEE ICB plans and buys healthcare services for our population. This function is commonly referred to as ‘commissioning’. To do this, we work within a budget of around £1.5 billion, which is set by NHS England, and work closely with local government and the NHS providers in our area. Our performance is judged by how well our local health and care system as a whole is working, including the health outcomes of our communities.
1.4 The ICB has delegated some authority to the three health and wellbeing alliances that operate in Suffolk and north east Essex to act on its behalf. This is to ensure that the needs of smaller, local areas are addressed. The ICB remains accountable for all of its functions, including those it has delegated. Local residents have a big role to play in the operation of the ICB. We rely on the experiences and perspectives of our communities to help shape our decision-making.
The Pharmacy Access Scheme has been created to support patient access to community pharmacy in remote areas, where dispensing volume may be low. A revised version of PhAS was started in January 2022 based on updated market conditions, resulting in larger volume dispensing pharmacies receiving lower PhAS payment. The PhAS criteria are fixed nationally and eligible pharmacies to automatically receive payment. PhAS only takes account of dispensing activity & distance from other pharmacies: it does not account for other pharmacy services which arguably undermines the drive towards greater service provision.
The COVID-19 pandemic demonstrated the innovation, agility, capacity and capability that the community pharmacy network can bring to communities and the NHS. Under the PhAS, there is currently no mechanism for local (ICB) knowledge to inform eligibility to include, for example, a pharmacy located within an underserved population or an area of health inequalities. The financial difficulties experienced by community pharmacy contractors has resulted in sustained reductions to supplementary hours and/or closures. We are particularly concerned about the financial attrition leading to closures of pharmacies in areas of deprivation. Total PhAS funding is fixed and comes from the global sum for community pharmacy. It would appear that, due to increasing operating costs, the current PhAS payments are insufficient to maintain the viability of the pharmacies. In order to assess the success of PhAS, it would be beneficial to see evidence if the revised scheme has reduced the volume of closures or reductions in supplementary hours for eligible pharmacies. We are mindful that, under the current system, an increase to PhAS payments would further reduce the global sum with consequential reductions to remunerations to the Single Activity Fee for already financially challenged contractors.
In principle, the Community Pharmacy Contractual Framework (CPCF) model to encourage greater service delivery is welcomed by all stakeholders. The challenge has been that the funding envelope that was agreed at the start of the 5-year term has not been revised or uplifted in light of significant unforeseen increases/challenges for contractors, e.g. inflation rates, impact of pandemic, cost of living increases, workforce crisis, business rates, etc. This translates to a real term 30% reduction in funding for the network since 2018. The Pharmaceutical Services Negotiating Committee (PSNC) reports that the Single Activity Fee no longer adequately funds contractors for the costs involved in medicines supply; a service which remains critical to patients, the NHS and the community pharmacy business model. We are observing sustained reductions to supplementary hours to reduce costs and the number of pharmacies permanently closing is accelerating, creating less access to pharmacy services during ‘extended’ hours.
Greater service delivery has been delivered by many pharmacies but has been enabled by reductions to core income for pharmacy operations. However, a concern for the ICB is that this trend now appears to be reversing as pharmacy contractors try to maintain the viability of their core provision against increasing financial pressures, resulting in many disengaging with new services. A recent example is the transition of the Oral Contraception Management Service (OCMS) pilot to a national Advanced Service: funding for the service has moved from the Pharmacy Integration Fund to core (global sum) funding. Contractors who had participated in the pilot service are ceasing provision and not offering the OCMS due to concerns of the financial impact of further dilution to core funding.
Financial and regulatory constraints have prevented many pharmacy contractors from engaging with automation and hub/spoke models for dispensing (implicit with the CPCF proposal) which might otherwise have supported financial and operational efficiencies. However, recent changes to the VAT status for services delivered by (non-pharmacist) pharmacy staff are welcome and should enable a greater contribution from the wider team, notwithstanding the financial balance between services and dispensing under the current funding model.
The creation of Additional Roles Reimbursement Scheme (ARRS) roles has undoubtedly created much needed additional capacity for primary care, creating a broader skill-mix of healthcare professionals within general practice. It has however had unforeseen adverse consequences on the stability of the hospital pharmacy and community pharmacy workforce with large numbers of registered pharmacy professionals moving into Primary Care Networks (PCN) or General Practice (GP) pharmacy roles. This has resulted in a shortage of these professionals within NHS Hospital Trusts (Trusts including acute and mental health NHS organisations (Trusts)) and community pharmacies with resultant supply-demand consequences of unsustainable rates of pay, low availability of pharmacy professionals to deliver pharmacy services and temporary pharmacy closures.
To achieve the aims of the Fuller Stocktake, integration needs to go further and be enabled by the necessary regulatory and financial levers. Contractual arrangements and funding streams for different healthcare professionals within primary care are not sufficiently aligned which maintains an element of competition to the detriment of effective collaboration.
Commitment 1
Following a phased roll-out, the Community Pharmacist Consultation Service (CPCS) will include referrals from the three care sectors - NHS 111, GPS and A&E. The initial service was launched through NHS 111 using a national IT platform and can be split into two domains; urgent medication requests and minor illness consultations. Overall, this service is an effective service for patients and the local health system. It is likely that the algorithm used to risk stratify and identify potentially suitable patients for referral to community pharmacy has greatly contributed to the success of the service. Such an algorithm does not exist for GP CPCS and it is probable that this has resulted in higher numbers of patients referred out of pharmacy into other care settings. Delegation of commissioning of community pharmacy to ICBs will facilitate further integration and collaboration between NHS 111 and our pharmacy network. The decision to move from a single IT platform to a ‘provider pays’ model has reduced the visibility of the service which is a missed opportunity and represents a backwards step for better digital integration.
Referrals from General Practice and A&E should include minor illness only (not urgent supplies). GP CPCS has been less successful nationally and locally, with only small pockets of practices utilising the service in significant numbers. The referral process is not well integrated into general practice operations/software and the lack of integration with community pharmacy operations and IT is mirrored. Local feedback continually highlights the barriers inherent with this service to the potential that could otherwise be realised within primary care with community pharmacy as an appropriate destination for minor illness. A service designed around the value of the consultation as opposed to the requirement for external referral into the pathway would deliver greater patient/stakeholder benefit and efficiency. ICBs have a responsibility to design (or redesign) and commission health and social care services centred on local need. ICBs now receive delegated funding to commission local services but with national constraints on how the funding can be used. In the absence of local flexibility, we potentially have integrated services without the necessary integrated commissioning.
CPCS is not linked to a national NHS minor illness service: patients unwilling or unable to afford over the counter (OTC) medications are likely to go without treatment or divert into general practice to obtain a prescription. This patient pathway has not been optimised and could lead to widening health inequalities. We welcome the recent NHS England (NHSE) announcement to enable community pharmacies to treat various minor illness (via national PGDs) without the requirement for a directed referral from another healthcare setting. Similarly, the potential to expand the scope of the minor illness pathway to include community pharmacists as NHS independent prescribers would further improve access and maximise the multidisciplinary skills of the healthcare workforce.
Commitment 2
Discharge Medicines Service (DMS) forms an important element of the transfer of care process from hospital to community care. It is an essential service and therefore must be provided by all pharmacy contractors.
Prior to the launch of DMS, various local systems were in place to inform community pharmacies of medication changes for specific patients, effectively meaning a change to a resource that was already in use by Trusts. Discharge information to pharmacies would predominantly be sent to communicate changes of medication for patients using compliance aids and rarely used for other patient groups. The discharge info would be limited to include only the revised list of medications at discharge. There would be no narrative around the admission/discharge and more detailed information on changes to medications (stopped/started/increased/decreased, etc) would be absent.
West Suffolk NHS Foundation Trust (WSFT) has e-prescribing capabilities which has made it easier to integrate a referral with DMS. This has not been as easy in other hospitals. Trusts also needed to design a consent process for patients to utilise the DMS – this is further complicated by how the patient presents to hospital. In addition, any IT enablement to support DMS needs to be funded by Trusts.
For the vast majority, the DMS has continued to be used for the same patient cohort and hitherto, most referrals have been sent to pharmacies who need to know about medication changes (e.g. patients using compliance aids). We are currently exploring the capacity to expand these criteria to include other patient groups (e.g. patients on high risk medicines, or those with specific long term conditions requiring Direct Oral Anticoagulants (DOACs). The hospital pharmacy department vacancy rate is limiting the ability to expand the scope of DMS and to increase the volume of referrals. As a system, DMS is viewed positively as an improved patient safety pathway to communicate across the hospital/community pharmacy interface.
DMS, within the hospital setting, is seen as a pharmacy task and does not integrate other healthcare professionals into supporting the referral. It is unlikely this view is to change due to workforce shortages throughout all disciplines. However, patients who may be suitable for DMS may not be identified unless a member of the pharmacy team is reviewing the patients discharge letter.
Holistic integration on discharge would present a scenario such that a change to prescribing at the hospital would be made to the core patient record (spine) so that all professionals are viewing one record without needing to make changes at every care setting. This would greatly reduce the risk of medication errors and reduce duplication of workload in an already stretched workforce. In one of our local Trusts, there exists an inability of hospital prescribers to utilise EPS for outpatient prescribing and simple discharge. The current system forces the patient to obtain medication from the hospital pharmacy or necessitates a request for the patient’s GP to prescribe. Under DMS, it is not possible for a patient to take their hospital produced prescription to a community pharmacy or dispensing doctor to receive medication. This results in the patient needing to wait in a Trust setting when their needs could arguably be better met in the community and hospital capacity could be freed up. For the patient, they would be presented with greater choice and convenience as to when and where they collected their medication. This is further evidence that services such as DMS need to be reviewed and incorporated into a broader picture to robustly integrate care upon discharge.
The DMS has improved local transfer of care communications which has resulted in a lower incidence of patients collecting and/or taking medication dispensed/prescribed prior to admission – previously this was of significant concern but has lessened since the inception of DMS. National data consistently suggests that ~20% of DMS referrals result in the detection of a potential safety incident which supports the value in continuing and expanding the service for wider benefit.
Visibility of completion rates at identified points (for an individual patient) within the three-stage process of the DMS is poor. Anecdotal evidence suggests that pharmacies are delivering the service to patients (at various stages of completion) but do not have the capacity to claim the payment. Tracking the patient throughout the three stages adds value at each stage, but this is not facilitated through appropriate IT which seems an opportunity lost for such an important national service. There is currently no application programming interface (API) to allow automatic claiming for pharmacies upon completion of the data entry. This is contributing to omissions from claims data, further adversely affecting the financial viability of the service for pharmacies and therefore reductions to robust outcomes data.
Paper prescribing in hospitals
SNEE is supported by two acute and community Trusts; the East Suffolk and North Essex NHS Foundation Trust (ESNEFT), and West Suffolk NHS Foundation Trust (WSFT).
- East Suffolk and North Essex NHS Foundation Trust
East Suffolk and North Essex NHS Foundation Trust (ESNEFT) provides acute and community health care services for Colchester, Ipswich, and local areas. Formed on 1 July 2018, ESNEFT is the largest NHS organisation in the East Anglian region with around 12,000 staff, serving a population approaching 800,000 residents. Since the merger of Ipswich, Colchester and Community Hospitals, the Trust and ICT’s strategy has been to support cross-site working, operating as one organisation.
The Trust considers itself to be digitally undeveloped with a current estate of disparate systems.
Pharmacy and medication management remains manual in many areas of the Trust, in particular those workflows sitting outside central pharmacy. The Trust has digital dispensing solutions (Omnicell) in limited areas but the true benefit in these systems arises from closed loop medication administration workflow supported via an EPR. Delays to care delivery and the discharge process are currently impacted by use of paper prescription charts.
In November 2021, ESNEFT was selected as one of four Acute/Community providers nationally to be part of the Digital Aspirant Plus programme, which supports core functionality of the Frontline Digitisation Programme and Levelling Up agenda in terms of delivering new, optimised, or re-procured EPRs. As an EPR Accelerator site, the Trust is committed to accelerating the pace at which the EPR will be delivered, ensuring levelling up the digital capability across the System which is enabled by a core set of digital capabilities that improve the quality, safety, and productivity of care, as well as providing a platform to enable wider innovation.
Following the establishment of the ICB, the organisation has considered what its future needs are to enable the possibilities of working at a system level across the ICS. The Trust is on track to procure an EPR Programme, to be implemented in 2024, that intends to establish a long-term strategic partnership. The EPR will provide the opportunity to work more efficiently as a system through interoperability and exchange of information, and scalability for future opportunities of direct collaboration with other partners.
With ‘Time Matters’ at the centre of the Trust’s strategy, the Time Matters philosophy will be at the heart of the EPR Programme. The EPR will help reduce staff time spent completing manual transference of information, duplication of information, by both individuals and across roles. It will provide access to information most appropriate to the patient/persons being treated, in a timely manner within the scope of the professional role. The implementation of the EPR is also expected to return time to staff in the wider ICS and the patients we serve. Through exchanges of information with other Systems of Record, colleagues within the system will benefit from the improvement in accessibility of information.
Aspirations to reach an equivalent level to HIMSS Level 6 (referred to ‘Transformation capabilities’) and Level 7 (referred to as ‘Innovation capabilities’) require organisational change to underpin the supporting technology in the EPR, including meeting operational demands by extended opening hours of specific services including pharmacy and digital support. As part of the tendering and procurement process, ESNEFT are assessing EPR suppliers’ capability in delivering the transformation and innovation capabilities of HIMSS, which is in recognition of the size and ambition of ESNEFT and the ICS.
ESNEFT intends to support partners within the ICS to work towards an effective real-time digital ecosystem, which is underpinned by shared standards and aligned governance that will deliver better information flow, research, data collection and decision-making to improve the health of the local population. Health and care professionals will have safe and secure access to near real-time information to improve the care we deliver. Data will be linked from across the health, care, and community continuum providing a shared care record facilitating joined up health and care across our services.
The medication governance by pharmacy will be supported with immediate access and review points to support appropriate treatment and offer direct communication to prescribers to ensure our approach to patient safety is maintained and optimised. Following implementation of electronic prescriptions and medicines administration, the EPR will offer a streamlined approach supporting safety for both nurse and patient in utilising closed loop administration of medicines and barcode medication administration (BCMA), which offers visibility on the application of safe practice throughout the patients stay. The EPR intends to mitigate many concerns toward patient safety and quality care delivery, including more efficient take home medication management and ensuring reliable and accurate data is captured which in turn can be utilised in the development of Artificial Intelligence (AI) and Machine Learning (ML) solutions in areas of Innovation and Research.
- West Suffolk NHS Foundation Trust
For several years, Electronic Prescribing and Medication Administration (ePMA) has been implemented within WSFT’s Inpatient, Outpatient and Emergency Department areas for most medications. The Trust considers itself to be digitally mature.
Since project inception in 2016, users have been familiar with the Trust’s implementation strategy and been receptive to iterative releases of new capability. The prescribing of some continuous infusions and complex medications is currently paper based. The implementation of the remainder of these medications via ePMA is on scheduled to go live across the Trust in July 2024. A detailed evaluation phase (inc. analysis of benefits realisation) will follow with particular focus on impact on health inequalities; patient safety; clinical effectiveness; quality and clinical governance; and operational productivity.
With oversight of the Trust’s Board and through a collaborative partnership of Change, IT and clinical leadership, two thirds of the investment required has been released to-date. Due consideration is given to a range of factors including long term affordability, digital innovation in the ePMA supplier marketplace and strategic workforce requirements (inc. funding requirements). Currently, the main strategic risk to delivery is resource availability in the ePMA Team – this continues to be actively managed.
During the pandemic, the Trust’s Covid-19 response inevitably led to some project delay. ePMA Pharmacists were redeployed to clinical pharmacy duties to meet the immediate operational requirement including configuration and workflow design (at pace) to facilitate introduction of emerging therapies for COVID-19. In line with the UK Government’s strategy to live with Covid-19, the Trust continues to adapt its practice to return to pre-pandemic ways of working as well as responding to clinical consequences of the virus as well as changing population needs.
EPMA interoperability between primary and secondary care providers is equally a key enabler to seamless patient care. Ongoing activity to transition the Covid-19 treatment services from acute provision into a shared model is a very real and current example of both opportunity and challenge. Whilst the appetite and ‘can do’ attitude of GP, community pharmacy and Trust (acute and community) partners is enabling a robust ICS-wide pathway of shared care to be developed, the practicalities of sharing patient records and prescriptions between primary and secondary care providers to facilitate high quality care and mitigate risks to patient safety is requiring innovation and workarounds in the absence of interoperable national infrastructure.
SNEE ICS Digital, Data and Technology Landscape
The ICS welcomes the announcement in NHS England’s Primary Care Recovery Plan regarding new funding to ensure the highest standard of care for patients, particularly investment to significantly improve the digital infrastructure between general practice and community pharmacy. The ICS is committed to working alongside NHS England to work with community pharmacy suppliers and general practice IT suppliers to develop and deliver interoperable digital solutions. We share the Government’s priority to streamline referrals, provide additional access to relevant clinical information from the GP record, and share structured updates quickly and efficiently following a pharmacy consultation back into the GP patient record.
The SNEE ICS DDaT Strategy is committed to addressing digital connectivity by joining up care settings to support better care for the population we service as well as health and care providers; working to implement NHS England’s ‘interoperability by default’ approach, the What Good Looks Like principles, and a data driven approach to shaping and informing our services and planning.
With 172 community pharmacies in the ICS, the pharmacy digital landscape has a mixed provision of infrastructure, and varying levels of interoperability, compounded by the CPCS IT Provider ‘Switching’ to a ‘provider pays’ model, which came into effect on 1st April 2022. As detailed above, this has unintentionally undermined the integration agenda.
In refreshing the DDaT Digital Strategy, the challenge initially is to ascertain how possible a bi-direction Health Information Exchange Shared Care Record would be, incorporating the new initiative for provision of prescribing for seven minor conditions and, aspiring to an integrated Electronic Prescribing and Medicines Administration (EPMA) system across the ICS that enables two-way communication for prescribed medication. Procurement processes within the ICS will support specification of interoperability and digital transformation expectations of other provider digital systems; this can be achieved by following the What Good Looks Like principles when making decisions about digital investments and products, improving value for money and quality of service. This will present a material challenge, but one that needs to be overcome to build capability (inc. digital) in community pharmacy so that the profession is truly an integral and equal provider within the national health and social care eco-system.
The population served by ESNEFT is growing at one of the fastest rates in the country and life expectancy is significantly increasing. These factors increase the number of people needing healthcare services which has seen a significant increase in the demand of aseptically manufactured products and pharmacy technical services in recent years. ESNEFT provide sterile and non-sterile production services across Ipswich and Colchester Hospitals via a hybrid licencing arrangement including Manufacturing Specials (MS) for human use, a UK Manufacturing and Import Authorisation of Investigational Medicinal Products (MIAIMP), with some additional activity under a Section 10 Exemption of the Medicines Act 1968.
Increased activity as part of pandemic recovery programme has increased the level of activity in clinical departments and further increased demand on pharmacy technical services. Regulatory compliance and workforce stability is acknowledged as being the essential priority for the organisation. Capacity constraints in the Aseptic and Non-Sterile Production and Quality Assurance (QA) sections has been remedied via significant investment in workforce to support the Trust’s transformation plan in relation to delivering the pharmacy technical service in a more standardised, efficient and consolidated manner.
The Colchester site will soon benefit from a new purpose-built aseptic unit facility, which complies with regulatory standards, and is designed to be large enough to accommodate more isolator units used in the manufacturing process. This will support increased production in the future via automation as part of a hub and spoke arrangement within the ICS. The additional space intends to improve the flow of the drug manufacturing process to meet increasing demand for aseptic services from the local community. The transition into the new facility is intended to take place in 2023/24 and aligns to the Trust’s strategic objectives.
The aseptic transformational programme will then focus on consolidation of resource and product manufacture for Sterile and Non-Sterile Services across ESNEFT, to enable batch manufacturing of products in larger volumes with extended expiry dates where supported by stability data. The opportunity benefits include more ‘ready to administer products’ which supports efficiencies in production time, reduces material and consumable costs, in addition to saving nursing administration time at the patient bedside which is widely accepted as an unmet clinical need.
Logistically, the purpose-built aseptic unit facility is located near major road links (A12 and A14) which serve the East Anglia region. It is therefore ideally positioned to support the delivery of such products to healthcare facilities within the ICS who administer injectable medicines. The system-wide benefit of automation and consolidation of services allows for delivery of the necessary increase in capacity per annum to release nursing time for care and enable more out of hospital care. Our regional and national committee involvement continues to ensure we contribute, plan and react to current and future work-streams.
To meet the patient need, the aseptic service will undergo a 7-day service review to adapt to the needs of the organisation, the ICS and patient experience. Our strategic workforce plan and intention to formalise partnerships and networks across the regional aseptic units intends to ensure a united approach to the hub and spoke model of care across the ICS.
Commitment 1
SNEE ICS actively supports and welcomes this commitment. Supporting pharmacy workforce transformation is essential to allow for positive impacts to patients and services users that currently find it difficult to access the right care, by the right profession, at the right time. The recently launched NHS England » Delivery plan for recovering access to primary care 2023 emphasises the key role community pharmacy has in implementing this plan, this is dependent on consultation with the PSNC and funding. As part of this work, it is also important that due consideration is given rural patients where their pharmaceutical needs will be met by a dispensing GP practice where they do not have access to a community pharmacy.
Transforming the pharmacy workforce, in particular the community pharmacy workforce, will have a direct benefit to patients allowing for easier access to care. We know that 1.2 million informal consultations a week are taking place in England’s community pharmacies (pharmacy-the-heart-of-our-community 2022), and more care could be delivered by upskilling the workforce, allowing for prescribing and relevant diagnostics to be completed at the same time. The Fuller Stocktake report NHS England Fuller report 2022 recognises the need to increase the role of community pharmacy in many areas including preventative healthcare ‘making every contact count’. This will require integrated and streamlined commissioning arrangements between partners, maximising appropriate funding streams.
One of the greatest challenges faced by community pharmacy is workforce; it is fragile as a result of a significant shortfall of community pharmacists in England (CCA Review Jan 2022). This is due to many factors including an ageing pharmacy workforce, burned out staff and many choosing to leave the sector and the profession.
In addition, the national drive to increase the pharmacy workforce in primary care working in PCNs has had a negative impact to community and hospital pharmacies across SNEE. Working toward the expectation of 5 to 6 clinical pharmacists per Primary Care Network (PCN) by 2023/24 and pharmacy technicians 1 to 2 per PCN, many of these have come from community and acute sectors. At July 2022 there were 96 wte known posts in the general practice pharmacy workforce; this number could be doubled with Additional Roles Reimbursement Scheme (ARRS) recruitment. The pharmacy roles are seen to be making a significant difference to GP practice workload.
SNEE ICS has implemented its 2022-2027 Pharmacy Workforce Strategy. This is a key enabler for system pharmacy workforce readiness. The strategy was developed due to the significant pressure around pharmacy (recruitment and retention difficulties, unprecedented levels of burnout of pharmacy workforce, pharmacy closures) and the need to understand the current and future pharmacy workforce challenges impacting patient care and staff. There are six key focus areas which includes modernising SNEEs approach to education and training delivery and introducing skill mix to release capacity.
Working in a collaborative manner to prepare the current workforce with upskilling and accessing the education and training support available via HEE is a key part of the strategy. To support delivery and ‘grow our own pharmacy workforce’, the ICB is working with the University of Suffolk to develop a business case to launch a pharmacy school – building upon the early success and learning from our partnership with the university to establish a Centre of Dental Development. As part of the implementation of the strategy, system wide pharmacy workforce transformation workshops have been delivered, staff surveys undertaken, pilots of pharmacy workforce initiatives agreed, and workforce collaborative task and finish groups set up. Challenges to implementation include lack of capacity to undertake the necessary work due to current work pressure and staffing shortages, and lack of investment in funds around education and training (e.g. supervision, leadership programmes).
The system recognises the urgent need for pharmacy workforce and services to be transformed due to future professional changes expected in 2025/26 when pharmacy undergraduate students will graduate as qualified Independent Prescribers (IP). Pharmacy commonly segregates roles which slows down workforce transformation. Evidence (delivering a future workforce vision for pharmacy, 2022) describes systemic deficiencies in the ability of pharmacy staff, across the entire career spectrum, to lead and innovate and current workplace cultures commonly do not empower staff to grow and utilise these skills in real life. There is a significant gap with upskilling the current pharmacy workforce to match the future workforce who will have additional skills with minimal plans on how the skills will be utilised. The increasing number of Pharmacy Accuracy Checking Technicians (ACT) available will support skill mix within the pharmacy settings but this requires pharmacy transformation..
The funding available for the training programmes does not include the additional investment required to support the trainees (e.g. designated prescriber supervisors, leadership support and ongoing supervision). Additional support is required to prepare the pharmacy workforce for the future including pharmacy working in multi-disciplinary team (MDT) settings. SNEE is actively developing joint pharmacy roles between community pharmacy/PCN, secondary care/PCN and secondary care/community pharmacy to maximise this important opportunity.
Commitment 2
The proposed legislative changes that can support better use of skill mix in pharmacies include:
- Additional investment secured to support the education and training programmes, allowing for sufficient capacity to provide the necessary support and leadership.
- Changes to commissioning arrangements for patient pathways to allow for the pharmacy workforce to be better utilised with consultant led services to include pharmacy consultant roles and pharmacy led services to include pharmacy technicians.
- Wider primary care service transformation to allow pharmacists to directly refer to relevant services without the need to refer back to the GP.
- Wider public awareness of the roles and remit of the pharmacy workforce to allow improved recognition of the skills available in the community.
- Support to allow for cross sector PCN and community pharmacy roles with the right infrastructure e.g. estates and IT interoperability.
- DHSC to clarify the roles of pharmacy professionals and enable a better use of skill mix, after consulting on the law on pharmacist supervision liaising with the General Pharmaceutical Council to revise the standards on responsible and superintendent pharmacists.
- DHSC develop the necessary guidance to enable pharmacy technicians to administer and supply medicines under PGDs subject to consultation.
- Legislative changes to allow pharmacists the flexibility to dispense medicines in their original packs and to widen pharmacy hub-and-spoke arrangements, both of which aim to facilitate greater use of automation to increase efficiency.
Additional information is required as the educational training programmes are implemented, such as the attrition rates to understand the additional support required at system level to upskill the pharmacy workforce.
Arguably of equal importance to legislation are the key enablers that facilitate practical change. One such lever is commissioning. In April ’23, NHS England delegated commissioning of pharmacy, optometry and dentistry to ICBs. This has enabled SNEE to start to explore opportunities with other commissioners (e.g. Public Health and Local Authorities) to streamline arrangements with the intent of moving away from independent and fragmented commissioning of disparate services to a more integrated, strategic and planned approach based upon common underpinning processes and contractual mechanisms. In so doing, the ambition is to improve services, increase efficiency and maximise workforce within and beyond organisational and geographic boundaries. National recognition of the opportunity with commensurate support would further support this locally driven initiative.
Commitments 1 and 2 around workforce education and training are appropriate commitments and will allow meaningful improvement for service users, healthcare staff and the healthcare system. The challenge is to secure and realise the additional funding, capacity and establish governance infrastructure that will enable these commitments to be realised over the coming years, which may be beyond a three-year horizon.
The NHS Long Term Plan determines the priorities for the Pharmacy Integration Programme, which is supported through the Pharmacy Integration Fund (PhIF). The CPCF created the ambition for developing new clinical services for community pharmacy as part of the five-year schedule. The PhIF has supported a range of pilot projects and their evaluation, with the intention of incorporating them into the national framework. In relation specifically to prevention and detection services, this likely includes: the NHS Community Pharmacy Consultation Service (all 3 iterations of the service); the NHS Community Pharmacy Blood Pressure Check Service; the NHS Smoking Cessation Service (hospital inpatients continuing their stop smoking journey within community pharmacy upon discharge); and the NHS Pharmacy Contraception Service (routine monitoring and supply of contraception) whereby Tier 1 has transitioned to an Advanced Service whilst Tier 2 remains at the pilot phase.
As previously mentioned, if it had not already been widely established, the COVID-19 pandemic highlighted the value of the community pharmacy network in its accessibility for patients and the significant impact the sector has (and could develop further) in improving public health and prevention. Therefore, the development of the above prevention and detection services is welcomed – the success of the implementation of these services presents a mixed picture.
Clearly not all pharmacies can engage with local pilots but there is a concern as to why only selected pharmacies choose to deliver these services when they become nationally available as Advanced Services. We have already referred to some of the barriers to success of the CPCS (GP CPCS particularly) and the NHS Pharmacy Contraception Service. Hypertension detection is a key priority for the ICB, aligned to NHSE’s priorities for the Core20PLUS5 domains in addressing health inequalities. Locally, some pharmacy contractors have engaged with the service and are delivering significant volumes of consultations to improve detection. As in other ICS’, this is not replicated across the system, and we need to understand (nationally) the reasons for this so that we are not widening inequalities. Local feedback refers to financial & workforce pressures alongside the potentially ‘punitive’ national funding mechanism for engaging with service delivery (to the detriment of core funding) as mentioned earlier.
Local integration of the blood pressures service has not been enabled to maximise the benefits of detection. Examples include poor visibility (for patients, commissioners and health & social care providers) of which pharmacies are providing the service; poor IT interoperability between general practice and pharmacy systems to facilitate referrals into and outcomes from the service; and crucially, capacity issues within General Practice to accommodate the management of newly diagnosed hypertensive patients identified through case finding. For a system to maximise the gains and integration of these services, broader implementation solutions need to be inherent from the outset of a national service.
The visibility of pilot evaluations prior to national rollout is perceived as poor – recent examples include the contraception service and UEC NHS CPCS. Similarly, for some of the services, there have been significant changes in the transition from the pilot to the full service, including reduced support for successful implementation and reduced remuneration levels, without explanation or evidence from the evaluation. It is therefore unlikely that the success of the implementation of the national service will mirror that of the pilot, nor is it likely that the initial pilot outcomes will be achieved – more evidence is needed for this to be reviewed.
Outside of the PhIF programme, community pharmacy has demonstrated increasing and sustained excellent service delivery for vaccination services. The success of both NHS and private Influenza vaccination through community pharmacy has cemented the sector as a key delivery partner in the patient pathway. This has now also been seen in the delivery of the COVID-19 vaccination programme, whereby the inclusion of community pharmacy as a delivery partner, significantly improved access in deprived areas and in communities who otherwise were not easily accessing services. The ICB understands NHS England is exploring this model to inform development of a potential national Integrated Vaccination Strategy for all immunisations. In so doing, careful consideration will need to be given to not destabilising viability of providers (particularly in primary care) recognising vaccination activity in all care settings facilitates and affords more than an immunisation service.
An appropriately funded future for community pharmacy to offer prevention and detection services more widely is very much welcomed. Future planned and existing services could be better integrated in their intended outcomes. Currently service outcomes are not sufficiently well integrated creating complex patient pathways which need to be overly managed locally, creating competition at the expense of collaboration between existing providers and often lead to friction rather than integration.
May 2023
