Written evidence submitted by The BMA (PHA0061)

July 2023

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding healthcare and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

Summary

-          Government should expand the role of pharmacy to enable it to support more patients in the community and to help reduce workload pressures on other parts of primary care, including GPs.

-          Pharmacists are ideally placed to work with patients to ensure medications are properly reconciled (correct) on discharge from hospital and performing structured medication reviews to ensure patients correctly take and understand their medications, including any potential side effects and interactions.

-          Dispensing practices are an essential element of community pharmacy services in rural areas and should never be forgotten in future care and medicines dispensing planning. All funding and services commissioned from pharmacies should also be available to / from dispensing GP practices to ensure equity of access for all patients. For example, this includes provision such as funding for community pharmacy hypertension services, which should be made available to all dispensing practices.

-          Interoperability should be improved by allowing GP access to notes from pharmacy consultations and pharmacies real time access to medication lists. This would ensure those treating patients in both settings have access to the necessary information to provide the best possible safe care.

-          To reduce delays to patients seeking treatment when a drug or treatment is unavailable due to shortages, pharmacists should be permitted to offer alternative treatments without having to return to the prescriber for permission. These changes should be communicated to the GP in real time via interoperable IT systems to ensure continuous and safe care.

-          Like GPs, hospitals should be given direct access to the e-prescribing service (e-PS) to prescribe medications electronically directly to community pharmacies and dispensing practices. This would reduce pressures on general practice and provide a more straight forward method of access to medication for patients.

-          Due to IT limitations dispensing practices are unable to use the e-PS for medicines dispensed by the practice itself. This situation should be addressed by improvements to IT systems through investment which will ensure patients using dispensing practices are not unfairly disadvantaged[1].

Questions

1. What does the future of pharmacy look like and how can the Government ensure this is realised?

1.1   General practice is under ever growing pressure with falling numbers of GPs and an ever-increasing workload. As of May 2023, we now have the equivalent of 2,165 fewer fully qualified full-time GPs compared to September 2015. Meanwhile, the average number of patients each full-time equivalent GP is responsible for continues to rise, and now stands at 2,297, an increase of 18.6%, since 2015[2].

1.2   To help ease some of the pressure on general practice, and ensure timely access to GP care for patients, government can do more to promote pharmacy as an alternative for some care provision and treatment options. This could include pharmacy first schemes for minor ailments, greater monitoring and review of long-term conditions such as hypertension or COPD and performing structured medication reviews to ensure patients correctly take and understand their medications.

1.3   Better communication and integration between pharmacies and other providers, including GPs, has the potential to deliver a more efficient service for patients. However, capital investment in premises and IT will be needed to achieve this. This will be particularly crucial in general practice where premises’ capacity is limited and often dilapidated, with funding for investment currently scarce. This places a major constraint on their ability to fully develop and utilise multi-disciplinary teams through approaches such as co-location.

1.4   Currently 9.28 million people are registered with dispensing GP practices, who provide primary healthcare to rural patients and can prescribe from those premises. In total, around 7% of all prescription items are dispensed by doctors[3] through a network of 1,107 dispensing practices across the UK[4].

1.5   These dispensing GP practices, which only exist in areas where pharmacies do not, ie where no community pharmacist exists within more than one mile from the dispensing practice, form a vital service in rural areas. Consideration of future care and medicines dispensing arrangements should reflect the necessity of the service dispensing practices offer to their patient community. It is imperative that any funding and services commissioned from pharmacies should also be available to / from dispensing practices to ensure equity of access for all patients, and to avoid a post code lottery effect.

2. What are the challenges in pharmacy workforce recruitment, training and retention, and how might these best be addressed?

2.1   As part of the GP contract agreement 2019/20 in England, practices working in Primary Care Networks (PCNs) received funding for 26,000 additional staff over five years, including nearly 4,000 clinical pharmacists. While this support for additional support staff is very welcome, it has also meant that PCNs have employed pharmacists and pharmacy technicians who previously would have been employed in community pharmacy, creating a more competitive market. To this end, greater emphasis should be placed on expansion of the pharmacy workforce, as well as enabling cross working and true collaborative working between practices and community pharmacy. This will ensure there is sufficient staffing to safely meet the needs of all service users.

2.2   Community Pharmacists are best placed to review patients’ medications, also known as reconciling, when they are discharged from hospital. They can take into account items that the patient had not collected, answer concerns about side effect, interactions and indication for new medications. They can also improve concordance (the agreement between a patient and prescriber as to the treatment’s therapeutic aims) and compliance with medication by ensuring patients understand their prescribed medication. When medications are added through GP practices there is often no opportunity to check a patient’s understanding of why, how and when the medications are taken, and this is assumed to have happened in secondary care. This is due to the patient often not then meeting directly with the GP. Pharmacists often have direct contact with their patients allowing this to be done more robustly. This approach would be supported by expansion of the e-prescribing service (e-PS) system into hospitals.

2.3   There is also a clear role for pharmacy in enabling short and long-term substitution of medications, this would greatly improve patient journeys by removing the need for repeat GP appointments and would also reduce workload in General Practice.

3         To what extent are digital systems used in pharmacy sufficiently interoperable with those in general practice and hospitals?

3.1   More must be done to improve interoperability between all health services including primary care, secondary care and pharmacy. While some progress has been made on this during the pandemic there is more still to be done, particularly to bring pharmacy into the fold. Currently pharmacy consultations are not visible to general practice, which prevents a GP from gaining the full picture of patient’s medical history when considering their notes. This will become more important as pharmacies take on more roles in community care.

3.2   Pharmacists should also be able to directly see when GPs have made changes to medications which would enable a secondary layer of reconciliation of medications and further reduce prescribing errors.

3.3   GPs and other prescribers in general practice are already able to prescribe medications electronically through the e-PS directly to community pharmacies. This means that GPs are now able to direct a prescription to any community pharmacy in England. We believe that this access should be opened to allow hospital doctors to also access the e-PS. This would mean they could prescribe following a remote consultation, without the need for the GP to prescribe or the patient to have to visit the hospital to collect their prescription. In addition, e-PS is currently limited in dispensing practices through IT barriers, this situation should be addressed to ensure equality for patients using these practices.

4         What innovations could have the biggest impact on pharmacy services and why?

4.1   n/a

5         To what extent are funding arrangements for community pharmacy fit for purpose?

5.1   N/A

6         What factors cause medicine shortages and how might these be addressed in future?

6.1   Medicine shortages which are currently being experienced can be attributed to several things including longstanding supply chain problems, the impact of Brexit, the pandemic, and high levels of demand. GPs regularly report shortages of hormone replacement therapy (HRT) treatments, which may be attributed to increases in demand for oestrogen. These delays are leaving both patients and doctors frustrated, and patients at risk of harm.

6.2   One way to address shortages is to use alternative medicines or dosing regimens, although sometimes this is not always possible, such as with HRT where often the alternatives themselves are also suffering from shortages. Even taking this into consideration, it would be beneficial for pharmacists to be allowed to offer alternative treatments without having to return to the prescriber for permission. This change would reduce workload for GPs and reduce instances of delay for patients.

7         To what extent does community pharmacy have the resource and capacity to realise the ambitions in DHSC's Primary Care Recovery Plan?

7.1   N/A

8         Are there the right number of community pharmacies in the right places, and how can we ensure that is the case across the country?

8.1   Where community pharmacies are not viable, dispensing general practices provide pharmacy services to people. Extra investment and services should be offered to dispensing general practices to enable equitable access for people to these services in these locations

9         To what extent are commissioning arrangements for community pharmacy fit for purpose?

9.1   N/A

July 2023