Community pharmacies are changing; meaning they now offer a wealth of services that can take the pressure off today’s busy GPs. Pharmacist Rod Tucker explains the changes and considers how GPs can make the most of what they offer.
Today’s community pharmacists offer a much wider range of services than simply dispensing prescriptions. This shift from their traditional role of compounding medicines was designed to reflect the needs of a modern-day community pharmacist, who is now expected to deliver a more patient-focused service. But what were the drivers for this change and have the purported benefits been realised in practice?
This article charts the evolutionary path of the modern day community pharmacist and provides a brief review of the evidence supporting their new roles.
History of community pharmacy services
The Pharmaceutical Society of Great Britain was established in 1841 and saw pharmacists involved with the preparation and sale of medicines and as a source of advice for those unable to afford a consultation with a doctor. Following the introduction of the NHS in 1948, pharmacists increased the number of prescriptions they dispensed, but as many items still needed making up they became less visible to the public. During the 1960s and ’70s, the introduction of drugs in tablet or capsule form reduced the need for pharmacists to prepare medicines, and by the late 1970s, doubts were raised over the future need for pharmacists.
In an effort to publicise their value as a source of advice to patients, the National Pharmacy Association, an organisation representing independent community pharmacists, introduced the Ask your Pharmacist1 campaign in the early 1980s. The decade also saw an increased recognition of the role for community pharmacists in health promotion, and pharmacies were paid for displaying health promotion leaflets. By the 1990s, pharmacists took on a greater public health role, with responsibility for harm reduction through smoking cessation services and needle exchange schemes.
Patient focused service
The development of the current patient focused role emerged in 2005 after the introduction of a new contract. Though traditionally as much as 80% of pharmacy income was derived from NHS dispensing (and remains so today), the contract provided pharmacists with the opportunity to receive additional revenue from new services. The contract consisted of three tiers, with the first tier – the essential service – being provided by all pharmacies. It requires every pharmacy to dispense prescriptions, offer health promotion advice and provide a repeat dispensing service. This latter service, which is best suited to those with stable, long-term conditions, allows patients to collect repeat prescriptions from the pharmacy rather than having to visit the GP. The service requires that the GP signs an initial prescription that authorises the frequency and number of supplies of that treatment, for example, every month for 12 months.
The second tier is an enhanced service, in which pharmacies are commissioned to provide services based on locally-identified needs. There are several enhanced services available, such as needle and syringe exchange, the supervision of administration (e.g. methadone), minor ailment schemes, chlamydia testing and patient group directions (e.g. provision of emergency contraception) and provision varies across the country.
While essential and enhanced services are broadly related to medicine supply, the final tier, the advanced level service, is directed at ensuring patients use medicines appropriately. There are currently five services as described in the Table 1.
What has been the impact on patient care of these new services?
During the past 10-15 years, various studies have been undertaken to evaluate many of the different services provided by pharmacists, and some of the key findings are described below.
The repeat dispensing service was the subject of a systematic review in 2006,2 which found that no firm conclusions about either the effectiveness of the service or possible savings to the NHS could be drawn. While there are potentially clear benefits to using repeat dispensing, the NHS medicines optimisation dashboard (https://www.england.nhs.uk/medicines/medicinesoptimisation/dashboard/) currently shows that there is a huge and inexplicable variation (ranging from 0 to 63% of all repeat dispensing items) in uptake of the service across the UK.3
Medicine Use Reviews
Medicine Use Reviews (MURs) can be conducted on any patients receiving multiple medicines for at least three months from the same pharmacy, though the service can be used if the pharmacist identifies a potential problem when dispensing a patient’s prescription – even if it is only one item. By evaluating the patient’s use of treatments, it is envisaged that an MUR will improve patient’s understanding of their medicines, improve adherence and therefore clinical outcomes.
Though several studies have demonstrated that an MUR leads to improved patient knowledge about their medicines, there is no evidence that the service leads to improvements in adherence and thus better clinical outcomes. Moreover, the potential value of the service is being undermined by emerging evidence that pharmacists working for larger pharmacy chains are
under pressure and threatened with disciplinary action if they fail to carry out these reviews.5
New Medicine Service
The principle of the New Medicine Service (NMS) is based on the notion that pharmacist consultations with patients who have recently started on a new medicine leads to improved adherence. The NMS service was introduced in 2011 and the Government commissioned research to appraise the effectiveness and cost-effectiveness of the service. The research found that after 10 weeks of patient follow-up, there was a statistically significant difference in adherence between the intervention (i.e. the NMS group) and control arm (i.e. normal practice).6 However, the research was subsequently criticised, as the original protocol stated that adherence rates were to be reported at 6, 10 and 26 weeks, and the 26-week data was not reported.7 Moreover, as the trial was not blinded and adherence rates self-reported, the potential for social desirability bias, i.e. that respondents answered the questions to present themselves in the best light, cannot be excluded.
Minor Ailment Scheme
The use of a Minor Ailment Scheme (MAS) by patients has the potential to transfer care from GP and accident and emergency services to community pharmacy. One systematic review of MAS found that while the service was effective, it remained unclear as to whether such a service shifted demand from GP services and there were no economic evaluations undertaken.8
A further cohort design study in 2015 compared the cost and healthcare-related outcomes for minor ailment consultations in community pharmacy, general practice and accident and emergency departments. While symptom resolution was similar across all three settings, costs were lower for patients treated in pharmacies.82 However, although the study provided tentative support for the role of MAS, a criticism of the cohort design is that patients have already self-selected their venue for treatment. It is therefore possible that patients who visited an emergency care setting believed that their condition was more serious and thus not amenable to treatment at a pharmacy. Furthermore, patients recruited at the pharmacies requested a medicine, rather than presented with symptoms as occurred at the other settings and therefore the results are not directly comparable.
Cuts to pharmacy funding
Pharmacies are paid by the NHS for the services they provide. It was announced by the Government that the overall funding provided to pharmacies would be reduced by 6% (£2.8 billion to £2.63 billion) for the financial year 2016/17. The rationale for the cuts was linked to the need to generate savings for the NHS, but also that there are too many pharmacies, some within a few minutes’ walk of each other. The impact of these cuts are still being evaluated by the profession, and there is a suggestion that some pharmacies may even close, which might affect the level of services which remaining pharmacies are prepared to offer.
Greater GP-pharmacist collaboration
The available evidence suggests that the emergent patient-focused role of community pharmacists has some value. Unfortunately, most of the 12,000 pharmacies in the UK are owned by a handful of multiples, and pharmacists are under enormous pressure to deliver patient services for financial gain rather than patient benefit, potentially reducing the value of those services. In fact it has been reported that one of the pharmacy chains has cut locum fees if the pharmacist fails to deliver an MUR.10
Nevertheless, greater collaboration between GPs and pharmacists, combined with a better understanding of what the pharmacy services are designed to achieve, could ultimately lead to greater engagement from GPs. For example, MAS are designed to reduce the workload of minor ailments in general practice. Alerting patients to the availability of local schemes within practices might encourage them to seek advice at the pharmacy prior to making an appointment with the GP. Similarly, if a patient is started on a medicine covered by the NMS, the GP could contact the pharmacy – perhaps via a message attached to the electronic prescription – to ensure that the patient is included in the service. Where a GP feels that a patient on multiple medicines is confused or unclear as to why or how they should use their prescribed treatments, then a referral to their regular pharmacy for an MUR could be made.
It is important for GPs to appreciate that the new pharmacy services are complementary to the work undertaken by GPs. The MUR, for instance, evaluates patients’ use of their medicines, since they invariably do not take their medicines at the correct time or appreciate the importance or regular use, or even understand how to apply topical treatments. These issues would be addressed during an MUR, and any suggested changes to medication can be communicated to the GP via a standard template form. The MUR is not a clinical medication review and this remains the responsibility of the GP.
In an appraisal of pharmacy services in 2016, it was acknowledged that although many achieve what they were designed to do, there is a lack of data evaluating their cost-effectiveness.10 It is thus unclear whether these services represent value for money to the NHS, which is problematic from a commissioning perspective. The advanced level services were introduced without the support of GPs, yet were designed to illustrate pharmacists’ contribution to patient care. With an increasing workload within the NHS, it is perhaps time for both professions to discuss and appreciate the relative contributions that each can make to patient care.
A potential worry is the increasing growth of internet-based pharmacies which may limit the scope for greater inter-professional collaboration and
question, once again, whether there is still a need for the community pharmacist.
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