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The missing link?

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The missing link?

With 78 per cent of people saying they are comfortable receiving health checks in their local pharmacy, is it time for a real push to further the profession’s role and responsibilities within local communities?

The Royal Society for Public Health (RSPH) is calling for further expansion of the healthy living pharmacy (HLP) initiative following the publication of its latest report1, which shows widespread public support for pharmacy services. The call is backed by a recent survey, which shows the public is comfortable receiving a wide range of services and advice from their local community pharmacy, including:

  • Health checks (78 per cent)
  • Information on other healthcare services (78 per cent)
  • Treatment of minor ailments (76 per cent)
  • Vaccinations (71 per cent)
  • Advice on managing long-term conditions such as diabetes and asthma (70 per cent)
  • Sexual health screening (39 per cent).

Many community pharmacies in England are already delivering a wide range of health improvement programmes, including services relating to the management and prevention of chronic disease, emergency hormonal contraception services and programmes relating to drug abuse, misuse and addiction. The growing evidence of their success has led the RSPH to:

  • Ask local authorities to commission further research into the effectiveness of pharmacy-based health improvement initiatives
  • Call on local authorities and pharmacy teams to enhance the visibility of pharmacy-based initiatives in local communities
  • Urge health and wellbeing boards (HWBs) to include pharmacy representatives.

Reducing the NHS burden

The pressure on the health service is not going to go away and more HLPs could be a solution, according to Mimi Lau, Numark’s director of pharmacy services.

“It is glaringly clear that the NHS has to look at disease prevention as well as disease treatment if it is to manage its costs. By all means look at what can be done with the GP workforce, but also look radically to other healthcare professionals who can take some of the pressure off, as well as provide choice to patients. Pharmacy has the ability to make a great contribution to the public health agenda and HLPs in particular are delivering exceptional results because the staff have the right skills and attitude to make the service work.”

The HLP pathfinder programme evaluation found that 20 per cent of the people surveyed said they would not have accessed these kinds of services elsewhere. This indicates that there is real potential for pharmacies to target ‘hard to reach’ groups, says the RSPH. Mimi Lau believes all pharmacies should share the HLP ethos but it would be better “if the HLP programme was rolled out nationwide”.

Alastair Buxton, director of NHS services at PSNC, points out that all community pharmacies provide healthy living advice to patients as part of the public health element of their contract and that provision of relevant healthy living advice is also a component of the MUR and NMS advanced services.

“The majority of community pharmacies will also provide at least one locally commissioned public health service – such as provision of EHC, stop smoking or supervision of methadone and buprenorphine – [and] there is a wide variety of locally commissioned services that have been developed to meet the needs of local communities and which are helping to create an evidence base for community pharmacy as a key public health service provider,” he says.

For its part, PSNC has set out a vision (psnc.org.uk/vision), which outlines the key service developments that it would like to see in community pharmacy. These are split into four areas:

  • Optimising the use of medicines
  • Supporting people to live healthier lives
  • Supporting people to self-care
  • Supporting people to live independently.

In developing services across these four domains, “we believe the NHS community pharmacy service can help by becoming the first point of contact for the public, supporting NHS service provision alongside GP practices and secondary care”, says Buxton.

While this primary care connection is to be encouraged, Janice Perkins, pharmacy superintendent at Well, stresses that the key for all pharmacy teams wanting to engage in public health services is to do them well and get the whole team involved. “Signing up to deliver a service but then not engaging patients and delivering few interventions just damages the credibility of community pharmacy as a whole,” she says.

 

Key facts

  • The Royal Society for Public Health is calling for the HLP initiative to be expanded
  • Hurdles to be overcome include investment, new ways of thinking and a lack of awareness of the services on offer
  • The RSPH believes the pharmacy profession should have a greater presence on health and wellbeing boards

 

Funding challenges

Consistent delivery of services means that other health or social care providers and previous customers will signpost suitable patients to pharmacy, but there are still obstacles to funding these services that are putting off smaller pharmacy contractors, according to Patrick Kirby, managing director of 1st Health Products Ltd, which supplies self-testing kits to pharmacy.

“The fundamental problem is that the Government [wants health services] to move closer to primary care,” he says, “and the natural vehicle for delivering this is pharmacy – but no one has clarified who is paying for the services to offer and on what basis”. More funding is needed for public health services or else why would pharmacists offer them? “Pharmacists see their GP colleagues getting an improved salary structure and fewer hours.

There seems to be a disconnect between where GPs fit and the theoretical objective of pushing health to a primary care situation where the pharmacist is central. It is not joined up.” Other than the major players like Boots “who can invest in the longer term, safe in the knowledge that [services] will generate profit and greater market share”, Kirby can’t see how this would work “if it isn’t modified or scaled”.

“The GP funding model will generate profit but it seems pharmacists often [offer services] for free, which is a disincentive and can’t be sustained. It means pharmacists won’t provide services willingly – and anything not done willingly isn’t done well.” While he believes it is possible to close this gap, it will require a long-term plan “which isn’t something that has worked well within healthcare.”

He wonders whether this could be down to cyclical changes in the way politicians view the future of the NHS.

“How is it to be funded in the long-term? Centralised funding cannot be sustained and the private sector is always going to remain peripheral, so what exactly are the plans for the NHS? We can’t look at primary care providers operating separately if we want a seamless approach, which is not taking place at the moment. It is not difficult: to progress, there has to be a strategy.”

There are also challenges in the current system where pharmacy services can be commissioned from a range of commissioners, all with differing requirements. Deborah Evans, English Pharmacy Board member for the RPS, says the challenges are “significant” because an intervention for a patient may involve services commissioned from more than one commissioner, adding to the complexity.

“For example, if I’m talking to a patient about their medicines during a MUR – commissioned through NHS England as an advanced service – I may identify a need that then leads to a local service such as stop smoking, commissioned by the local authority, or an enhanced clinical review, commissioned by the CCG. Patients just want a great service that is centred around their needs but paperwork, reporting requirements and inconsistencies across boundaries may make joining up the offer difficult.”

Funding is also an important issue both for sustainability and to ensure that pharmacy can resource the services appropriately to be responsive, she says. “Effective, high quality delivery of services requires a skilled and motivated workforce, which takes time to develop and maintain. Changing commissioners and insecurity may then lead to patchy implementation and a dissatisfied public.

“HLPs help to address the issue of workforce development, focusing on providing pharmacists and managers with leadership skills to engage, develop and motivate their teams and free up time to deliver services – and the call for new models of care from NHS England [Five Year Forward View] provides the opportunity for innovating.”

 

The challenge for pharmacy is to secure service funding at a time of severe cuts

 

Greater visibility

If the hurdles of investment and new ways of thinking can be overcome, pharmacies then have to deal with a lack of awareness within their local communities of the breadth of services they can offer as well as, in some areas, the need for greater collaboration between pharmacy and other healthcare professionals. So how can pharmacy teams make themselves more visible within the community? Start with your customers, says Janice Perkins.

“Engage with the national PHE campaigns such as Stoptober and Change for Life. They have loads of great ways to open conversations with customers and useful tools to help patients change behaviour. These campaigns are also widely advertised outside of pharmacy and so reach patients who are not regular pharmacy visitors.”

“Next, awareness needs to be raised in places where people are, such as social centres or through radio. Raising awareness with commissioners of the great work that pharmacy does in this area is also important. Make sure that your work is documented and shared with your local pharmaceutical committee or pharmacy network as they will have links into the commissioners, who will be able to build on your model and replicate it elsewhere.”

Deborah Evans says doctors and other healthcare professionals should “do their bit and send people into pharmacy”, adding: “I’d like to see NHS 111 signposting people to pharmacy as well, because we can help triage patients, ideally with a national common ailments scheme.” Gary Warner – owner of Regent Pharmacy in East Cowes on the Isle of Wight, as well as chair of PSNC’s services development sub-committee – gets up at the crack of dawn in order to make connections with his local community.

“There is a local business association in our town and we attend regular breakfast meetings to build up relationships with other businesses and think what we can do to help in our community,” he says. “If you don’t have one in your area, then ask your parish or town council if you could talk to the councillors for 10 minutes at their next meeting to find out what you can do to help. Tell them about the NMS and MURs, tell anecdotes without sharing patient information, and talk about the success stories of pharmacy initiatives elsewhere.”

“Find the thing that captures their imagination and work together to make it happen. It might be that all they are looking for is an information outlet, but maybe they have a key idea that you could deliver or talk to your local commissioners about delivering in your area.”

Pharmacy on board

The RSPH believes another link that should be made is for the greater presence of pharmacy on health and wellbeing boards because they are responsible for producing pharmaceutical needs assessments, joint strategic needs assessments, and the joint health and wellbeing strategies for each area. The Health and Social Care Act 2012 says the boards must have a core membership and, while this does not include community pharmacy, local authorities are free to add additional members.

PSNC believes that it is beneficial for pharmacists and pharmacy organisations to influence the work undertaken by HWBs to advise and support local commissioners, says Alastair Buxton. “However, it is equally beneficial for pharmacy to work with other influencing groups, which is why many LPCs are actively involved with their local professional networks.”

Pharmacy representatives on health and wellbeing boards “would seem to be a good idea to ensure pharmacy is in the planning and not an afterthought or completely disregarded”, says Mimi Lau, while Janice Perkins points out that, “if we are not at the table, then we won’t know where we can help”. However, Gary Warner advises caution.

“Yes, we should all have representation everywhere, but the skill-set needed to perform in such a forum should not be underestimated. It is more important to have good contacts on the health and wellbeing board who can put your ideas forward in the first instance. However, make sure you make contact every six months to bring pharmacy to the forefront of the board’s attention.”

“If you’ve got ambitions for a political future then go for it, but otherwise I’d say don’t worry about getting on the actual board; just make members’ lives easier by sharing your knowledge.” A HWB role would certainly raise the profile of the profession locally, but Deborah Evans agrees with a subtler approach. “It is more important to make sure pharmacy is absolutely integrated into the plans of the health and social care system, and that might look different in different areas.

“An effective local professional network lead might not have a formal position on the board yet is so well connected that having the title is irrelevant. You may, on the other hand, have a pharmacist on a board who is less effective, and there is no point having somebody there if they don’t have the time, energy or influencing skills to contribute.”

“The trick for the future is how we pull the capabilities together across the pharmacy profession. If healthcare is person-centred, we need to work out how we make this work across all service provision helping individuals navigate around the system. “Community pharmacy must work more closely with pharmacists wherever they work [GP practices and secondary care colleagues] to help patients and the NHS get the most from medicines and to minimise harm. This is in our hands.”

 

Reference

1. ‘Reducing premature mortality: the role of community pharmacies’. RSPH, February 2015

 

Bite-sized HLP

Since its launch in 2009, the HLP framework has been adopted by over 800 pharmacies, with an estimated 3,000 pharmacybased health champions now trained to offer brief advice and brief interventions. This model consists of a tiered commissioning framework with three distinct levels of service provision:

  • Level 1 – health promotion
  • Level 2 – disease prevention
  • Level 3 – health protection.

Each level represents a further development in a pharmacy’s capability and responsibility for health and wellbeing. While there are other models available, the HLP concept offers an identifiable brand, uniformity and quality assurance.

 

Health Screening- self-testing kits

Selling home health monitoring kits can complement pharmacy-based screening services and empower patients to take control of their health. However, with such a wide variety of products on the market, stock decisions can be tricky. Pharmacists should aim to stock affordable, reliable devices and ensure that staff are competent to answer questions on when and how to use them.

Blood glucose meters

Blood glucose meters vary in size, speed and cost. Patients who test several times a day will need a meter with a large result memory and the cost of test strips may also be a factor. Meters with large screens and easy-to-use buttons may be preferable for older people, while young people may opt for versions that display a lot of data. Some meters also measure the presence of ketones.

Blood pressure monitors

The British Hypertension Society (bhsoc.org) has a list of blood pressure monitors validated for home use. To get accurate readings, customers should use the most suitable cuff size for their arm. Upper arm monitors give more accurate and consistent readings than those for the wrist or finger.

Cholesterol tests

The reliability of cholesterol testing kits varies, with some only measuring total blood cholesterol levels, while others give separate readings for high density lipoprotein (good) and low density lipoprotein (bad) cholesterol. Home tests should not replace those done by healthcare professionals and should be considered in relation to a wider range of health indicators.

Pedometers

Pedometers detect body motion and count footsteps and can be useful motivational tools to help people boost their physical activity levels. Those known as accelerometers are more accurate than cheaper spring models. Some devices contain extra features such as calorie counters and pulse monitors.

Pregnancy and ovulation tests

Digital ovulation monitors help women to identify their most fertile days during their menstrual cycle, which may help to increase their chances of conception. Market research suggests that price does not influence a woman’s choice of pregnancy test.

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