We don’t want more access to services, we want access to better services; more planned and less walk-in care; policies that promote patient-professional relationships; and systems shaped by clinical need rather than financial or managerial considerations.

  1. I have long been opposed to patient lists for pharmacies. My feeling is that having to ensure people come back because they want to encourages good service. But the modern advanced services such as Medicines Use Review and the New Medicines Service only work well if we have patient lists, and it’s very hard to drive standards up if we have no denominator for uptake of services. For these reasons I think we should encourage patients to develop a relationship with their local pharmacy and a list system could drive that.
  2. NHS Pharmaceutical Services are more than just dispensing. The recent hub and spoke consultation and what a friend calls the Amazonisation of dispensing shows that even NHS England don’t understand this. In fact, separating dispensing from good advice services is a profoundly stupid move and we need a commitment to tying the two together. Dispensing factories might be popular with patients but they are losing something by using them – and they put strain on the rest of us. I spend a lot of time now dealing with people who want advice about medicines they’ve had dispensed elsewhere (and of course I can’t answer a lot of the questions, nor should I be expected to do so free of charge).
  3. It follows from 2 that the position of dispensing doctors can’t be ignored any longer. I have no particular dislike of them, and some of them have high standards, but certainly general GP services should not be subsidised from dispensing. I have no doubt that GPs are overworked, but it’s interesting that I never hear one say that they could do with getting rid of dispensing. Their core purpose is to diagnose and there is no point in putting pharmacists into practices to do clinical work when doctors are still dispensing. Accordingly, there should be a long-term plan to remove the need for dispensing practices and ensure that a full range of pharmaceutical services are available to everyone equally.
  4. Hospitals have been creating outsourced outpatient dispensaries as a means of avoiding VAT – in fact, some of them aren’t HMRC-compliant and it may not work for them, but it cannot be right that the service patients get is being shaped by a tax liability rather than a clinical need. We need an inquiry into how this could be avoided. Some patients are being allocated to homecare for the same reason.
  5. Manpower planning under the current government is being left to the market. The problem is that we’ve got a pre-registration bottleneck. Taking a pre-registration student is an expensive business and the current payment is inadequate – but, more to the point, we need proper assessment of manpower needs and provision, probably in all the healthcare professions.
  6. The last Labour government championed access, pushing for walk-in centres and increasing the number of pharmacies dramatically. This was an expensive policy and the Tories are now reversing it, but using market forces rather than good planning to achieve it. The likely result is that rural pharmacies (which are more likely to be independents) will suffer while the urban ones (which are allegedly the government’s target) will have deeper pockets and be parts of chains which can cross-subsidise. There is a philosophical point hidden in this: it gave patients the idea that each encounter with a healthcare professional could be self-contained. From this, it followed that providers have argued that it doesn’t matter if they run pharmacies entirely with locums, or change staff frequently, because so long as their procedure manual is followed the patient will get the same care. However, my experience of 36 years as a community pharmacist is that the enduring personal relationship improves patient care. I’m sure the same will be true of GPs. It also happens to be what patients say they want. For example, we have a patient whom we’ve just persuaded to have a memory assessment. She’s relatively young, but we can see she has suddenly become very vague. If we hadn’t know her for years, we wouldn’t have spotted that. So we need to ensure that policies promote patient-HCP relationships and that providers are inhibited from changing staff frequently. Including some element of “continuity payment” in the contracts may help here.
  7. Community pharmacists have had real trouble getting accepted onto prescribing courses. I managed it, but only because I was also working for the PCT at the time. The argument was that I didn’t have access to a prescribing budget, but it’s chicken and egg. If I could prescribe, I could then apply for work that required some prescribing. We need to drive for all pharmacists to become prescribers in the long run – included in undergraduate courses and with access to courses for those already in practice.
  8. Dr Charles Alessi, who is big in the NHS Commissioning world, argues that the future is for GPs to diagnose and monitor, with pharmacists adjusting therapy in long term conditions. That’s not a bad model to aim at. It could take workload off GPs and thus allow them to accept some load back from specialist services and consultants. For example, our local rheumatologist says – and the evidence backs him up – that the key to successful treatment of rheumatoid arthritis is to see patients within 6 months of diagnosis, ideally within 3. He can’t do that at present because his clinics are full of people coming back for their treatment which he could pass back to GPs if they were happy to prescribe DMARDs. This calls for mutual backscratching. If GPs will prescribe DMARDs under shared care, the consultant can give their patients better care. It’s common sense, but it founders on the insistence of some GPs that they are not going to take part because “consultants should be doing this”. They have the right not to join in shared care – my view is that if a local medical committee thinks a shared care arrangement is acceptable, the norm should be that all GPs will join it. They shouldn’t be able to say no – “not yet” is an acceptable answer if there are educational needs to meet, but an action plan should be produced specifying when they will join in. The relevance to pharmacy is that primary care shared care could be from consultant to pharmacist on some occasions.
  9. There are some very innovative pharmacists in the community. However, implementing their plans requires that they persuade their local NHS England or CCG, and some won’t even look at plans, even when they’re cost-sparing. We need a central “suggestion box” system with a royalty payment on uptake.
  10. The Drug Tariff is a daft way of managing drug costs. Too often we’re having to buy products at prices above the reimbursement cost and make a loss. The NHSBSA Pacific Programme is being steered by a vocal group (including me) to look at this rather than tinker at the edges. But the current government’s mania for driving drug prices down simply means that we get shortages because some companies stop making things when the price is too low. NICE handles new drug cost-effectiveness, and the Pharmaceutical Price Regulation Scheme is meant to deal with existing drugs, but it’s not working well, and a small number of companies are gaming the system to make unreasonable profits out of key medicines. The whole approach to drug pricing has to look at developing a drug industry that contributes through increased taxes (because they’re making healthy profits) rather than reduced prices.
Trackbacks are closed, but you can post a comment.

One Comment

  1. jcashbyblog says:

    Excellent informative article. I think more attention needs to be drawn to the VAT scam where NHS pharmacies have to pay VAT, while Boots et al don’t.

What do you think?

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Subscribe to Blog via Email

Enter your email address to subscribe to this blog and receive notifications of new posts by email.

Join 478 other subscribers

Follow us on Twitter

%d bloggers like this: