Health and Social Care Committee
Inquiry into the contribution of community pharmacy to health services in Wales
CP 30 – Alliance Boots
National Assembly
for Wales
Health and Social Care Committee
Inquiry into the contribution of community
pharmacy to health services in Wales
A
submission from Alliance Boots
Executive summary
o There is a real opportunity for the Welsh Government to realise the full potential of pharmacies and help them to support patients in a meaningful way.
o Progress with developing the pharmacy contract in Wales has been slow and patchy. A clear timetable for progress with national services is urgently needed.
o Development of services is impeded by local variations in commissioning, service specifications and tariffs. There should be a presumption towards all-Wales services in future.
o A national minor ailments service should be introduced within the current assembly term. This could release £57m-worth of GP appointments for more appropriate clinical care.
o The pharmacy contract needs to be developed with a vision of providing a greater range of public health services, medicines management services and of using pharmacies as a cost-effective location for other healthcare provision.
o WG should work with the profession on the development of a clear vision and strategy for enhancing medicines management and pharmaceutical care through community pharmacies in order to deliver better outcomes for patients, concentrating in particular on those with long-term conditions.
Crynodeb gweithredol
o Mae cyfle gwirioneddol i Lyworaeth Cymru wireddu potensial llawn fferyllfeydd a'u helpu i gefnogi cleifion mewn ffordd ystyrlon
o Bu'r cynnydd wrth ddatblygu'r contract fferylliaeth yng Nghymru yn araf a darniog. Mae angen brys am amserlen glir ar gyfer cynnydd ar wasaanaethau cenedlaethol.
o Caiff datbygiad gwasanaethau ei lesteirio gan amrywiadau lleol mewn comisiynu, manylebion gwasanaeth a thariffau. Dylai fod tybiaeth tuag at wasanaethau Cymru-gyfan yn y dyfodol.
o Dylid cyflwyno gwasanaeth cenedlaethol ar gyfer mân anhwylderau o fewn tymor presennol y Cynulliad. Medrai hyn ryddhau gwerth £57m o apwyntiadau meddyg teulu ar gyfer gofal clinigol mwy addas.
o Dylai'r contract fferylliaeth gael ei ddatblygu gyda gweledigaeth o ddarparu ystod ehangach o wasanaethau iechyd cyhoeddus, gwasanaethau rheoli meddyginiaethau a defnyddio fferyllfeydd fel lleoliad cost-effeithiol ar gyfer darpariaeth gofal iechyd arall.
o Dylai Llywodraeth Cymru weithio gyda'r proffesiwn i ddatblygu gweledigaeth a strategaeth glir ar gyfer gwella rheolaeth meddyginiaeth a gofal fferyllol drwy fferyllfeydd cymunedol er mwyn sicrhau gwell canlyniadau i gleifion, gan ganolbwyntio'n arbennig ar y rhai gyda chyflyrau hirdymor.
About Alliance Boots
At Alliance Boots, our mission is to be the world’s best pharmacy-led health and beauty group. The group’s businesses in the UK employ over 70,000 people. These businesses include:
o Boots UK pharmacy chain (2,472 stores)
o Boots Opticians (655 practices)
o Alliance Healthcare (Distribution) Ltd, our full-line wholesaler (12 service centres)
o Central Homecare, our clinical homecare specialist division
There are 101 Boots stores in Wales, of which 99 have registered pharmacies. In Wales, our business employs around 2,000 people, including:
o 180 pharmacists
o 280 healthcare assistants
o 30 trainee pharmacists (one-year posts)
Boots pharmacies are well distributed across Wales and are located in places where people live, shop, work and travel, with many open well beyond normal office hours and at weekends. Our chain encompasses those which serve small, local and rural communities, including some of the most deprived locations in the country, through to high streets and those which are part of the largest retail and destination shopping centres.
Alliance Healthcare (Distribution) Ltd is the only UK wholesaler delivering medicines to all pharmacies, dispensing doctors and hospitals. Our Swansea service centre makes deliveries to pharmacies across Wales. Alliance Healthcare also offers innovative added-value services to its independent pharmacy customers across Wales, such as flu vaccination training, an online service for private prescriptions (Web-prescriptions), support materials for medicines use reviews and for other NHS-commissioned services. Alliance Healthcare also supports Alphega, a pan-European virtual pharmacy network. Alphega has 19 participating independent pharmacies in Wales.
1. The role for community pharmacy in Wales
1.1. Community pharmacy has expanded its role in recent years and now provides a wide range of clinical and public health services (NHS and non-NHS) within easy reach of the people who need them most.
1.2. Pharmacists are able to help people maintain and improve their health; providing health messages, advice and services in areas such as physical activity, diet and weight management, stopping smoking, minor ailments and sexual health.
2. The effectiveness of the community pharmacy contract in enhancing the contribution of community pharmacy to health and wellbeing services
2.1. Since the current pharmacy contract was introduced in 2005 in England and Wales, there has been a gradual divergence between England and Wales as a result of devolution and health policy reform.
2.2. While patients have benefited from Medicines Use Reviews (MURs) and some enhanced services, and the NHS has seen greater efficiency delivered from community pharmacy, the full potential of the pharmacy contract in Wales has yet to be realised.
2.3. Despite Welsh Government commitments since 2005 to develop National Enhanced Services, these have not yet fully materialised: only one of the four agreed services is being delivered across all seven LHBs; an emergency hormonal contraception (EHC) service.
2.4. The EHC service was introduced in April 2011. While pharmacist training and accreditation is in place on an all-Wales basis, finance for the service remains with HBs, and this is causing problems for Boards and for community pharmacy.
2.5. Meanwhile, little progress has been made on smoking cessation, needle exchange or supervision consumption of prescribed medication being rolled out as national services.
2.6. These are services that are already being delivered in a number of Boots stores across Wales. For example, supervised consumption is in place in around 70 stores. We ensure consistency in these stores through our own standard operating procedures, but there is a lack of consistency across the country due to different patterns of commissioning by HBs and variations in service specifications. Services are patchy and despite being national priorities, not everyone in Wales can access them.
3. What are the barriers to implementation?
3.1. Lack of national frameworks As a national pharmacy chain we believe that there is undue emphasis on finding local solutions to what are clear national priorities for healthcare and public health, such as heart disease, COPD, smoking, sexual health and flu vaccinations. National frameworks and tariffs would allow the consistent delivery of quality services across the country and better collaboration with other healthcare professionals in primary care, while still allowing local commissioners the freedom to choose the range of services, the volume of provision and delivery locations that meet their local requirements.
3.2. Lack of scale/efficiency A lack of national frameworks leads to inefficiency in the commissioning system. Fragmentation also impedes the use of the large-scale awareness campaigns that are essential in improving rates of prevention or uptake of services. A lack of scale and varying formats of provision also leads to a lack of standardised data on outcomes, ie, about what is working. This makes it difficult for the NHS to judge the value of what is being provided.
3.3. Failure to involve pharmacy All too often pharmacy is seen as a supplier of products rather than as a skilled profession with expertise in medicines and their use. Consequently opportunities for improving the patient experience, and realising cost savings through efficient drug use, are rarely achieved.
3.4. Poor patient journeys The continued emphasis on providing health services at NHS locations, such as hospitals or surgeries, is not always conducive for improving the patient experience, especially if consultancy times are limited to normal working hours. Patient convenience rarely seems to feature in pathway design and the extended access offered by community pharmacies is ignored.
4. What more could pharmacy do?
4.1. We see three key areas where greater and more integrated use of community pharmacy would help the NHS in Wales: medicines management, public health and providing services in cost-effective settings.
4.2. Medicines management
What is the problem?
Medicines are the main stay of treating long-term conditions (LTCs), but at present there is little focus and few incentives for delivering better patient outcomes. Targets and incentives reward output (volume), but rarely recognise outcomes, waste, increased costs of treating complications and hospital admissions or re-admissions. In addition, unnecessary costs and time are incurred by GPs to providing minor ailments consultations that could easily be done in pharmacies.
What can pharmacy do?
We can deliver a comprehensive range of pharmaceutical care services that focus on improving outcomes for patients with LTCs. This would include being able to adjust medication as appropriate and provide services that support patients to understand, remember and be able to take their medicines. We can also provide minor ailment schemes to release valuable GP time
What are the barriers to be addressed?
An evolution of the national pharmacy contract framework is needed to produce incentives that support the delivery of better outcomes, alongside an efficient supply chain. There will need to be a shared responsibility with other professions and the pharmaceutical industry. Changes will be needed to legislation covering professional supervision in pharmacies to allow more efficient use of technology and skill mix. National frameworks and accreditation will remove inefficient duplication of effort. New systems for prescription transmission and reimbursement should be developed by pharmacy for adoption by the NHS. The development of expert patients making best use of their own data should be encouraged. A national minor ailments scheme should be developed and implemented as a matter of urgency so that GP time savings can be realised.
4.3. Public health
What is the problem?
The Welsh Government is committed to concerted national action on key public health issues, such as smoking, obesity, sexual health, drug and alcohol use, and self-care (including first aid), but this is being is undermined by variable and inconsistent local approaches across Wales.
What can pharmacy do?
We can deliver effective public health services through pharmacies that are located in all the places that people live, work, shop and travel. This would build on the Healthy Living Pharmacy model (England) and the pharmacy Public Health Service (Scotland), supported by consistent national advertising using appropriate media, and running alongside a range of private services that offer choice, access and convenience.
What are the barriers to be addressed?
A full range of nationally agreed and funded services should be developed. There would be a single, simple standard of accreditation. Pharmacy operators, large and small, would use their experience in marketing and promotion to help deliver public health awareness campaigns. These should be run on an all-Wales basis to allow better reach through local and national media.
4.4. Efficiency/cost-effective settings
What is the problem?
The NHS needs to be ready to adopt best practice from both public and private sectors and roll it out across the whole estate. National standards for services commissioned locally will help avoid expensive redesigns and duplication of effort. Boots, when seeking to roll out a new service nationally, asks: “Is it simple for stores?” (ie, does it allow staff to spend more time on improving the customer experience?) This mantra has worked well and we believe the NHS needs to take a similar approach to avoid unnecessary complexity. Only if it does this can the NHS truly get ahead of the curve and change its focus away from treatments towards supporting general wellbeing, prevention and self-care.
What can pharmacy do?
We can work with professional bodies and the Welsh Government and NHS Wales on national service frameworks and realistic plans for implementation (alongside a new approach to funding, see Section 4.2). We can work to design pathways that start with the patient journey and use pharmacies and other community settings (including homecare). We can work to help patients produce their own records, which they can share with health professionals as they see fit.
What are the barriers to be addressed?
There needs to be an acknowledgement that national solutions are needed to national problems, so as to reduce duplication of effort, and that patients should not be expected to make unnecessary visits to fit in with existing locations or opening times when the same service could be provided more efficiently or conveniently.
4.5. Overall, the community pharmacy contract has delivered the basics for patients and pharmacists in Wales. On the supply side, processes are well-developed and embedded in the system. However, the development of pharmacy services has been disappointing and the full potential for pharmacy-delivered services has not been realised. Despite national direction over several years and the work of the Task and Finish Group, pharmacy has lacked an effective action plan and sustained commitment from politicians and the NHS to new service development.
5. The extent to which Local Health Boards have taken up the opportunities presented by the contract to extend pharmacy services through the provision of ‘enhanced’ services and examples of successful schemes
5.1. Since the introduction of the contract there have been cases where pharmacy has worked well with LHBs to deliver innovative, effective services to patients.
5.1.1. Minor ailmentsBoots pharmacies are among 19 in one locality in Torfaen HB providing a “Pharmacy First” minor ailments scheme. This encourages patients to visit pharmacies rather than GPs for treatments for self-limiting conditions, such as hayfever, head lice or colds/flu. The service has been well received by customers with lots of positive feedback. Regretfully, the HB has announced that it plans to decommission the scheme, despite an ongoing need and Labour’s manifesto pledge.
5.2. During the transition from 22 to seven HBs in 2009 much of the best practice, experience and good working relationships that had been built up was lost.
5.3. Despite the reduction in Board numbers, there remains inconsistency in the design and remuneration of services. For example, Cardiff & The Vale HB covers the largest population in Wales and yet it commissions the fewest services from pharmacy among the Boards.
5.4. There is also an issue about how community pharmacy should effectively engage with Boards: after 18 months, there are still a number of posts across HBs that remain unfilled. At Board level, we would also like to see more coordination between the Locality Director, the Medical Director and the Primary Care Director. This would ensure more effective commissioning of services across the locality. Closer working between these key roles could also instigate a culture change to finally move funding from secondary to primary care.
5.5. Boards also need to do more to make the most of the clinical expertise, capacity and accessibility of community pharmacy. For example, plans to pilot flu vaccinations through community pharmacies in Aneurin Bevan and Cwm Taf HBs did not make enough progress to be implemented in time for the 2011/12 flu season. This is to be regretted.
5.6. WG has set targets thatimmunisation uptake rates should reach 75% for key groups (over-65s and at-risk under-65s). In 2010/11, uptake was only 66% in over-65s and just 48% in at-risk under-65s. Failure to use pharmacy to boost uptake is a wasted opportunity and cannot be considered to be in the best interest of patients.
5.7. The Welsh Government should urgently introduce a full range of all-Wales services. These would allow a consistent level of quality, cost-effective services across the country, supported by fully-trained pharmacists and effective public awareness campaigns.
6. The scale and adequacy of advanced services provided by community pharmacies
6.1. MURs The first advanced service to be provided under the pharmacy contract is the medicines use review (MUR).
6.2. Boots has delivered a significant number of MURs since their introduction. Since 2005, Boots has delivered over 100,000 reviews to patients in Wales. These reviews allow patients to have a discussion about any problems they might have with taking their medicines (such as side effects or being able to take the medicine at the right times).
6.3. We find patients are open with their pharmacists during these reviews and this has on a number of occasions led to more serious health issues being uncovered, requiring referral to a GP or other healthcare professional.
6.4. MURs also offer opportunities to address specific issues in groups, such as improving inhaler use among asthma patients. They can also highlight opportunities to reduce medicines waste by identifying products that patients are not using or where more appropriate therapies could be considered.
6.5. AURs Pharmacies can also provide a similar appliance use review (AUR) to patients who use stoma products. This is a relatively new service, serving a much smaller population, and has yet to gain significant uptake.
7. Scope for further provision of services by community pharmacies in addition to the dispensing of NHS medicines and appliances, including the potential for minor ailments schemes
7.1. Alliance Boots believes that there is a real opportunity for community pharmacy to deliver effective health services in Wales. With much of the infrastructure and clinical staff already in place, pharmacy could be developed to effectively deliver on key services for the public over the course of this Assembly term. Evidence of pharmacy services from across the UK highlights the benefits to the public and to the NHS.
7.2. Minor Ailments Service for Wales
7.2.1. One inevitable drawback of “free” prescriptions is that patients may seek a GP appointment to request prescriptions for products to treat minor ailments, rather than obtaining these directly from pharmacies.
7.2.2. Around 18% of appointments are taken up with such consultations, representing a considerable opportunity cost. A national minor ailment service would allow pharmacists to supply such medicines on the NHS, freeing GP time to deal with more serious or specialist cases.
7.2.3. Scotland introduced a national minor ailments service (MAS) through pharmacies in July 2006. Currently, 14% of the Scottish population is registered for MAS, each making just under two visits a year to a pharmacy on average. This equates to just under 800,000 people saving around 1.5 million GP appointments by visiting pharmacies instead.
7.2.4. Similar schemes in Wales have already been successful at a local level (see Para 5.1.1). We believe that a national minor ailments service should be rolled out across Wales with urgency.
8. The current and potential impact on demand for NHS services in primary and secondary care of an expansion of community pharmacy services and any cost savings they may offer
8.1. We estimate that introducing a national repeat dispensing service would deliver cash savings of £8m through increasing efficiencies in pharmacies and GP surgeries. It would also release around 300,000 hours of GP time a year, based on UK Cabinet Office figures.
8.2. Allowing community pharmacies to deliver flu vaccinations would broaden the accessibility of this NHS service, especially to working age people in at-risk categories. This gives an opportunity to increase vaccine uptake rates (thus reducing other healthcare costs relating to episodes of flu).
8.3. Introducing a national minor ailments service (see Para 7.2) would produce benefits in the order of £57m a year by saving on GP consultations, at a cost of pharmacy provision of only £7m a year. These figures are based on extrapolating the successful Minor Ailments Service in Scotland, which has been running for five years, to a Welsh population. This does not include additional savings that could also be realised by reducing unnecessary A&E attendances.
9. Progress on work currently underway to develop community pharmacy services
9.1. Using our experience and expertise, Boots continues to develop innovative new products and services that deliver high quality, accessible healthcare. Examples of recent developments include:
9.1.1. BootsWebMD An online portal (developed in conjunction with WebMD, a leading internet health content provider) to offer in-depth information on health topics
9.1.2. Prescriptions DirectAn online service providing access to selected medicines through private prescriptions, where appropriate. Medicines can be delivered to patients’ homes or workplaces or collected from selected Boots stores
9.1.3. Private PGDs Working under the supervision of a registered Independent Medical Agency, trained Boots pharmacists are able to offer customer services that include the supply of prescription medicines. These services include weight management, hair retention and erectile dysfunction
9.2. In order to offer the widest range of services to customers, Boots has created a network of 200 Pharmacy Service Centres across the UK. These are equipped to provide a full range of NHS and Boots services. They have upgraded consultation facilities, offering greater privacy, and serve as collection points for Prescriptions Direct orders.
9.2.1. There are currently seven Boots Pharmacy Service Centres in Wales: Swansea, Newport, Carmarthen, Bridgend, Cardiff, Llandudno and Cwmbran.
9.3. Boots stores, with their convenient locations and long opening hours, make excellent bases from which other healthcare services can be provided, increasing access for patients. Pharmacies can also serve as a base for services in deprived and rural areas. Examples of such services include:
9.3.1. GP practicesBoots now has 22 GP practices that are located within existing stores. These operate on a landlord/tenant basis and can either be a relocation of an existing practice or an additional satellite surgery. Approval has recently been given for the first Welsh instore GP practice in Llanelli. This should open during the current financial year.
9.3.2. Sexual healthIn Birmingham a sexual health clinic, located alongside an NHS Walk-in Centre in our city centre store, has managed to increase the percentage of under-25s accessing its service from 20% to 60% as a result of offering a seven-day service with longer opening hours from a convenient central location
9.3.3. Ophthalmology Our Boots Opticians practice in Watford plays host to an outpatient ophthalmology clinic run by local GPs and Moorfields Eye Hospital
9.4. Boots also works with charities and other providers of healthcare support, information and advice. Our current partnership is with Macmillan Cancer Support:
9.4.1. Helping with cancer Macmillan Cancer Support and Boots UK launched a three-year partnership in September 2010, which aims to help people living with cancer, and their family and friends, through increased access to information and support.
9.4.2. We have trained our pharmacists in signposting within cancer care, and information about cancer services in Wales is available in all our pharmacies. Boots’ reach and accessibility across Wales will allow these skills to be utilised by people in Wales affected by cancer. During the recent National Eisteddfod in Wrexham, our joint stand with Macmillan attracted over 100,000 visitors and more than 1,000 had a health check with our trained staff while on the stand.
10. Recommendations
10.1. Alliance Boots would like to make the following recommendations to the Health and Social Care Committee as part of its inquiry onto the contribution of community pharmacy to health services in Wales.
10.1.1. The Welsh Government should set out a clear timetable for the introduction of a full range of national enhanced services through community pharmacies during the course of the current Assembly term. These services would have national specifications and tariffs.
10.1.2. These national services should include:
o Minor ailments
o Enhanced sexual health, including the provision of EHC
o Smoking cessation
o Flu vaccinations
o Medicines management for patients with specific long-term conditions
10.1.3. Planning for any future pharmacy services should start with an assumption that they will be delivered on an all-Wales basis with a single national service specification and tariff.
10.1.4. Community pharmacies should be used as a location from which other healthcare services can be provided, including in deprived and rural areas.
10.1.5. WG should work with the profession on the development of a clear vision and strategy for enhancing medicines management and pharmaceutical care through community pharmacies in order to deliver better outcomes for patients, concentrating in particular on those with long-term conditions.
Response submitted by:
Paul Harris, MRPharmS
Country Manager, Wales
Regional Pharmacy Office
Boots UK
36 Queen Street
Cardiff CF10 2RG
23 September 2011