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SUBJECT: |
REPORT ON THE PHARMACY SERVICES REVIEW 2009 |
REPORT OF: |
STRATEGY AND COMMISSIONING OFFICER AND PUBLIC INVOLVEMENT OFFICER |
STATUS: |
FOR DECISION |
CONTACT: |
LINDA TAYLOR / DAVID KENNY |
DATE |
Friday, 27th AUGUST 2009 |
PURPOSE:
The purpose of this report is to enable Area Committees to examine the information and evidence gathered on the provision of Community Pharmacy Services that are funded by the NHS, throughout Gwent.
BACKGROUND:
Gwent CHC decided in January 2009, to move towards more formal reviews of NHS services to inform the development of a structured scrutiny approach to our monitoring duties. It was agreed that the first review would be undertaken between March and September 2009 and would focus on the provision of Community Pharmacy Services.
AIM OF THE SERVICE REVIEW:
In representing the interests of patients and the public in the NHS, Gwent Community Health Council aim to keep under review the local provision of pharmacy services by assessing; current local provision, the medium and long term plans for developing and sustaining reasonable access to pharmacy services, assess any inequalities in provision and make recommendation for service improvements.
OBJECTIVES OF THE SERVICE REVIEW:
1. Identify the number and location of pharmacies in each Local Health Board (LHB) area
2. Identify the provision and access to ‘out of hours’ pharmacy services
3. Identify the range of services available from each pharmacy including;
· Stop Smoking Services
· Minor Ailment Service
· Supplementary Prescribing by Pharmacists
· Emergency Hormonal Contraception Service
· Supervised consumption of methadone
· Prescription collection and delivery service
· Drugs return and disposal service
· Needle exchange
· Health screening
· Individual patient medicines reviews
4. Examine the level of access to premises and the quality of the patient environment
5. Examine what contract and performance monitoring is undertaken by LHBs
6. Examine the local joint working initiatives and arrangements between GPs and Pharmacies
7. Examine the LHB strategy/plans for pharmacy services or level of inclusion in primary care needs assessments and strategies and how these services are promoted and patients informed of their benefits.
8. Examine the LHB strategy/plans for dealing with minor ailments long term conditions.
9. Examine the level of investment by LHBs into pharmacy services to provide support to vulnerable patients, their families or carers.
10. Examine how repeat dispensing is made available to patients in the LHB area, how patients are made aware of the services.
11. Examine how the LHBs are planning to deliver on the ‘National Service Framework for Older People’ through joint GP and pharmacy initiatives.
12. Examine information on Patient and Public experiences of services
EXAMINATION OF THE SERVICE INFORMATION AND EVIDENCE
1.1 Community pharmacies are stores or shops which dispense prescriptions and provide over the counter medication. These stores are found on the High Street in many towns and sometimes in large supermarkets. They mainly provide the dispensing service of drugs/therapeutic aids/medication that help patients either with their treatment or with maintaining a quality of life.
“Community Pharmacy Services are seen by patients and the public as essential local primary care facilities and a major part of community and social networks, pivotal to generations and sustaining local retail activity”
1.2 A new contractual framework was introduced for community pharmacy in April 2005, drawing on the skills, expertise and the experience of pharmacists and their staff. Given its presence in the community with a tradition of ready access to all, community pharmacy aims should:
I. be – and be seen to be – an integral part of the NHS family in providing primary care and community services
II. support patients who wish to care for themselves
III. respond to the diverse needs of patients and communities
IV. be a source of innovation in the delivery of services
V. help deliver the aspirations within Designed for Life, and
VI. help to tackle health inequalities.
1.3 There is increasing emphasis on community pharmacies providing a greater range of services to improve access for patients and reducing the workload of GPs. However, there is an emerging variation of services provided from pharmacies in different locations, which may in time exacerbate inequalities in access to health services for some population groups.
1.4 Pharmacy is a profession which does not have a ‘performers list’. A performers list is a list of medical personnel who can provide services to the general public. Pharmacists are not required to be on a performers list, unlike GPs and Dentists who provide treatment for patients, the pharmacists dispense the patient’s drugs or medication, they do not provide a ‘treatment’ service.
1.5 Pharmacy is a ‘notifiable’ profession, whereby the police have a responsibility to inform the professional registration body of all misdemeanours. Pharmacists are not routinely checked against police computers; however, there is ongoing debate around the need for Criminal Records Bureau (CRB) checks considering some of the more sensitive services that Pharmacists provide for the public. Within the Gwent area, Monmouthshire is the only area where pharmacists are checked against the Criminal Records Bureau.
2.1 The NHS Community Pharmacy Contract was agreed between Pharmaceutical Services Negotiating Committee (PSNC), the Department of Health (DOH) and the NHS Confederation (NHS Employers) and was accepted by pharmacy contractors in two ballots. The new arrangements began in April 2005. The contract applies to both England and Wales and is made up of three different service levels:
· Essential services - provided by all contractors and includes; Dispensing of Medicines, Repeat Dispensing, Waste Management, Public Health, Signposting, Support for Self-Care and Clinical Governance
· Advanced services - can be provided by all contractors once accreditation requirements have been met. An example of this is Medicine Use Review. The review will help patients understand their therapy and it will identify any problems they are experiencing along with possible solutions. A report of the review is provided to the patient and to their GP.
· Enhanced services – are commissioned locally by Local Health Boards (LHBs) in response to the needs of the local population. This includes services such as condoms dispensing, methadone dispensing and the morning after pill etc. A needs analysis should enable Local Health Boards to ascertain what services will need to be purchased at a local level.
2.2 There is increasing emphasis on community pharmacies providing a greater range of services to improve access for patients and reducing the workload of GPs. However, there is an emerging variation of services provided from pharmacies in different locations, which may in time exacerbate inequalities in access to health services for some population groups.
3.1 All Local Health Boards undertake Contract and Performance Monitoring of pharmacy services. The Local Health Board send a contract monitoring self assessment document to all pharmacies within their area and four of the five Local Health Boards then select pharmacies they wish to visit. Caerphilly Local Health Board visits all their pharmacies on an annual basis. Once the New Local Health Board has been established, all pharmacies across Gwent will be evaluated on an annual rolling programme.
3.2 The selection process for performance monitoring visits is based on:
· the quality of the returned self assessment
· whether the self assessment has been returned
· if there are significant action plans from previous year's visit
· change of premises, relocation, or change of ownership
4.1 There are 126 pharmacies in the Gwent Area. The service locations are coterminous with Local Authority and Local Health Board boundaries and the breakdown of these services by borough are as follows:
|
Local Health Board area |
Number Of Pharmacies In Each Local Health Board |
|
Blaenau Gwent |
16 |
|
Caerphilly |
43 |
|
Monmouthshire |
17 |
|
Newport |
30 |
|
Torfaen |
20 |
|
Total Pharmacies in Gwent |
126 |
5.1 Out of Hours pharmacy service operates throughout Gwent and provides urgent access to medication outside the normal working hours. This service is provided on weekday evenings, Saturdays and Sundays and Bank Holidays.
5.2 Patients requiring medication out of normal working hours may first access the General Practitioner Out of Hours Service which carries a limited amount of prescription/over the counter drugs that can be given to a patient for a short period of time until patients are able to visit their own GP or access a pharmacy. However where there is a clinical need, a full course of antibiotics will be administered by the Out of Hours General Practitioner service. In some cases this service may offer “a delayed antibiotic service”, which entails the clinician providing the patient with a prescription for antibiotics to be dispensed should the patient’s symptoms persist.
5.3 Out of Hours Pharmacy Rotas are also provided across Gwent for special bank holidays – New Year’s Day, Easter Sunday, Christmas Day and Boxing Day. Lists for all pharmacy services across Gwent are published and displayed in prominent and appropriate venues.
5.4 Opening times for Sundays and Bank holidays by each Local Health Board area are as follows:-
Ebbw Vale 5:30-6:30
Abertillery 12-1
Tredegar 5:30-6:30
Brynmawr 12-1
Bargoed 5:30-6:30
Caerphilly 12-1, 1-2, 4-5
Crumlin 5-6
Newbridge 5-6
Blackwood 9-5:30, 12:30-1:30
Ystrad Mynach 2-3
Nelson 2-3
New Tredegar 11:30 12-30
Abergavenny 10-6, 10-4
Caldicot 11:30 -12:30
Newport 11-1
Newport 2-4
Pill, Newport 4-6
Rogerstone, Gaer, 5-6
Always, Bettws and Malpas
Blaenavon 12-1
Cwmbran, Pontnewydd, 9-5, 4-6
Old Cwmbran and Llanyrafon
Pontnewynydd 9 -5:30, 9-5, 11:45-2:45
and Pontypool
5.5 The pharmacy rota excludes some pharmacies which open outside normal working hours for commercial reasons and although they have a pharmacist on site and are able to dispense medicines, this service is not part of the pharmacy out of hours funded service.
The range of services available from each pharmacy will vary, where some of the free services available to patients will be provided purely on a commercial basis i.e. health screening and the prescription collection and delivery service. These services are not part of the NHS and as such are not funded by the Local Health Board or the NHS.
6.1 PRESCRIPTION COLLECTION AND DELIVERY SERVICES
Although the prescription collection and delivery service is valued by patients, the clinical benefits are questionable and concerns have been raised that it leaves little interaction between the clinical professional and the patient. However, it could be argued that the lack of contact between the patient and clinician is not a consequence of the collection and delivery service but as a result of the prescribing practices and the mechanisms in place to ensure appropriate medicine reviews by GP practices. From a patient/public perspective, the collection and delivery services can be invaluable for those with limited mobility and those with long term conditions that have limited family or community support to access their prescriptions.
7.1 The main or essential role of the community pharmacy is to dispense medication. The essential services are provided by all contractors and include dispensing of medicines, repeat dispensing, waste management, public health, signposting and support for self-care. All essential services are subject to clinical governance policies and procedures.
8.1 When
patients need to see their GP, the GP will make a clinical decision
on whether the patient will benefit from prescription medication to
alleviate symptoms and/or to improve health. Prescription
medicine is now being provided free, as part of the
treatment.
8.2 The purchase of non-prescription medication,
‘over-the-counter’ without the need to see your GP,
continues in the normal way and the pharmacist is available to
advise the patients and the public on the appropriate use of these
medications. Those that prescribe medication, decide on
clinical
grounds what a patient needs on prescription to
help improve their health.
9.1 All patients registered with a Welsh GP, who get their prescriptions from a Welsh pharmacist, are entitled to free prescriptions.
9.2 Welsh patients who have an English GP and who get their prescriptions from a Welsh pharmacist will be entitled to free prescriptions. They will need to present their prescription with an accompanying entitlement card.
9.3 Along with free prescriptions, charges for wigs and appliances were also abolished. Patients who receive these services from an English NHS Trust should have their costs met by their Local Health Board.
10.1 Free prescriptions should specifically benefit those people on modest incomes or who have chronic illnesses, such as heart disease, high blood pressure and cancer. Research shows that many people on moderate or low incomes were deterred from taking regular medication that would help them live healthier lives, because of the cost of paying for regular prescriptions.
11. WHAT ARE THE DISADVANTAGES OF FREE PRESCRIPTIONS?
11.1 The cost for providing free prescriptions in Wales is £30m per annum.
11.2 Where patients no longer pay for prescriptions, there is a risk that they do not consider the actual amount they need and that repeat prescriptions are ordered with less thought than if the items are chargeable, therefore increasing waste and the cost to the NHS.
12. SCHEMES TO REDUCE MEDICINES WASTE AND THE COST OF DRUGS.
12.1 Medicines waste is a significant problem for the NHS and the Gwent area is no exception. Large quantities of medication are dispensed by repeat prescription with many instances of patients requesting medication that they do not need or are unwilling to use. There are numerous schemes to reduce the costs of prescribing some of which are described below;
13. ‘GENERIC PRESCRIBING’ AND ‘SPECIALS’
13.1 Generic prescribing is a means of looking at the most medically and cost effective drug to be prescribed for the patients symptoms. Pharmacy leads in Local Health Boards undertake the work to promote generic prescribing and advise General Practitioners on which generic drugs to prescribe. . However, General Practitioners do not have to adhere to this advice and hence some surgeries may prescribe more expensive drugs.
13.2 ‘Specials’ are drugs that come in a different shape or form to normal drugs, and are prescribed to cater for the specific needs of the patient where tablet, capsule, soluble form or suspensions can be prescribed. The cost for these different preparations varies and a prescription for the same drug in a different form can substantively increase the costs of prescribing. The variation in the costs of these different preparations is an area of major concern for the NHS and subject of ongoing debate as to the reasons for patient choice and GP preference in prescribing.
14.1 The purpose of these schemes is to reduce the number of medicines and appliances supplied unnecessarily. The ‘non dispensing scheme’ or ‘not required scheme’ enables the pharmacist to discuss with patients, who receive repeat prescriptions for medicines or appliances, their actual needs and the effective use of their medications. The process can identify items that are either not needed or those that can be reduced from monthly request to accommodate the patient’s needs and avoid dispensing unwanted or underused medications. In full agreement with the patient, the pharmacist will mark the prescription ‘Not Required (NR)’ and record the prescription information on a record form. This enhanced service is currently being piloted in Gwent and offers the following benefits;
14.2 A Non Dispensing Scheme in England has been successful in Primary Care Trusts and has been proven to lessen waste, improve safety and decrease prescribing costs. However the benefits of these schemes in Wales may not be realised in the short to medium term but may have an impact on waste reduction in the long term.
15.1 A Medicines Use Review (MUR) or medicines check up is a meeting between the patient and the pharmacist to talk about:
15.2 This NHS funded service usually takes place in the local pharmacy and the purpose of the review is to:
15.3 If changes to medications are required, the pharmacist will write to the patient’s GP with a proposal to change drugs or modify the patient’s prescriptions.
15.4 The majority of pharmacists in Gwent are accredited in this area of work, where 110 out of 126 pharmacies provide the service. The Business Services Centre validates this information based on the pharmacist’s letters to General Practitioners. A Pharmacist will only be accredited to provide this service if they are able to provide a separate consultation room, where two people can sit and talk without being overheard using normal speech. All pharmacies that have been accredited in the Gwent area have been visited by staff from Local Health Boards to ensure that rooms are fit for purpose.
15.5 This service can be provided to ‘housefast’ patients and these patients would probably benefit the most from this service; however in reality very few house visits are undertaken. Where a pharmacy has only one pharmacist, if they were to leave the pharmacy to conduct a home visit, the pharmacy may be left without a dispensing pharmacist.
15.6 This service is validated by the Business Services Centre and pharmacists must be accredited to operate it. Pharmacies are allowed to claim for up to 400 Medicine Use reviews per annum and this is supervised by Local Health Boards. No patient details are given to Local Health Boards, but pharmacists may use a patient identifier to monitor the system. A full list of the pharmacies which have accredited pharmacists that operate this service is below.
|
Local Health Board |
Number Of Pharmacies In Each Local Health Board |
No Of Pharmacies Undertaking Medicine Uptake Review In Each Local Health Board |
|
Blaenau Gwent Local Health Board |
16 |
13 |
|
Caerphilly Local Health Board |
43 |
39 |
|
Monmouthshire Local Health Board |
17 |
16 |
|
Newport Local Health Board |
30 |
24 |
|
Torfaen Local Health Board |
20 |
18 |
|
Total Pharmacies |
126 |
110 |
16.1 All pharmacies in Gwent deliver one or more enhanced services, which are extra to the pharmacy contract and contracted (based on population need) and monitored by the relevant Local Health Board. They include the following services:
Emergency Hormonal Contraception
Condom Card
Methadone Dispensing
No smoking Level 2
Needle Exchange
Non dispensing /not required Service
Out of Hours palliative care
Pharmacy Care Homes Review
Minor ailments
16.2 There are varying reasons why some pharmacies offer different services not least local population needs for services such as Emergency Hormonal Contraception or the Methadone Enhanced Services, or because they are unable to comply with the environmental requirements for the service. To deliver the Medicine Use Review service they are required to provide a separate consulting room or area, whereas the delivery of other services such as the Methadone or contraception services, pharmacies do not require the provision of ‘a quiet corner’.
17. 2 Pharmacists that offer this service are required to inform the Local Health Board of the numbers of treatments offered in order to receive payment for the service.
17.3 Within Gwent there is only one scheme in place which covers the Torfaen area. The scheme, although widely used in England, has not been generally picked up in Wales because of a range of factors, not least the lack of evidence that it actually reduces the burden on GP services. Feedback about the service from professionals and the public has been positive, but this may not be sufficient to determine the ongoing viability of the scheme. It is not yet decided if this scheme will be rolled out across Gwent once the Aneurin Bevan Local Health Board has been established.
18. CONTRACTED PHARMACY HOURS
18.1 Pharmacies are required to
open for a minimum of 40 hours a week unless they get permission
from their LHB to open for a shorter period. Contractors were
required to notify the LHB of their actual opening hours by 30 June
2005 so that the LHB could carry out a local assessment of the
available pharmaceutical services. It was important that
pharmacies disclosed their full hours so that the LHB obtained a
reliable picture of the services available. Future changes of
hours will require an application to amend the 40 core contractual
hours, or notification with at least 90 days notice to amend hours
other than the 40 core contractual hours.
18.2 Provided the pharmacy is opening for the minimum of 40 hours,
the LHB is able to issue a direction to the pharmacy to open
for longer hours, but only if it is satisfied that the
pharmacy will receive reasonable payment. There is a right of
appeal where a LHB directs a pharmacy to open for additional
hours.
19. PHARMACY PRACTICE LEAFLETS
19.1 The clinical governance requirements for pharmacies require the pharmacy to “… produce in an approved manner, a practice leaflet containing approved particulars in respect of his pharmacy”.
The Department of Health published on 15 October 2008, a clinical governance system acceptable to the Secretary of State for the pharmacy practice leaflet. From 15 October 2008, all pharmacies must produce a practice leaflet that complies with the specification.
19.2 The practice leaflet must include the following:
19.3 The leaflet must be printed using a plain font in minimum size 12 pt. The leaflet must be branded with the NHS logo and the pharmacy descriptor line "Providing NHS Services" in the bottom right hand corner on the first page. The NHS logo must, as a registered trademark, be used in accordance with the NHS identity guidelines for pharmacies. A review of the leaflets available from pharmacies in Gwent is currently underway and the results will be made available to Committee by the end of August 2009
20. HANDLING COMPLAINTS
20.1 Under the provisions of the National Health Service (Pharmaceutical Services) Regulations 2005 pharmacy contractors are required to make arrangements for the handling and consideration of complaints. These arrangements must ensure:
The new regulations introduce several major changes which are described in detail below. These are:
21.1 Gwent Community Health Council members have visited 35 of the 126 pharmacies in Gwent during 2008/9 as part of our local monitoring programme (28% of the total). In terms of Boroughs, 2 pharmacies were visited in Blaenau Gwent, 14 in Caerphilly, 4 in Monmouthshire, 9 in Newport and 6 in Torfaen.
21.2 Prescription collection and delivery service.
Of those visited the overwhelming number (33) operated a prescription collection and delivery service. Only 2 did not.
Conclusion: The overwhelming number of pharmacies offered this service, though there are many permutations and criteria for availability – ie the service could be generally offered or just on the basis of individual patient need. When considering the competing perspectives of those providing the service, those recieving the service and the concerns raised through a clinical governance perspective, issues of convenience for the patients, good clinical governance, and the potential for wastage, are all factors that should be considered. This is an area for more detailed scrutiny.
21.3 Drug return and disposal service
All pharmacies visited offered this service.
21.4 Staff identification:
In more than half (20 pharmacies) staff wore name badges, the highest proportion being in Torfaen where in 5 out of the 6 pharmacies visited staff were identified. 2 pharmacists reported that they did not want their staff to be named for personal safety reasons.
Conclusion: CHCs in Wales have taken the view that all health professionals should be identified by name and position, a requirement which is also widely enforced for assistants in retail outlets. This principle should therefore be applied to pharmacy staff and clearly there is a level of resistance to this principle.
21.5 Lunchtime cover :
More than half the pharmacies (20) claimed to offer lunchtime cover, with clear majorities in Newport and Torfaen. In Caerphilly a small majority (8 out of 14) did not have lunchtime cover, and neither did the 2 pharmacies visited in Blaenau Gwent. Closures ranged between an hour and one and a half hour.
Conclusion: This could be a problem where there is limited choice in a small community. Ideally pharmacies might close at differing times to ensure continuity of service though this may be difficult to achieve as Pharmacists have a retail aspect to their services where there seems to be a reluctance to work collaboratively with competitors.
21.6 Average time for dispensing:
The great majority of pharmacies (28) said that they dispensed prescriptions within 5 to 10 minutes.
Conclusion: The wait for dispensing does not appear to be a problem, however enquiries and complaints received by Gwent CHC would indicate that further work is required to establish patient satisfaction with dispensing times.
21.7 Extra services such as health checks, blood tests, health promotion and the minor ailments scheme.
A clear majority (26 out of 35) pharmacies visited offered extra services, with a particularly high proportion in Caerphilly. All the 6 pharmacies visited in Torfaen offered extra services.
Conclusion: A high proportion of pharmacies appear to offer extra services
21.8 Policy on handing complaints:
Of the 32 responders to this question only 2 pharmacies did not have a policy. 1 pharmacy reported that they “didn’t get complaints” so this was not required.
Conclusion: All pharmacies are required to have a policy for handling complaints and the Local Health Boards should ensure compliance.
21.9 Complaints leaflet:
9 of the 32 responders to this question did not have a complaints leaflet. Half the pharmacies visited in Torfaen (3 out of 6) did not have a complaints leaflet.
Conclusion: All pharmacies should be able to produce a complaints leaflet and approaching a third of our sample could not offer a copy on request. This is an area that requires improvement.
21.10 Communication with those with sensory impairment
Of the 32 responders to this question, 23 did make special arrangements – loop system, magniyfying glass, dispensing aids etc. 9 pharmacies did not, including half those visited in Torfaen (ie 3 out of 6 pharmacies).
Conclusion: Generally positive though some progress needs to be made to ensure equitable service delivery for patients with a sensory impairment.
21.11 Bilingual service (Welsh)
Only 4 of the pharmacies visited; 1 in Newport and 3 in Caerphilly had special arrangements to offer a bilingual service. 11 pharmacies considered that this service was “not applicable” to them.
Conclusion: There is no obligation for pharmacies to offer a service in Welsh and this facility is likely to be demand led. It is recognised that this provision may be difficult for smaller pharmacies to offer this service.
21.12 Communicating with people who do not have English/Welsh as a first language
Only 6 of the pharmacies visited had special arrangements for people in this category. 3 of these pharmacies were in Caerphilly with 1 positive response from Newport, Blaenau Gwent and Torfaen. The need might be expected to be particularly high in Newport, though this is not obviously reflected in the sample. Language Line seems to be the arrangement of choice for most pharmacies. No pharmacies indicated this issue was “not applicable” to them though one reported that “they had no customers who did not have English as a first language”
Conclusion: This is an area for improvement. With a more mobile population, asylum seekers and economic migrants this is likely to be a growing need, particularly in major centres such as Newport.
21.13 Needle exchange programme
A relatively small number of the 35 pharmacies sampled (4) operated a needle exhange programme for intravenous drug misusers. None of the Monmouthshire or Blaenau Gwent pharmacies sampled operated this service. 11 pharmacies considered the service “not applicable”.
Conclusion: This is understood not always to be a “popular” service with pharmacists, and the number operating the service seems to be small. To ensure safe practice and compliance there does need to be reasonable cover.
21.14 Policy for the disposal of “sharps”
Only 8 of the sample of 35 have a procedure for the disposal of “sharps” 12 pharmacies described such a service as “not applicable” probably reflecting the fact that local authorities in Gwent provide a household collection service for patients who take medication intravenously (eg diabetic patients).
Conclusion: This is a client group which now seems well served.
21.15 Methadone programme
A small majority of the sample (19) operate a methadone programme. 5 pharmacies did not participate with 11 pharmacies describing the service as “not applicable.”
Conclusion: Reasonable cover needs to be provided but there are parallel centres in each locality, operated by the drug misuse service which also provide this service.
21.16 People with learning disabilities
All the pharmacies visited agreed they had special arrangments to support patients with learning disabilities – charts, medicine calendars, bubble packs etc.
Conclusion: A very positive response.
21.17 Access
Conclusion: Generally positive response but more progress needed on disabled access.
21.18 Decoration /Appearance ( Entrances, Reception, Common areas)
Generally phamacies scored well. 12 pharmacies were placed in the Excellent category including all the 6 visited in Torfaen. 19 were rated as Good, 3 Fair. 1 was rated Poor, a pharmacy in Blaenau Gwent.
Conclusion: Generally positive feedback.
21.19 Patient information
Conclusion: Pharmacies are required to have a practice leaflet and most appear to do so. Lack of information on making a complaint is the major area of concern.
21.20 Private consultation
Private consultation rooms are a requirement for Medicine Use Reviews (MUR), undertaken by the large majority of pharmacies. Of the 35 pharmacies only 4 identified a private consultation facility as “not applicable”. Of the others 20 were described as Good, 7 as Excellent, and 2 as Fair. 2 pharmacies rated Poor for private consultation, both in Newport.
23.1 The number and location of pharmacies tend to mirror the resident population. Most pharmacies undertake Medicine Use Review -110 out of 126. All pharmacies undertake some or all enhanced services – albeit some different services for different pharmacies. However the following issues identified from the service review require further consideration;
A. Patterns of service
Given the different patterns of pharmacy services between rural, valley and urban areas, it is essential that Council take a view on what constitutes fair access to services throughout Gwent.
Recommendation:
That Council further discuss the distribution of pharmacy services across Gwent and form a view on the following;
B. Variations of Service
There are variations in the services provided such as Emergency Hormonal Contraception for under age patients, Needle Exchange Scheme, health promotion, health screening and disease prevention. Although it is reasonable for each locality to provide services tailored to local needs, should there be more central direction from the new LHB for pharmacies to develop a more comprehensive and an equitable range of services for each locality?
Recommendation;
That Council review the different pattern of services between localities and form a view on the following;
C. Generic Prescribing
We have been informed that prescribing costs in Monmouthshire are substantially more than any other Borough in the Gwent area because of the level of GP dispensing to rural communities. We have also been informed by the Local Health Board that ‘Dispensing GPs’ are resistant to introducing cheaper generic prescribing because of loss of income to local practices. The effect on patients is probably neutral in regards to the efficacy of the medication, but this inflexibility does have substantial resource implications.
Where local pharmacies have applied to provide a service to local communities, we have experience of complaints from GPs about the viability of their practice and the potential or real loss of primary care services.
Recommendation;
For the Council to request evidence from the NHS in regard to actual cost of the reported resistance from GPs to generic prescribing, the level of disadvantage to GP surgeries from reducing the prescribing budget and the consequent effects on patient services. Should the CHC recommend that this issue be actively addressed.
D. Medicines Use Reviews
Currently the review of medications is undertaken by both GPs and Pharmacists and although it is recognised that the pharmacist delivery of Medicines Use Reviews and the Non dispensing/Not required schemes is intended to reduce unnecessary dispensing and hence wastage of medicines, there would seem to be a duplication of effort. It could be argued that pharmacists are more expert in the efficacy of medications and in a better position to judge when actually dispensing, though they have to refer suggested changes back to the GP.
Recommendation:
Council is requested to come with a view as to whether pharmacy reviews represent “added value” in terms of professional scrutiny, value for money, and patient convenience or is it an unnecessary duplication of the regular reviews of repeat prescription medication which GPs are, or should be, undertaking?
E. Privacy and dignity
Pharmacies are only required to have available a private area/consulting room if they provide Medicine Use Reviews. Most pharmacies undertake MURs and therefore have this facility, though a number of smaller pharmacies do not. Should this be extended to other areas of consultations/ advice giving eg hormonal contraception.
Recommendation:
Council should consider whether to recommend that all pharmacies should be required to offer private area/consulting rooms together with an implementation time-table, recognising that ensuring compliance may be difficult.
F. Dealing with Complaints
Pharmacies are required to have a practice leaflet. From our pharmacy visits few pharmacies appeared to have a complaints leaflet. Most practice leaflets received by the CHC, however, appear to have details on how to make a complaint.
Recommendation:
That LHBs should seek to require that all pharmacies either have a complaints leaflet or include details on how to make a complaint within their practice leaflet.
G. Staff name badges
A substantial minority of pharmacies visited by the CHC did not identify staff by name badge. A range of responses were received on the grounds that local people knew the staff anyway or that wearing badges had implications for personal security. CHCs have always maintained that health professionals should be readily identified to patients and that identity badges should be worn.
Recommendation:
Council is requested to consider their views on the ‘wearing of name badges’ to inform a recommendation to the Local health Board on the patient expectation of good practice in identifying clinical staff and their relevant positions.
H. Criminal Records Bureau (CRB) checks
GPs and dentists who clearly have a close professional relationship with patients, often on a one-to-one basis are required to have a CRB check. Pharmacists currently are not required to have a CRB check. Given their extended role and wider professional contacts with patients there is a case for pharmacists to be included.
Recommendation:
Council is requested to consider the issues of patient and public safety in regard to clinical staff being subject to Criminal Record Bureau Checks and agree a recommendation to the Local Health Board on this issue.
I. Prescription collection and delivery services
The great majority of pharmacies offer a prescription collection and some a delivery service. Though there are many permutations and criteria for availability, most are on demand to everyone. The service is free and provided on a commercial basis.
Recommendation:
Council is requested to consider undertaking a patient survey to identify the patient experience of the service and further consider the wider implications of a collection and delivery service.
J. Communication with those having sensory impairment and special needs
The majority of pharmacies visited by the CHC did make special arrangements for those with sensory impairment – a loop system, magnification aids, dispensing aids etc. A significant number of pharmacies, however, did not have such arrangements and very few pharmacists were able to offer specifics on the way in which they made reasonable adjustment for disabled patients, the older confused patients or those with learning difficulties.
Recommendation:
Council are requested to consider the value of undertaking a full audit of Gwent pharmacies re their arrangements for people with special needs with a view to making recommendation on expected best practice in service delivery.
This suggests that the resident population could have an inferior Out of Hours Pharmacy service, because of the local geography.
Recommendation:
That Council request further information from the NHS on how the decision on the provision of the Out of Hours Pharmacy in Monmouthshire was made.