The Implications of the New Pharmacy Contract
Around 60 PM Society members heard two thought-provoking presentations at a meeting exploring the implications of the pharma industry of the new pharmacy contract, due to be introduced in October 2004. (l-r) Paul Lowndes, Director, Mediapharm; Ms Sandy Thomson, Vice-Chairman PM Society; Farid Poonja, Business Development, Enigma Pharma |
The new contract will profoundly change the way that chronic conditions are managed in primary care. Pharmacists will be paid for offering a range of new patient-centred professional services, and not just on the number of prescriptions dispensed. With historical new prescribing powers in place, pharmacists are increasing their influence on the use of medicines. The module looked at what these changes will mean for patients, GPs and pharma companies.
Farid Poonja, himself a practising community pharmacist, started out by outlining some of the history of pharmacy from its beginnings in the 17th Century up until the present day. He explained that in 1701, a legal case brought about a change allowing Apothecaries to charges for diagnosis and advice, leaving an opening for the Chemist and Druggists trade association to sell over the counter medicines, and it was only in 1911, with the introduction of the National Insurance Act, that this association routinely started to be paid according to the number of prescriptions they dispensed.
With new contracts being introduced throughout the NHS, the same kind of imperatives driving change for other healthcare professionals has led to a contract review for pharmacists as well: cost, concentration on outcomes (as opposed to numbers), PCOs assuming responsibility for ensuring patient access.
Farid told the meeting that the profession was traditionally conservative, but that it had shown itself ready to accept change through a 95% vote in favour of the new contract. The basic tenet of the contract is a move away from being dispensers towards becoming Chronic Care and Minor Ailment Managers.
Although funding arrangements are not finalised, it seems clear that there will be three sources of funding for the new services pharmacies will deliver: a 'global pot' which already funds pharmacy activity; extra funds from central Government; and by re-allocating funds currently given to GPs to manage chronic patients (and it is here that the biggest impact might be felt by the industry).
The new contract will require pharmacists to deliver services in three areas: essential, advanced and supplementary enhanced. The essential services will include dispensing and repeat dispensing (this change already having been implemented in some areas). But the biggest change will be the requirement to give advice about health and about therapies, as well as auditing therapies and the pharmacist's own CPD (a reflection of the new view of pharmacists as HCPs).
The 'advanced' services will see a staggered implementation, but Farid suggested that they would eventually also become essential services. It is in this category that the biggest shift occurs, with pharmacists responsible for medicines use reviews and a prescription intervention service, which could see them optimising doses or even doing therapeutic substitutions. This hands the pharmacist a great deal of influence in deciding which drug is prescribed to long-term patients requiring ongoing care.
The 'supplementary enhanced' services will be implemented at a local level, but based on national agreed programs (i.e. based on NSFs), and will include minor ailments management, diabetes and CHD screening, concordance and disease specific medicines management services.
Farid pointed out that the positioning of the pharmacy as central in patient care would have a big impact on the industry. Pharmacists as prescribers could erode still further the ownership of the individual GP of the scripts written and medication chosen.
He said that new pharmacy services would need support from the industry, describing pharmacists as 'fearful', but ready to change - and needing support to effect that change. He called on the industry to abandon its traditional sales-based, product-led promotion-driven approach and work collaboratively with pharmacists for the mutual benefit of everyone involved.
Farid said that the industry understands chronic diseases better than pharmacists do, and between them the two parties could be a 'two-way influence' for good on the PCT.
Paul Lowndes called what is happening a 'historic moment; pharmacists have an important role to play in managing patients." He said that the role of community pharmacists in supplementary prescribing was well illustrated by the fact that they represented over half of this year's intake into Kings College supplementary prescribing course.
He maintained that the focus on healthcare would lead to a change in emphasis in pharmacies, with longer opening hours, investment in premises and the introduction of new professional services. In short, there would be a need to marry together the professional and the business sides of pharmacy.
He gave three very apt examples of pharmacists which have started to do just that, albeit in very different ways.
Leicester-based Medicine Box is already working with the industry to provide a range of extra services, including blood pressure and cholesterol monitoring, weight management and diabetes services and many other extended services. Much of this activity is supported by pharma companies, all of which has led to a big increase in footfall, turnover and profit for the pharmacy, and access to a large number of chronic patients for the industry.
By contrast, Green Light Pharmacy in Camden has turned to collaborative funding via the local PCT to focus on healthcare and professional services. Similar services such as diabetes and weight management have been introduced, alongside smoking cessation and asthma clinics. Most are fully-funded by the PCT, a reflection of the joint approach to meeting NSF targets in certain therapeutical areas.
The third example was Maguire's Pharmacy in Northern Ireland which set up a diabetes medicine management service to assess the commercial impact and value of pharmacy intervention. The conclusion of the study was, that "medicine management services can make profit and in so doing pharmacists do not compromise their professional standing."
Paul suggested that the industry had a role to play in collaborating with pharmacists to ensure the success of the new contract. The industry has much experience in combining professional and business skills, managing chronic diseases in a commercial environment, and therefore has much to teach pharmacists.
Opportunities included developing models of practice, training on chronic diseases and patient management, as well as coming up with resources, templates and guidelines, not just for pharmacists, but for all pharmacy staff (much as practice staff are important within a GP's surgery).
More traditional commercial collaboration would be appropriate in marketing, sponsoring multidisciplinary workshops, helping with auditing, supporting health education clinics for the public and even having individual sponsored pharmacists.
Paul concluded that the new contract means that pharmacists need support in training and business development, expertise which the industry has. He said that helping pharmacists would establish strong advocates for industry brands.
Questions
A lively question time covered various areas, and in many it became clear that much detail still remains to be sorted out between now and the launch of the new contract in October.
The biggest issue was the implications of pharmacists switching prescriptions, both in terms of cost and considering the medico-legal issue. Who would retain ultimate responsibility for patient care - the GP or the pharmacist? To what extent would the pharmacist be limited by the PCT's formulary?
There was also uncertainty that the necessary IT improvements would be in place by October to allow pharmacists access to patient records to back-up their prescribing powers (and the related confidentiality issues are also unresolved).
One questioner raised the prospect of pharmacists asking for industry support having to drop the practice of parallel importing. Farid said that if the benefit from industry support was greater than that of parallel importing, the business imperative would be to acquiesce.
Conclusion
It seems clear that the industry has to come to terms with the fact that pharmacies are changing from dispensing retail units to health centres, an integral part of the NHS which will have an increasing influence both on patient behaviour and on healthcare professional attitude.
The implications of the new pharmacy contract to the industry are enormous. Certainly for those needing chronic or ongoing care, the pharmacy, rather than the GP's surgery, is likely to become the main point of contact. As pharmacists take a greater role in prescribing decisions, they will become important influencers over drug choice - and this means that the industry ignores them at its peril.
Held on: 25/03/2004