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Events
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9/22/2011
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2011 Avicenna conference: Implementing NHS Change
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The picturesque Oxfordshire countryside was the backdrop to the Avicenna conference at the Crowne Plaza Hotel.
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Pharmacy's struggle for survival
The pleasant countryside of Oxfordshire provided the backdrop to the Avicenna conference 'Implementing NHS Change' where community pharmacists were warned to be proactive or risk sliding into oblivion, writes Neil Trainis...
Lurking within the tranquillity of the Oxfordshire countryside, complete with its picturesque scenery and entrancing history, was the menace of a demanding future that promises untold challenges for community pharmacists. Those who belong to Avicenna congregated at the elegant Crowne Plaza Hotel, a venue surrounded by stark reminders of the past all woven into the fabric of England's history; Blenheim Palace, Oxford University, Oxford and Warwick castles. Oxford, the “city of dreaming spires,” as poet Matthew Arnold once wrote, had become the “city of further enlightenment” as far as pharmacy was concerned.
Avicenna, like other pharmacy bodies and pharmaceutical companies, holds its conferences all over the world but the clear and consistent messages UK community pharmacy must absorb transcends borders and continents. The message that it must tear itself from its traditional function, that of dispensing medicine, and take on a more holistic approach to healthcare, taking on the jobs doctors struggle to do as they strive to relieve the burden on hospitals. That it must prove its capability stretches to blood pressure monitoring, cholesterol checks, diabetes, hypertension management and so on. That it must engage with GPs and other healthcare disciplines, commissioners and local authorities in actively promoting what it can offer a reconfigured National Health Service beyond medicines management and a unique access to the community.
The theme in Oxford was dressed up as “Implementing NHS Change” and the warnings were stark. Salim Jetha, Avicenna's chief executive, quickly established the tone. “This is the fastest pace of change I've ever experienced,” he said. “What should we do to keep up with these changes? It's very easy to bury your head in the sand but that won't get you anywhere.”
The concern is that many community pharmacists, buried deep within their communities and struggling to comprehend what form commissioning structures will take, will do exactly that. Many pharmacists regard the NHS reforms, which has dragged community pharmacy into a very different shape and imposed unprecedented demands, as a lingering nightmare from which they may awake.
Intensified
One of their biggest concerns, the notion of intensified competition within the commissioning of healthcare services, was brought to the surface by Dr Howard Stoate, the chair of Bexley Clinical Cabinet. In spite of the Government's promise to dilute the role of Monitor, the agency charged with overseeing competition, and introduce it only where it benefits the patient, Dr Stoate proceeded to proverbially slap those pharmacists in the face with a wet fish to rouse them. “You can run for cover if you like but that won't stop the juggernaut that's coming your way... you'll be up against some very stiff competition,” he said.
In his area, Bexley, there will be an open bidding process for INR (International Normalized Ratio) services for patients on anti-coagulant drugs. He was asked whether such a procedure would be thrown open to pharmacists. “Pharmacy will be able to bid,” came his instant reply. “This will be an open contract. Pharmacy will be able to bid for it, either collectively or in partnership with the GPs. There's nothing to stop a couple of practices, whether with a couple of local pharmacies, to do a joint bid across the whole of the patch.
“We'll put up an opening tender for a primary care delivered INR service and we'll want some high quality bids. You'll bid against the private sector, I'm sure, people like Virgin or Tesco or one of the big pharmacy chains might want to do it. But there's no reason why pharmacy shouldn't get involved in this.
“Three or four pharmacies working together with a couple of GP practices can produce the service we want. That's how we envisage it. A collaboration of different providers coming together and tendering for that service.” This was what Andrew Lansley perhaps envisaged when he insisted his NHS blueprint would promote “healthy competition.”
One pharmacist in the audience grabbed the microphone and insisted that, in her area of Brighton, the tendering process was unfair. Stoate's response was again instant. “I can't speak for Brighton. You wouldn't expect me to. All I can say is that in Bexley, we're going to be scrupulous. If someone felt that our tendering process wasn't fair or there had been a conflict of interest, I'm quite confident that some people will tell us and we'll sort it out.” He warned pharmacists to create bids of a “high quality” or face losing out on services. Then came the warning that, if pharmacy does not embark on a process of evolution, it will become a “dinosaur.”
“Roles are changing,” he said. “The GPs' roles are changing. The pharmacist's role will change just as radically over the next few months and years. If you don't get ready for it, you're going to be in big trouble.”
The theme of evolution ran right through the conference, from talks given by Alastair Buxton at the PSNC to Gul Root at the Department of Health. Hemant Patel, the secretary of North East London LPC, attempted to enlighten and instil a sense of urgency into the pharmacists present. Yet when he asked them to put their hands up if they knew what to expect from future NHS commissioning, not one arm was raised into the air. “It's about grabbing people's emotions,” he exclaimed with typical bluster. “You've got to sell yourselves.” He asked how many of them in the room were leaders, prepared to engage, be proactive and take the lead. Again, not one hand was lifted above the head. It was a reticence that spoke volumes.
The time for pharmacy to act
Dr Howard Stoate, the chair of Bexley Clinical Cabinet, pulled no punches at the Avicenna conference when he told pharmacists to engage and extend their services...or become extinct...
Pharmacists must consider joining up with local GP surgeries to prepare “high quality” bids for health services if they want to avoid being swallowed up by the Government's reformation of the National Health Service, Dr Howard Stoate, chair of Bexley Clinical Cabinet, warned the Avicenna Conference.
The notion of competition under the agency Monitor is expected to be watered down under a revised health and social care bill and will be introduced only where there is a clear benefit to the patient, underpinning the concept of healthy competition under Health Secretary Andrew Lansley's blueprint.
Pharmacists are largely wary of competition within healthcare commissioning and Stoate gave Avicenna members a blunt reminder that they will have to be proactive and engage with GPs and what is currently known as GP-led consortia if they wish to successfully tender for services.
“You can run for cover if you like but that won't stop the juggernaut that's coming your way...you'll be up against some very stiff competition,” he said. Stoate used the tender process for INR (International Normalized Ratio) services for patients on anti-coagulant drugs in Bexley to illustrate his point.
“Pharmacy will be able to bid,” he said. “This will be an open contract. At it works at the moment, most of the anti-coagulation is done through secondary care, in hospital anticoagulation clinics. Patients don't like them because they're quite remote from their communities.
“They tend to be not very nice places to go, so patients want to have their INR done at their GP surgeries or their pharmacies. Actually, it's much much cheaper to do it in primary care or in pharmacy. Pharmacy will be able to bid for it, either collectively or in partnership with the GPs. “There's nothing to stop a couple of practices, whether with a couple of local pharmacies, to do a joint bid across the whole of the patch. We'll put up an opening tender for a primary care delivered INR service and we'll want some high quality bids.”
Competitors
He warned community pharmacy it will be up against experienced, quality bids from competitors, including the private sector. “You'll bid against the private sector, I'm sure, people like Virgin or Tesco or one of the big pharmacy chains might want to do it. But there's no reason why pharmacy shouldn't get involved in this,” he said.
“There will be a tender document. An open tender will go out and you'll be able, if you want to, to put an individual tender in. My advice would be it would be better to do it through your LPC and get together as a group. Because it'll be quite a big contract covering the whole of Bexley, it would be unrealistic to think it's something one pharmacy will be able to deliver to the standard that we want.
“But three or four pharmacies working together with a couple of GP practices can produce the service we want. That's how we envisage it. A collaboration of different providers coming together and tendering for that service.”
One pharmacist said the INR tender process was unfair in Brighton and Hove but Stoate maintained that the process would be fair in Bexley and told pharmacists to focus on submitting bids “of a very high standard.”
“I can't speak for Brighton, he said. “You wouldn't expect me to. All I can say is that in Bexley, we're going to be scrupulous. If we're challenged on our tendering process, then we're challenged. We have to be accountable.
“If someone felt that our tendering process wasn't fair or there had been a conflict of interest, I'm quite confident that some people will tell us and we'll sort it out. I don't have a problem with a level playing field.
“What I do have a problem with is that the experienced players who have done this sort of thing before will come up with a very slick presentation, a very slick document which it will be difficult for you to compete against. I want pharmacy to be prepared for the fact that INR will be the tip of the iceberg. There will be a lot more stuff like that coming out.
“If you're up against people who have done it all before, major multiples, major private sector bidders, you're up against stiff competition. GPs will want to compete for this business as well, but it will be a fair competition in Bexley, I can assure you. I can't speak for other parts of the country.”
Pharmacy upping its game
As community pharmacy moves to a more clinical, holistic approach under the New Medicine Service, Alastair Buxton, head of NHS services at the PSNC, warns the profession to up its game, writes Neil Trainis...
The warning was crystal clear. Pharmacists can and, indeed, must improve medicines adherence by strengthening their relationships with patients after they have begun their course of treatment. In short, the days when a pharmacist's duty to the patient ended with the dispensing of a medicine are well and truly over.
Alastair Buxton, head of NHS services at the PSNC, was unflinching as he gave watching pharmacists a peek into a future they must embrace or face the consequences. The New Medicine Service, as part of the pharmacy contract, comes into force on October 1 but, by way of sobering reminder, he reiterated the demands placed on pharmacy to maximise its existing skills and develop new ones if it is to earn an integral role in a restructured National Health Service through the effective treatment and prevention of illness and reduction in drugs wastage.
Pharmacy has been warned by various influential figures within the health industry that it must go beyond the dispensing of medication and part of that process of evolution involves what Buxton described as the “after-sales service for that new medicine” to ensure patients maintain their course of treatment.
“Ask the patient to come in and chat about how they are getting on with their medicine. Patients may start to have a different experience of a medicine once they begin to take it. Check whether they've got any questions and tell them you can have a chat in a couple of weeks' time,” he insisted.
“Sell it in that way. It's all about pharmacists caring about patients and wanting to help them with that new medicine. It's after-sales service for that new medicine. I'm sure most patients will agree to that if you present it to them in the right way. We then move on to the time to talk to them at the intervention which normally between day seven and day 14.”
To enhance the process of medicines intervention, Buxton advised pharmacists to talk to patients in person rather than over the telephone. That, he said, would improve the chances of keeping a patient on their medication and overcome the “psychology” of medicines adherence.
“It can be face to face or over the phone. I recommend you get patients back to the pharmacy as much as possible,” he said. “You can miss the visual (aspect of communication). So much communication is non-verbal. It can get the patient to open up and discuss their concerns and issues about their medication, draw out if they're taking their medication and whether they're using it effectively.”
Reservations
He suggested that the New Medicine Service, in which many pharmacists have harboured reservations in relation to increased workload, would inspire better patient outcomes and warned it was vital for pharmacy to embrace it “for the future sustainability of the sector.”
“We've really got to take hold of the medicines optimisation agenda. It's all about getting the best value from the medicines patients take and use and, of course, getting the best value from the NHS,” Buxton said. “We can really lead the field in community pharmacy, with targeted MURs and the New Medicine Service.
“There's a real risk that if we don't improve our service offering, build services and offer added value around the supply function, be it DHL or other providers, could get in there and have central distribution. Certainly our colleagues at the Treasury would absolutely love that. They would say it's a cheaper way to distribute medicines.
“We all know the value we offer as pharmacists and the value our teams offer and the value added around the supply function that the face-to-face contact brings. It brings so much benefit to patients. But we need to demonstrate that effectively with an evidence base. We have an opportunity to demonstrate that with the targeted MURs and the New Medicine Service.
“The changes we've got in the pharmacy contract are, potentially, going to be hard to deliver but its absolutely essential that we do deliver them for the future sustainability of the sector. The New Medicine Service demonstrates what we can do with an evidence base.
“Fundamentally, the service is about improving adherence for patients but it is really about talking to patients and solving their problems with new medicines. We know that when people start to take new medicines, they often have difficulties and concerns.
“They worry about side-effects, read information on the internet, talk to friends and family and get worried about the medicine and we need to support them and stop them from stopping that medication very early on which often happens.”
He cautioned pharmacists, though, against referring too many patients to GPs who may resent being swamped with work at a time when pharmacists are expected to alleviate the pressure on GPs themselves preoccupied with helping over-strained hospitals.
“If we refer lots of patients back to the GPs,” he mused, “GPs will say 'this service is just dumping a load of work on me. Thanks for nothing community pharmacy colleagues.' It will irritate them and we do not need that.”
“Pharmacists can get the patient to open up and discuss their concerns about their medication, drawing out if they're taking their medication and whether they're using it effectively.” Alastair Buxton, head of NHS services, PSNC
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