Freelance journalist specialising in pharmacy
It is the view of the Chronic Medication Service (CMS) architects that GP practices will benefit from the new community pharmacy service in three ways: first, practices will become less involved in the administration of repeat prescriptions; second, patient compliance with medicines – and thus prescribing cost control – will improve; and third, participation in the scheme will help the practice to score in a number of Quality and Outcomes Framework (QOF) domains, specifically markers associated with the management of certain chronic diseases and annual medication reviews.
However, success of the service relies heavily on the effectiveness of the patient's pharmacy team and on GP surgeries and pharmacies working well together, and it will involve practices and pharmacies in a lot of administrative "legwork". With Scottish practices already running repeat dispensing schemes, and many also scoring highly on, among others, medication review QOF scores (with an average national score of 98.6% across the Medicines 11/12 indicators), practices may be asking: is it all really worth it?(1)
Issues to consider
Essentially a pharmacy-led repeat script management service, the CMS demands that pharmacies take a more formalised and more holistic approach to the management of long-term conditions (see Box 1).
In a nutshell, the CMS looks to see pharmacies not only manage the administration of repeat prescriptions, but also solve medicines-related issues in the whole range of therapy areas relevant to that patient, including: drug-related problems; compliance; identifying and acting on markers of poor control; prompting referrals; and providing high-quality patient information/education in the holistic context.
To establish the CMS, GP practices will have to spend considerable time upfront with pharmacies, discussing administrative arrangements such as the logistics of dealing with repeat serial prescription renewal requests or cancellations, preferred communication routes and changes to current working practices – for example, to cater for individual patients' requirements.
Practice GPs will also have to spend time with patients, bringing them onboard with the service, helping them to understand how the service works (for example by distributing leaflets detailing the service), and encouraging patients to give pharmacies the explicit consent required for clinical data sharing.
There may also be resource implications in terms of the amount of GP, locum and administrative staff training required to work the new CMS hardware and software, and manage any ongoing problems.
In return, it is envisaged that GP practices will see reductions in what can be a considerable workload associated with repeat prescriptions, and helpfully, for practices with an eye on their QOF coffers, financial reward for improving levels of patient care. The CMS targets a number of chronic diseases frequently associated with drug therapy (see Box 2), which tick not only specific medicine management QOF boxes, but a number of condition-specific QOF boxes as well.
GPs in the driving seat
As GPs are in the driving seat of the CMS (see Box 3) it is important to the overall success of the programme that general practices see the CMS as something worth getting involved in. Research suggests that one of the main reasons for patients' non-compliance with their medicines is a pervasive failure to establish effective therapeutic partnerships between healthcare professionals and patients.(2)
However, improving compliance takes time, and for those practices with already established repeat prescription partnerships, it may take a long time for the incremental benefits of participation in the CMS to become apparent – particularly as implementation is gradual, to allow pharmacies time to familiarise themselves with the system, and until 2011, only people with age-related or medical exemptions may be given a serial prescription, due to the inability of the CMS system to undertake fraud checks.
So far, the trial has been very limited in its remit, with the result that both nationally and locally, GP stakeholders say it is too early to gauge the benefits. For its part, the British Medical Association (BMA) says it is unaware of any research modelling the likely impact on practice prescribing budgets, and it cautions practices against expecting any significant financial savings.
Dr Dean Marshall, chairman of the BMA's Scottish GPs' Committee, adds: "Any savings would, of course, also have to be set against the cost of introducing the service and paying pharmacists for taking part."
On the local level, GP practices in NHS Fife have participated in the trial of the service. Mary Scott, practice manager at the Anstruther Medical Centre, in Cellardyke, is equally undecided on the benefits to practice. She says: "We need to wait and see how it goes, with more drugs being added and with more complex patients."
But, more fundamentally, involvement in the CMS also requires faith in the competence and clinical governance of the pharmacy team; under the terms of the CMS, pharmacies will take the lead on identifying patients, conducting the initial risk assessment, monitoring patient compliance and generally managing the service on an ongoing basis.
Mary Scott believes that good working relationships with her partner local pharmacy have played an important part in minimising problems encountered during the trial. She says: "This has helped immensely – if this wasn't the case it would not have been so easy."
Dr Marshall says this is an issue that needs to be resolved on a national scale: "Some GPs, for example, have had a mixed experience with their local pharmacies. There are naturally variations in standard of practice, and in the closeness of the working relationship.
"Some GPs have also had mixed experience with other new services. An example is the Minor Ailments Scheme, where some pharmacies have proved so risk-averse that they actually cause GPs more work through referrals. Clearly, this will result in a mixed picture for the CMS."
Increasing pharmacy portfolio
The national roll-out of the CMS across Scotland, from 11 May, is the final piece in the jigsaw of new community pharmacy services, which was first set out in 2006, and which has also included the Minor Ailments Scheme and the Acute Medication Service.
Since the outset, one of the main aims of the community pharmacy service development programme has been to improve patients' use of medicines and, according to official figures, there are indications of success. Statistics show that, on average, 12% of patients registered with a GP in Scotland are also registered with a pharmacy for the Minor Ailments Scheme, equating to some 600,000 registered patients, and that pharmacies had collectively dispensed more than 1.2 million items (between April 2008 and March 2009) via the scheme.(3)
According to the Scottish government, usage of the Acute Medication Service, which involves the dispensing of e-scripts for acute conditions by community pharmacies, has been holding steady for some months, with overall figures running to around 82% of all generated e-scripts being downloaded in pharmacy, and 78% completing the e-cycle by reaching the payment division.(4) Such is the success of the ePharmacy Programme that Scottish ministers are now planning for other prescriber groups, such as out-of-hours and nurse prescribers, to join the e-prescribing ranks.(5)
By reducing GP repeat script workload, and encouraging better use of medicines, improving pharmaceutical services, and formally recognising pharmacies and their staff as the experts in medicines, the CMS hopes to continue the good work of the past four years. It is the hope of all involved that this last piece of the jigsaw will fit effortlessly into place.
1. Information Services Division Scotland. General Practice – Quality & Outcomes Framework for April 2008 – March 2009. Available from: http://www.isdscotland.org/isd/6005.html
2. Scottish Government. Establishing Effective Therapeutic Partnerships – a generic framework to underpin the Chronic Medication Service element of the community pharmacy contract. December 2009. Available from: http://www.scotland.gov.uk/Publications/2010/01/07144120/0
3. Information Services Division Scotland. Registrations (Minor Ailment Service). Available from: http://www.isdscotland.org/isd/information-and-statistics.jsp?pContentID...
4. Scottish Government update data on file.
5. ePharmacy News. February 2010. Available from: http://www.communitypharmacy.scot.nhs.uk/epharmacy_news/issue6/ePharmacy...
Community Pharmacy (NHS Scotland)
Information on the Chronic Medication Service:
CMS Service Specification, issued 13 April 2010
Directions and Implementation Plan for the CMS, issued 10 May 2010