Freelance journalist specialising in pharmacy
When the new pharmacy contract in England and Wales was launched in April 2005, contract negotiators the Pharmaceutical Services Negotiating Committee (PSNC) said that the aim was to establish pharmacists as "partners" in the delivery of healthcare services in the primary care setting.
The new pharmacy contract is centrally funded to deliver seven essential services, among them managing repeat prescriptions, and advanced services, such as Medicines Use Review. The new contract also allows for the delivery of nine enhanced services, to be delivered and paid for locally according to the local primary care trust's (PCT) pharmaceutical needs assessment.
Key elements of the new contract
As of 1 October 2005, pharmacists have had to be in the position to dispense a repeatable prescription if presented with one. The aim of the service is to ensure that each repeat supply is required, and that there is no reason why the patient should be referred back to their GP.
Medicines Use Review (MUR)
MUR is a new, centrally funded service in community pharmacy, which involves the delivery of a structured review of patients receiving medicines for long-term conditions. The idea of the service, which is conducted on a routine basis and can be initiated by either the pharmacist, the GP or the PCT, is to establish a picture of the patient's use of both prescribed and nonprescribed medicines, help them understand their therapy, identify any problems and where possible provide solutions. It is not intended to be a full clinical review.
Initially the new contract also allows for nine enhanced services, including:
So what do GPs think?
For a new contract for which there were such high expectations, the statistics from year one make disappointing reading.
Figures from the NHS Information Centre reveal that around 150,000 MURs were conducted in year one of the new contract.(1) This falls well short of the 1.69 million advanced services that the new contract was funded to provide in year one.
The report also states that pharmacists provided 16,835 local enhanced services (LES), mostly around the areas of smoking cessation, the supervised administration of methadone, minor ailment schemes and PGDs – this is a level described by the University of Manchester in a subsequent report as "comparatively low".
Progress towards the Electronic Prescription Service (EPS), and connection to N3, which underpins the delivery of many of the new contract services, has also been slow, with only two out of the 10 EPS "release one" pharmacy systems getting the go-ahead from Connecting for Health (CfH) to go live on the market.(2)
Not surprisingly perhaps, GPs have fairly ambivalent feelings about the benefits the new pharmacy contract has brought to their practices, their Quality and Outcomes Framework (QOF) targets and their personal work experience.
Dr Peter Holden, a GP serving on the British Medical Association's (BMA) GP negotiating committee, personally believes that so far the contract has had zero impact and may, in fact, have increased competition for PCTs' very stretched enhanced services budgets.
Dr Holden also questions whether the new pharmacy contract will deliver the supposed benefits in the long term: "We live in an era of patient choice, where patients may choose not to go to their local pharmacy and instead will use technology to have their prescriptions delivered to their door."
Adding to these concerns, Dr Richard Vautrey, a GP at the Meanwood Group Practice in Leeds, believes that all MURs have done is to "create a big paperchase" and an increase in his workload. He also adds that repeat prescription management really needs the EPS in place before it can get going.
However, even the EPS may not prove a practice manager's salvation. Grove House Surgery, based in Ventnor on the Isle of Wight, has been involved for some months in EPS pilot testing, and has already transmitted hundreds of electronic scripts. According to practice manager Sarah Rochford, the EPS has "had no effect on the practice whatsoever".
For year two of the contract, PSNC has negotiated a new MUR limit of 400 per pharmacy, which even proactive MUR providers describe as challenging. As a result, both pharmacists and GPs will need to consider how this uplift will be accommodated into day-to-day practice. Local research from the Hampshire and Isle of Wight regions suggests that GPs initiate only 5% of MURs,(3) despite the accepted benefits to compliance. As Dr John Draccas, chair of the Southwest Hampshire Local Medical Committee (LMC), says: "Improving concordance and compliance should improve health outcomes, reducing workload for GPs and unnecessary secondary care admissions."
New Scottish contract
Scottish pharmacists have a different contract, which only came into effect in April of this year, and two of its four core services – the minor ailments service (MAS) and the chronic medication service (CMS) – may be of some direct benefit to GPs' workloads.
The MAS, which opened to patients on 1 July, allows patients who are exempt from prescription charges to register with and use a community pharmacy as the first port of call for the treatment of common illnesses on the NHS. The pharmacist advises, treats or refers the patient according to their needs. The CMS, meanwhile, which is not due to start until April 2007, allows patients with a long-term medical condition to have their medicines provided, monitored, reviewed and, in some instances, adjusted for up to 12 months as part of a shared care arrangement between the patient, their GP and their community pharmacist.
Scottish GPs have had little chance to assess the benefits of the MAS, although according to Dr Dean Marshall, chairman of the Scottish General Practitioners Council, MAS pilots have demonstrated success, particularly in deprived areas. For his part, he says he is still seeing patients with minor ailments, although he accepts that it is impossible to know how many patients he would have seen if the MAS was not up and running.
As for the CMS, perhaps this will deliver a positive impact on GPs' workloads, says Dr Marshall. "But," he adds, "this will be over time, and it will be a learning curve for patients."