Review of NHS Pharmaceutical Care of Patients in the Community in Scotland

National and Local Planning

45. The arrangements for NHS pharmaceutical services in Scotland are set out in primary and secondary legislation and in Directions. The core services for community pharmacy have been negotiated and specified nationally, along with the related funding envelope. Some nationally recognised pharmaceutical services such as those for drug misuse are arranged and funded locally, and, increasingly, NHS Boards have been entering into local arrangements for other services to meet local priorities and patient needs which they believe are appropriately provided by community pharmacy, e.g. palliative care, alcohol screening, out-of-hours services etc. In addition, Boards have engaged pharmacist prescribers to work with general practice in clinics for hypertension, respiratory disease, diabetes etc. We were given a very helpful summary of these locally arranged and funded services by the Primary Care Pharmacy Group.

46. We support having an appropriate balance between what is determined nationally, to ensure consistency of approach across Scotland, and what is arranged locally to meet specific needs. But we were struck by the duplication of effort across NHS Boards in the specification of a number of the services which they wished to secure locally and we would recommend that, where possible, there should be a more co-ordinated approach organised through the professional groups. This would also have the benefit of greater efficiency and consistency for patients wherever they live and for the pharmacy providers.

47. A key role for NHS Boards is to administer, through their Pharmacy Practices Committee, the "control of entry" regulations which govern applications to join the local pharmaceutical list. While these regulations have played an important role in maintaining a network of pharmacies across Scotland, they are essentially reactive to applications made and, notwithstanding some recent changes, are not seen to be sufficiently responsive to local needs. The Smoking, Health and Social Care (Scotland) Act 2005 contains provisions for a more proactive approach whereby Boards would more systematically, and with appropriate consultation, review the local needs for pharmaceutical care and prepare and implement a pharmaceutical care services plan to meet these needs. We recommend that these provisions should now be brought into effect as a key element in ensuring that pharmaceutical care services are available and readily accessible to the population of Scotland. An important by-product of more systematic planning will be to ensure that the core and any additional pharmaceutical care services are properly integrated with the other community based services for which the Board is responsible.

48. A key element of local planning is ensuring equitable access to services. One of the hallmarks of community pharmacy has been its accessibility, providing a rapid and flexible response to public and patients. That needs to be maintained in the increasing focus on delivering a broader clinical service in addition to the dispensing of medicines. There are further opportunities for pharmacy premises to be seen as a wider community asset. Examples from the Pharmore+ programme³⁰ have demonstrated the potential for pharmacy to provide, and expand access to, a wider range of health and health improvement services. Some of the pilots included extended hours and prescribing of medicines, co-ordinated with other out-of-hours primary care provision. However, a significant challenge was engaging with and securing support from other professional groups. The pharmacy can also been used as a signposting agent, for example in referring patients on to the voluntary sector organisations that can provide additional expert support and information. We recommend that NHS Boards could usefully learn from and adapt the models developed under this programme to meet local needs.

49. In some rural areas where there is no community pharmacy the dispensing of medicines is carried out by general medical practices. Changes brought about by applications to open a pharmacy under the current "control of entry" system have caused significant concerns for local communities, and have, on occasions, undermined the professional partnership between pharmacists and GPs which the development of pharmaceutical care is intended to enhance. We take the view that the more proactive planning of services by NHS Boards needs to address these issues, and that, until that has taken place, no further changes should take place to the current disposition of services.

50. We recommend that the following principles might apply as part of the consultation with public and professional interests which should accompany the planning process -

• GP services in rural areas should not be destabilised
• people should have access to pharmaceutical care and the associated input from pharmacists wherever they live, in addition to any dispensing service
• the establishment of a professional partnership between GPs and pharmacists
• the funding of GMS should be sufficient to provide an appropriate level of medical service, and not be dependent on payments for dispensing
• standards of dispensing and the payment arrangements (including drug cost reimbursement) should be the same for pharmacies and dispensing doctors
• appropriate notice needs to be given of any proposed change to service provision

Where the planning process results in the continued provision of dispensing by a medical practice, it would be for the NHS Board to make arrangements for a pharmaceutical care service to be provided to complement the medical dispensing service, by contracting with or employing a pharmacist or pharmacists. It would be important to have a clear understanding of the working relationships between the pharmacist and the medical practice, including the opportunity to use telehealth facilities.