A Study of Pharmore+: Pharmacy Walk-in Service Pilots

4 Findings: Pilot Implementation

4.1 The development of the pilots required considerable preparatory work before new or enhanced community pharmacy services could be offered to the public. Such work related to: infrastructure such as facilities, equipment and IT; workforce recruitment and training; and building links with other services. In many instances this work carried on long after the pilots had 'gone live' either because issues needed longer to be resolved or because of the need for those pharmacists who took on enhanced practitioner roles to undertake training and develop ongoing professional support.

Infrastructure: Equipment, Facilities and IT

4.2 Facilities available within the pilot pharmacy had a significant impact on the types of services pilots were able to offer. In NHS Greater Glasgow and Clyde, limited space in both of the pharmacies in turn limited the availability of services, for example difficulties in accessing the consulting room by both voluntary organisations and pharmacy staff delivering the services. NHS Tayside had pre-existing facilities (e.g. meeting/consulting rooms) on site which meant they were able to offer facilities for a wider range of services. NHS Grampian experienced difficulties and significant delays with implementing their nurse-led minor injuries clinic due to building and occupancy requirements and the requirement to construct a purpose built clinical room. To enable these facilities to be installed, the pilot required to adhere to organisational requirements such as obtaining an Agreement to Occupy. Setting up and implementation also required sustained project management resource and a Steering Group to keep the project on track.

4.3 Information Technology (IT) also presented major issues for the pilots, especially those that were introducing new services. NHS Lanarkshire, NHS Tayside and NHS Grampian all experienced significant difficulties and delays with establishing a workable system and back up support for enabling their clinics to link up with NHS IT systems to enable the secure transfer of patient data from the clinic to NHS. In order for this to happen, the pharmacies required access to the N3 net connection however this proved extremely problematic due to the large scale NHS organisational requirements, the difficulties linking to external multi-companies and the relatively small scale of the pilot. NHS Grampian experienced long delays and required much more time and resource that anticipated installing a system which could enable the safe transfer of patient data at a basic level. NHS Lothian linked to N3 and the equipment is maintained by NHS Lothian eHealth department. They also use the ADASTRA system over this network which is the same system used by Lothian Unscheduled Care Service. This allows peer review of prescribing decisions and allows continuity with that service should the patient then need to be referred for more specialist input.

Workforce Recruitment and Development of Professional Practice

4.4 Where pilots sought to introduce either minor illness or minor injury clinics into the pharmacy they needed to secure staff with the right skills and experience and to provide them with additional training and ongoing support to enable them to deliver the service. The experience of the pilots in recruitment and development of staff is outlined below:

• Staff recruitment: NHS Grampian was interested in securing services of nurses who had experience in community minor injury units. They also needed to ensure there were enough nurses to deliver the service taking into account holidays, sick leave and rotational requirements. NHS Lanarkshire and NHS Lothian employed pharmacy independent prescribers to deliver their minor illness clinics however they were keen to recruit pharmacists who were able to work autonomously and had experience in prescribing. It was noted that, although the independent prescriber may already be operating out of specialist clinics, their skill set may be constrained by their work setting (e.g. focused on specialist clinics such as diabetes or blood pressure) so therefore they may not feel able to take on an expanded role.
• Training and ongoing support: nurse and pharmacy-led clinics also required staff to undergo additional training. NHS Grampian nurses attended a minor injury course; in NHS Lothian pharmacists attend the acute minor illness course at Queen Margaret University. A local GP mentoring system was established in NHS Lanarkshire and in NHS Lothian which aimed to develop competence in diagnosing, treating and prescribing for patients attending the Out-of-Hours (OOH) services. The training allowed for review of case work on a regular basis and provided ongoing professional support to pharmacists. Pharmacists in both the NHS Lanarkshire and NHS Lothian pilots described how they had really valued and benefited from the extended training and support. In their view they felt that the training enabled them to operate more as pharmacy practitioners and offer a more flexible and enhanced service which they felt responded to the needs of the patient.

4.5 There were several challenges reported by the pilots in the development and support of new and extended roles within minor illness clinics:

• difficulties in securing GPs to provide ongoing mentor/training;
• ensuring a common skill set for Pharmacist Independent Prescribers for unscheduled care which would be recognised and accepted outside pilot boundaries;
• maintaining skills and providing a consistent level of training which would assist with dealing with the unpredictability of unscheduled care;
• sustainability of service, and need to consider long-term arrangements for funding community pharmacy to employ Pharmacist Independent Prescribers;
• lack of national training available to meet the needs of service.

4.6 All pilots looked to the wider pharmacy team, in particular the pharmacy technicians, to extend their roles in for example in providing non clinical health improvement services. NHS Greater Glasgow and Clyde, for example, explored what might be possible with existing pharmacy resources. This pilot provided 3-4 days training for pharmacy technicians covering different health improvement topics. Technicians were supervised by the pharmacist and CPD training offered though the health board. The technicians were keen to engage with the pilot as this enabled them to offer a greater range of skills and services. Where specialist services were introduced, pilots noted that technical staff also became more skilled and confident in delivering health improvement services.

4.7 Although pharmacy support staff in the pilots were keen to engage in providing wider range of services there were tensions with incorporating new services within existing demands of a busy pharmacy. NHS Greater Glasgow and Clyde pilot reported at times it was difficult to maintain constant delivery of new services due to fluctuations in staffing and availability of staff to provide services in addition to core pharmaceutical contract services. Some interventions required time to deliver, for example the health improvement service within Braehead pharmacy required a 40 mins structured interview in a private area, however staff were able to adapt this by shortening the health improvement sessions. Demands on resources (in particular staff time) required pharmacies to be selective in the kinds of services they were able to offer. Focusing on a more limited range of services also provided an opportunity to build on expertise on specific aspects of health improvement.

Links to other services

4.8 Pilots included a variety of ways to link with existing health and health improvement services, these included:

• NHS services within the pharmacy to deliver health services
• Formal and informal links with NHS services to receive/refer patients and to inform NHS and out-of-hours services of patient interventions received through the pharmacy
• Other NHS services training pharmacy staff to undertake non-clinical health improvement services
• Including voluntary sector within the pharmacy to expand the services provided.

4.9 All pilots made links with relevant NHS services, with some pilots including delivery of other NHS services out of pilot sites. In addition to NHS services, two of the pilots also made links to voluntary organisations to deliver their services though the pilots. The NHS Tayside pilot included a range of services such as parenting class, weight management and mental health support provided by voluntary organisations and NHS Greater Glasgow and Clyde included the CAB services within the Braehead pharmacy.

4.10 Closer working with relevant NHS services saw services developing to complement each other. For example, the sexual health service provided by the NHS Greater Glasgow and Clyde pilot linked to the Sandyford sexual health clinic which adjusted its opening hours to complement the new service provided by the pharmacy.

4.11 Some pilots had initially explored the possibility of introducing minor injury/illness clinics to complement out-of-hours services, however they were less successful where there was less support from Community Health Partnerships (CHPs) or difficulty in engaging GPs. NHS Tayside, for example, were unable to progress the nurse-led pilot due to the financial risk (as the Board was unwilling to commit to the recruitment of staff when funding was not confirmed). Those pilots which were successful in establishing unscheduled care clinics had developed links in the form of staff recruitment, training and ongoing support between the pilot and out-of-hours services which enabled greater joint working and potential to build closer working relationships. NHS Lothian emphasised the importance of working with out-of-hours services to develop a complementary service rather than duplicate existing out-of-hours services.

4.12 NHS Lanarkshire pilot tested a new care pathway using on formal links through out of hours service, with patients triaged to the pharmacy where appropriate. Although this system was demonstrated to be workable, there were challenges in enabling a large organisation such as NHS24 to link to a small bespoke service (logistical constraints around referral and presentation). Informal contact between pilots and out-of-hours services (such as the GP mentoring and ongoing support with the NHS Lothian pilot) highlighted potential for greater collaboration between services.