The great patient medication returns debacle

Johnathan Laird Serial Nudger

 

The amount of money drained from the NHS via the oversupply of medication must be staggering and largely unmeasured.

 

I’m talking about the at times mountainous piles of returned medicines that get handed into community pharmacy for disposal.

 

The great patient medication returns debacle.

 

If you’ve ever worked in community pharmacy you’ll know the routine. The bin bags approaching up the middle aisle usually unfortunately from a bereaved close relative. In my experience, these great excesses of prescription drugs handed back to the community pharmacy usually come to light after the passing of a patient. The sadness of the moment is balanced by the mortification of the family members returning said medicines.

 

The empathetic shake of hands happens as you try your best not to raise an eyebrow at the three bin bags of returned medication about to be handed over.

 

Insulin, inhalers and dressings are expensive patients returns but the winner is usually the unused diabetic test strips and lots of them.

 

This problem needs to be tackled. It’s a classic lose-lose situation all around.

 

At the beginning of my career, I really did get irate when this happened. And on occasion, I will admit this probably clouded my mood so that I did not provide the highest level of patient-centred care. These situations would often involve offering condolences which in my more formative years was difficult through a mist of outrage. I’m not really proud of these occasions because family members deserve the care of their community pharmacist at that moment shortly after a bereavement.

 

I’ve often wondered what the public would think if the amount of money that the NHS wastes in this way. What is the average prescription item value these days? Something like £10-£12 per item? I honestly think the general public don’t have any idea about the scale of this problem. Perhaps putting the problem into context might help.

 

And on the flip side the problem really is conveniently difficult to measure because the system assumes that every patient will be adherent to their medication all of the time.

 

Well as pharmacists we know that even the most engaged patients will struggle to achieve 100% adherence.

 

The causes will be multifactorial but no doubt free access to medicines drives a certain amount of volume. Market forces are at play too. There is also the trend towards ‘managed repeat’ services but that’s whole other opinion article altogether. I think any conversation about waste must bring the desire for pharmacy contractors to sign up loyal repeat prescription patients. A patient on a managed repeat prescription service will I’m told generate higher annual dispensing sales compared to those patients not using such a service. I guess it’s easy for me to pontificate given that I don’t currently own a community pharmacy that still depends on prescription volume for profit.

 

One of the reasons I decided to write this article was the link from this topic I made with the charge that was initiated for plastic bags supplied from retailers in recent years.

 

I remember working in a community pharmacy in Scotland when the plastic bag charge was initiated. I found it absolutely hilarious the lengths some folk would go to to avoid the 5p investment in a bag to ensure their walk to the car was comfortable. Instead that first year there was some heroic resistance to splashing out on the bag charge. Things have moved on from then because any form of the plastic bag would surely be frowned upon now due to environmental considerations.

 

Now that’s all very interesting to you I’m sure but the bottom line about the plastic bag charge idea was that it actually worked. The number of bags used by the pharmacy absolutely plummeted. I’m guestimating here but I’d say in the six months after the charge came in the usage of plastic carriers bags in the pharmacy dropped by as much as 80%.

 

The difference before and after implementation of the charge was stark.

 

I think that was probably an example of nudge theory. I highly recommend the book, surprisingly called ‘Nudge’, where these ideas have been articulated.

 

The first chapter of that book involves a little story about a school headmaster. Basically this headmaster was tasked with improving the levels of healthy eating amongst the youngsters at lunchtime. The headmaster was given no extra budget and his brief required student choice to be respected. His solution was to rearrange the cafeteria. He put the fresh fruit, veg and healthy options at the front and the chips, burgers and other less healthy options behind the screen at the far end of the room.

 

Much like in the plastic bag example the plan worked and he began to ‘nudge’ the children towards making healthier options.

 

So what is the ‘nudge’ solution that could be applied to our patient medication return problem?

 

Well unlike our headmaster striving for healthier eating choices we can’t really make it more difficult for patients to access or re-order their medicines in the first place but perhaps we could disincentivise it. At the very least I’d like to support patient education to such an extent that the decision to order is at least considered. There has always been the argument that some kind of charge on prescriptions would be draconian and to be honest I agree.

 

But the lever in the plastic bag success story was a monetary one albeit a very low-level charge. Perhaps the solution could be something simple like making the price of the medicine really clear to our patients or enforcing a nominal 5-10 pence charge per item.

 

I’m not sure what the answer is but what I am fairly sure of is that things can’t get much worse. Wouldn’t it be great if we could stumble upon a low cost ‘nudge’ type solution that tackles this issue once and for all?

 

This amount of waste has to stop so come on clever people answers on a postcard, please.

 

Johnathan Laird is a pharmacist who likes to think he is a serial nudger but probably often doesn’t realise he himself is being nudged.

 

 

 

Scottish community pharmacy and optometry collaboration

 

As part of the planned developments to NHS Pharmacy First Service and the remobilisation of NHS primary care services, a nationally agreed two-way pathway between community pharmacies and optometrists, which helps support the Scottish Government’s “Integration of Eyecare Services” programme has been announced.

 

The broad aim of the collaboration is to allow patients to make best use of the services available from each professional group.

 

This type of pathway has been in place in several Health Boards for many years, with all involved giving positive feedback on how it operates. The Scottish Government is fully supportive of this development as it encourages the fostering of local partnerships between primary care providers which will benefit the people of Scotland.

 

In a letter to stakeholders Alison Strath Interim Chief Pharmaceutical Officer and Dr Janet Pooley PhD MCOptom Optometric Advisor at the Dentistry and Optometry Division commented:

 

“This Circular provides information for community optometry teams about the NHS Pharmacy First Scotland (NHS PFS) service. It also provides guidance aimed at both community optometry and community pharmacy teams and a referral form for the assessment and treatment of minor eye

 

“The NHS PFS service came into force in community pharmacies on 29 July 2020 and replaced the Minor Ailment Service (MAS).

 

“The NHS PFS service seeks to encourage people to go to their local pharmacy for support with minor and acute health conditions. It extends access to a wider group of people than those who were able to use the Individuals who are registered with a GP practice in Scotland, or who live in Scotland, are eligible to use NHS PFS subject to certain exceptions for visitors to Scotland.

 

“Pharmacies undertake an NHS PFS consultation and provide advice, treatment or referral to another healthcare professional if appropriate.

 

“As well as minor conditions, it continues to provide advice and treatment for two specific common clinical conditions, uncomplicated Urinary Tract Infections in women and impetigo. Further common clinical conditions will be identified and added in due course.

 

“Guidance for community optometry and community pharmacy teams relating to the assessment and treatment of eye conditions under NHS PFS is attached.

 

“A two-way Optometry-Pharmacy Referral Form has been designed for community optometrists to refer patients to their local pharmacy for NHS PFS, and for community pharmacy teams to refer patients to community optometry practices where a patient has initially presented at a pharmacy but specialist advice is required.

 

“Ongoing discussions between community optometry teams and their local pharmacies is strongly encouraged to develop ways of working which take local needs into account, whilst ensuring a safe and efficient patient journey.”

 

You can read the full circular below.

 

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This time last year…

Philip Galt is Superintendent Pharmacist and Managing Director at Lindsay & Gilmour.

 

This time last year, it would have been impossible for any of us to imagine just what challenges lay ahead in the coming months.

 

In truth, it’s hard to overstate what a significant year this has been for community pharmacy in Scotland. More than ever I have watched with pride as colleagues across the community pharmacy network have worked together tirelessly to offer nothing short of a lifeline to some of the most vulnerable members of our communities at a time they needed us most. And it’s not gone unrecognised.

 

National polling carried out by the National Pharmacy Association in June found that there is strong public support for a greater role for pharmacies within the NHS.

 

  • 74% want pharmacies to provide more NHS services.
  • 89% of people believe pharmacies play an essential role.

 

Yet at the same time, the survey reported that only 3 out of 10 people are “definitely aware” that community pharmacies are part of the NHS, despite the fact that pharmacies are the most visited of all settings where NHS care is offered. Indeed, throughout the pandemic community pharmacies were one of the few healthcare settings that kept their “doors open”, providing much needed, face to face convenient access to healthcare services to the public.

 

Community pharmacies provide a range of NHS services and pharmacy teams work with other professionals, such as doctors and nurses, to give you the best possible care as part of the local healthcare team.

 

Community pharmacists demonstrated incredible resilience and fortitude from the front line of the COVID crisis, ensuring that as many people with minor medical needs and long-term conditions were kept safe at home. At Lindsay & Gilmour, both our online prescription management service and free home delivery service grew in demand exponentially.

 

This, in turn, played a vital role in protecting hospital beds and secondary care resources available for those who were directly affected by COVID-19.

 

The recent introduction of NHS Pharmacy First Scotland means even greater access to your community pharmacist to discuss a wide range of health and healthcare issues, not just about medicines. Sometimes people go to a doctor or even a hospital for problems that could be sorted out more conveniently at the pharmacy. It’s estimated that up to 18 million GP appointments per year and 3.7 million A&E visits could instead be handled in a pharmacy.

 

So please, do remember to Ask Your Pharmacist for:

 

  • Advice and treatment for minor illnesses such as coughs, colds and earache
  • Advice on staying well and preventing disease
  • A range of vaccinations
  • Help to quit smoking
  • Personalised support to get the most from your medicines

 

Pharmacy teams deliver prompt, professional health care advice when and where it is needed. The community pharmacy network in Scotland and beyond is a precious resource. We are proud to be part of the NHS team and privileged to be able to serve our community.

 

Philip Galt is Superintendent Pharmacist and Managing Director at Lindsay & Gilmour.

 

 

Report reveals extent of hidden value of community pharmacy

 

A report commissioned by Community Pharmacy Scotland published today has quantified the ‘ART’ (Advice, Referral and Treatment) of pharmacy within the community pharmacy network in Scotland.

 

The report estimates that community pharmacy teams in Scotland give advice to people accessing their services 2100 times every hour. Extrapolated over a week this equates to 84,000 advice only consultations. The study estimates therefore that community pharmacy teams in Scotland conduct advice only consultations 1.67 times every hour.

 

Pharmacy Sites 1 2 3 4 5 6 7 8
Total Advice 37 78 146 84 85 85 80 62
Hours Open 53.5 47.5 50.5 40.5 41.5 62 55 51
Advice Per Hour 0.69 1.64 2.89 2.07 2.05 1.37 1.45 1.22

 

Table adapted from the ART of pharmacy report.

 

Although the pharmacist was found to be the pharmacy team member giving advice most often, the pharmacist advice only interventions account for less than half of the total contacts in the study.

 

Staff Role n %
Pharmacist 305 46.4
Technician 61 9.3
Counter Assistant 269 40.9
Student 22 3.3

 

Table adapted form the ART of pharmacy report. (n=657)

 

Across Scotland, eight community pharmacies were selected for inclusion in the study. The study sites were sought to represent the diversity of community pharmacies based on several factors: relative deprivation of the pharmacy postcode, urban and rural locations of the pharmacy, and whether the pharmacy was independent or part of larger multiple groups. The results from these eight pharmacies were then extrapolated to estimate Scotland wide activity in the community pharmacy network.

 

Other key findings in the report include:

 

  • Over 80% of people are completely satisfied with their community pharmacy experience.
  • 90% of people want GPs and pharmacists to work closer together for their benefit.
  • Around 60% access their community pharmacy due to their relationship with the pharmacy team.
  • 41% of people would go to their GP if the pharmacist was unavailable.

 

The most common reason for accessing the services of community pharmacy was to collect prescribed medication (60.3% of visits), followed by buying medicines (23.3% of visits), seeking medical or health advice (13.7% of visits) and general shopping (2.7% of visits).

 

The authors of the report concluded the following:

 

“Community pharmacy in Scotland is highly regarded by the patients that access their services and provides alleviation to general practice services. Perceptions of both the service and interactions with staff were highly reported and the staff-patient relationship appears to be at the cornerstone of patient experience.

 

“Instances where advice-only is the outcome of patient consultation should receive greater recognition in its contribution to the services community pharmacy provide due to the time it occupies and the staff knowledge demonstrated therein. The service provides full satisfaction to most of those who access it, despite a limited public knowledge of the capacity and diversity of community pharmacy.”

 

In a statement released today Community Pharmacy Scotland commented:

 

“Community pharmacy teams have forever known that they dispense advice and refer on to other parts of the healthcare system with no way of knowing the scale of that impact. This study highlights the significant role community pharmacy teams play in encouraging self-management and acting as a touchpoint for Health and Social Care at the heart of the community as a key component of the primary care team.

 

“As well as the headline statistics we also have a report that has experience of team members and the public through case studies. The diverse range of individuals highlight community pharmacy’s impact in terms of lived experience. These are individuals that are supported in communities throughout the country in pharmacies every day. They value their relationship with community pharmacy.”

 

Professor Harry McQuillan CEO of Community Pharmacy Scotland said:

 

“CPS is delighted with the report which demonstrates the clear value of community pharmacy team. The report allows us to highlight this value with key decision-makers. NHS Pharmacy First Scotland will only add to this report in terms of data.

 

“This report, alongside this new service, should support further development of Pharmacy First so that the right person can receive the right care in the right place, with that place so often being the pharmacy at the centre of the individual’s community.”

 

“CPS would like to thank everyone who contributed to and helped produce the report the report.”

 

 

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Scottish contractors secure funding for May bank holiday opening

 

The Chief Pharmaceutical Officer for Scotland has written to the community pharmacy network in Scotland to inform them of the arrangements around additional bank holiday funding to the network in Scotland.

 

The circular (see below) outlines the agreed arrangements for fee’s payable for community pharmacy contractors providing pharmaceutical care services on the May Bank Holidays.

 

Community pharmacy contractors have been requested, where possible and safe to do so, to open and provide a full range of pharmaceutical care service on either both or one of the scheduled May public holidays; or if this holiday falls in early June, taking account of regional variation.

 

Fees payable will be set at the same level as that provided for opening on Good Friday and Easter Monday: that is, £1,200 for a full day opening; £700 for a half-day opening.

 

The Chief Pharmaceutical Officier for Scotland Rose Marie Parr recognised that opening at Easter was a significant ask especially given that many community pharmacy teams had already given up their Easter break already. She added that the community pharmacy network was best positioned to anticipate and support demand and that given the prolonged nature of the pandemic it would important to have support form the community pharmacy network during the May bank holiday.

 

Chief Executive of Community Pharmacy Scotland Harry McQuillan made comment about the announcement in the now regular YouTube video. You can view the video below.

 

 


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Scottish pharmacy out in force to lead the primary care agenda

 

As part of the Health and Sport Committee enquiry into primary care Director of Operations Matt Barclay from Community Pharmacy Scotland and Chair of the Royal Pharmaceutical Society Scottish Pharmacy Board Jonathan Burton gave evidence.

 

The enquiry is being run in two phases. The first phase has already been completed and a report on the findings on the initial phase one survey can be viewed here. A summary of the conclusions from phase one are as follows;

 

  • From the surveys and the deliberations of the public panels, there is clear public support for change in the way Primary Care is accessed and delivered.
  • The public has indicated they want change and to experience the benefits of technology.
  • The public has universally indicated they want solutions and do not regard the status quo as an option.

 

The second phase of the inquiry is more like a “traditional” Parliamentary inquiry driven by the views of service users from the activities in phase one and will involve hearing from the professions, including seeking their views on what the public have told the committee in phase one.

 

The meeting involving pharmacy representatives was convened by Lewis Macdonald MSP and in attendance in addition to Jonathan and Matt were David McColl, who is chair of the Scottish dental practice committee of the British Dental Association; and David Quigley, who is chair of Optometry Scotland.

 

To what extent is integrated planning taking place nationally across all healthcare professions? What is your input to that?

 

Matt Barclay replied indicating that a lot of work has gone on. He pointed towards the work done by Lewis Ritchie:

 

“We have had the national clinical strategy, the transformation moneys and the out of-hours review that was led by Sir Lewis Ritchie. How effective all that has been in changing practice to date is questionable. I reiterate what my colleagues said about information sharing. In a community pharmacy context, day-to-day information sharing certainly needs to improve. It would be really good if that work was joined up. Things are happening in the background on information-sharing arrangements, following conclusion of the general medical services contract, but improved arrangements are certainly far from the reality.

 

There is a willingness, as can be seen in the fact that all the bodies that are represented here today are part of the primary care clinical professionals group

 

“The group was, largely, created because there was so much work going on and there was a realisation that all primary care professionals needed to look for commonality and to work, as a group of professions, towards common goals. That willingness on the professions’ side needs to be matched on the other side.”

 

Jonathan Burton continued by explaining the difficulties for pharmacy professionals to communicate effectively as part of the wider primary care team;

 

“It is difficult to integrate healthcare services when the professionals in the services cannot easily communicate with one another. We see that in community pharmacy practice, and it is echoed in other contractor professions that sit outside the general practice surgery model. It is, for example, difficult for us to access patient records. Changes are starting to be made in some areas, but access to basic electronic care summaries is still not commonplace in community pharmacy. In pharmacy, the range of services and the complexity of care that we offer are forever increasing.

 

We lack not only the ability to see records but to populate them with a record of the care that we provide. That limits integration. Every minute that we spend struggling with communication with our colleagues is a minute away from patients.

 

The questioning turned to patient data and who might own said data. Brian Whittle MSP specifically probed on this issue and indeed the wider issue of the need for a centralised system to allow the input and output of patient data so that pharmacists and others could work more effectively.

 

Matt Barclay responded by saying;

 

“We are on a journey, on which the right first step is probably to give the professional networks wider access to information. Ultimately, if we want to inform and empower patients, they should own their data and authorise the right professionals to see the data at the right time. That is the endpoint for me. I appreciate that there are GDPR and information governance issues in that regard.”

 

Jonathan Burton said;

 

We should be aiming for a centralised digitised record, of which the patient has ownership.

 

“Professions that are arguing for increased access to records and increased ability to write into records should be mindful that we need to take patients with us on the journey: their consent is essential. We should use the appropriate information in the appropriate way.”

 

Who is responsible for delivering change and the level of integration that is sought?

 

Matt Barclay responded;

 

“It must be the Government that takes the lead. The first paper that the primary care clinical professions group drafted was on digital-enabled health technology, a facet of which is health information sharing. All the professions agreed that a once-for-Scotland approach is the right one. We have 14 health boards and 31 health and social care partnerships; my view is that that fragmentation across Scotland creates issues for integration.”

 

Emma Harper MSP asked made it clear that she would be interested to hear about any discussions that have taken place about the enhanced role for community pharmacy and asked the following question.

 

Are pharmacists best placed to undertake anticipatory care and preventive work?

 

Matt Barclay responded;

 

“Discussions are taking place. In April 2020, there is to be an evolution of our contract, to extend the minor ailment service so that it covers more services.

 

For example, the scheme will cover services to do with urinary tract infection and impetigo that GPs have traditionally provided.

 

“That type of thing is happening. To go back to Sandra White’s point about public awareness, we would look for a public awareness campaign to go hand in hand with that to signpost people to the community pharmacy.”

 

Jonathan Burton commented;

 

“I am a practising community pharmacist. It is fair to say that, over the past 15 years, the pharmacy contract and the range and depth of the services that we offer have continually evolved. We are at a point at which we have to look at the resource that needs to go behind the complexity of what we do and the breadth of the service offering.

 

We need to look at the training, the continuing professional development and the support that are needed to maintain that first-port of-call access service.

 

“I very much consider myself the first port of call, but the lack of infrastructure and integration makes that challenging in a time when an increasing number of patients are coming to see us. The evolution has been positive, but we need to take a serious look at the resources. I am a massive fan of referring to optometry, but the process is rather clunky.

 

“It is not my place to comment on optometry remuneration, but I was very pleased to see supplementary eye examinations mentioned in the Optometry Scotland submission and the fact that more support is probably needed to make those appointments more available. I very much second that. We are the first port of call—the guys people walk in to see—and we need to be able to refer to one another easily. That involves GPs and the professions that members see represented here today. However, a resource ask comes with the increasing complexity and the increasing workload.”

 

Emma Harper MSP asked; If everybody was to collaborate, how would we fund all the training requirements? Do we need more pharmacists or optometrists?

 

Matt Barclay responded;

 

“As Jonathan Burton said, the complexity is increasing, certainly in community pharmacy, due to the number of people who are coming to see us as the first port of call. I would echo Jonathan’s call for the resource to go into the training to match that. We are working in partnership with the pharmacy and medicine division to develop the contract in that direction.

 

“I mention in my submission the extension next year of the new pharmacy first and minor ailment services.

 

We are also looking at a co-ordinated independent prescribing strategy because we see it as an endpoint for community pharmacists to have independent prescribing status for dealing with patients who come through the door. We have that skill set in mind, too.

 

“It is easy to say that more money is the answer, but we are working within our financial envelope to shift money from certain areas to support what we and the Government department see as strategic areas. We are not looking for huge amounts of money to supplement that but, as Jonathan Burton says, we need more resource to support the direction of travel, certainly for community pharmacy.”

 

Emma Harper MSP continued with the following line of questioning;

 

How long does it take to break down the barriers? Is it six months? When you reflect back on the process, do you think that it has taken five years for people to realise that they can go to pharmacy as a first point of contact or to optometry for eye health exams?

 

Jonathan Burton responded;

 

“It is an evolutionary process. Ten or 15 years ago, eyebrows were occasionally raised when pharmacists referred to our clientele as patients rather than customers. Thankfully, those days are long gone.

 

“To go back to the previous question about the acceptability of our service to others in the medical professions, the majority of GPs are supportive of our front-line role in community pharmacy and of having GP practice pharmacist colleagues working shoulder to shoulder with them in their buildings. We all have a role to play. It is not just about easing the workload or the pressures on any one profession. It is often said that our work saves GP time, but it is not about that; it is about making sure that patients have good access to the appropriate level of care so that we can all do what we are best at.

 

“In our submission, we mentioned transformational change.

 

We would like to see a continuation of the evolution in community pharmacy practice so that our remuneration and training support pharmacists who offer patients a package of care, not just a package of medicine.

 

“As we have said many times before today, the complexity of what we do is ever increasing.

 

“On what the public wants, the evaluation of the minor ailment service, which was an independent evaluation that was done by the two schools of pharmacy, showed that patients value accessibility. They value being able to speak to somebody they are familiar with. They also value the fact that they do not need an appointment.

 

It takes resources to offer those sorts of services in the community.

 

“I feel that that is the right way to offer care. We are fortunate to have such amazing networks of pharmacies, optometry practices and dental practices across the country, and we need to use the fact that we are close to where our patients are.”

 

Brian Whittle MSP asked about workforce planning in pharmacy;

 

If we are going to maximise the skill set of a pharmacist, do you agree that we want pharmacists to have more time with patients? Anecdotally, I have heard from quite a number of pharmacists that we could train staff in helping to dispense medicines so that the pharmacist does not have to do that constantly. However, I also hear that, as soon as that happens, the staff get pinched by secondary care. We are always talking about the number of clinicians we need; are we failing to look behind that at the support network?

 

Jonathan Burton responded;

 

“We have a finite number of pharmacists who work in Scotland. There are quite a few of us—more than 4,000—and we are the third-largest profession, but it is fair to say that our skills are in demand. We all know that medicines can be wonderful things and can do fantastic things for people’s health. However, they can be risky and can sometimes cause harm, which is why our profession’s knowledge and skills are sought after.

 

“That has led to some fundamental changes to the GMS contract. Many of our pharmacist colleagues are now actively working side by side with GPs and nurses in practices, which is very positive. As I said, we are a finite workforce. We are in hospitals and community pharmacies, and there is only so much of our time to go around. We need more highly trained support staff. We have a very hard-working workforce, who already do a lot of dispensing and technical activities for us.

 

It is fair to say that transformation has probably been more rapid in hospital practice than it has been in community practice.

 

“There are many underlying reasons for that. We need to ensure that we are able to put our pharmacists where they are needed, which is right in front of the patient. At the moment, we have some issues with that.

 

“Our workforce is becoming increasingly stretched, and the Royal Pharmaceutical Society does not believe that that is in anybody’s interests—least of all patients’. It is positive that pharmacists are able to work in general practices but, if our services are taken away from hospital wards and community pharmacy consultation rooms, that will have a negative feedback effect on those general practices. We need to ensure that patients get accessible and safe healthcare and do not always gravitate towards general practice for anything and everything.

 

We need to look at our workforce planning.

 

“We have a lot of workforce surveys, which throw off a lot of interesting information, but so far we do not have a coherent plan that takes account of the fact that patients are now fellow professionals who need us in a lot of different settings. Wherever there are medicines, there needs to be pharmacist input, whether it is administrative and technical or whether it is right there with the patient, the doctor and the nurse. That is becoming increasingly difficult.”

 

George Adam MSP asked the witnesses to consider the design of the health service from a blank canvass;

 

How would you make the system work, if you had a blank canvas?

 

Matt Barclay responded;

 

“It was interesting to read the evidence from the meetings that the committee had with the public in phase 1 of its inquiry. It was heartening that the public did not regard the status quo as an option and that they wanted the evolution to continue.

 

They also mentioned the professionals they most want to see. I think that mental health professionals were top, followed by physiotherapists and pharmacists.

 

“That was heartening. A large majority wanted their information to be shared—that is fine.

 

“Although a community pharmacy operates in a building and our GP and other health profession colleagues operate from a building, it is more a question of creating a virtual hub, through which patients are transferred seamlessly. That might involve public awareness to make sure that people know which professional to see and that they see them at the right time for the right reason. There needs to be such awareness within the profession, too, so that we can refer people on. There also needs to be a link to secondary care expertise as and when that is required. As a generalist, I can go only so far, but the ability to refer people on to experts is important.

 

“I do not know whether that answers George Adam’s question, but that is what I would like to see happening in the future. I would like us to still be at the heart of communities, with patients coming to see us as and when they require to do so. I hope that we will have an upskilled workforce at the front and the back, so that the technical stuff is done and the pharmacists who see patients upfront will be able to share that with the wider primary care workforce.”

 

Jonathan Burton added;

 

“I absolutely agree with that. Anybody who works on the front line will say that they are part health professional, part navigator
and part adviser. We feel that we could build on that significantly in community pharmacy if only we were better linked into the system.

 

“The issue comes back to the arguments about central patient records, electronic communication and the need to make referral between different agencies as slick as possible. If we can navigate a patient through the service and explain to them why they need to see their dentist or—if they have gravitated towards us with an eye problem—their optometrist and can smoothly facilitate their being moved on to the right service, that is a powerful message in itself. I spend a lot of time working with young people, as I work in a pharmacy that serves a predominantly student population.

 

It is a joy to be able to teach people how to use the NHS properly at that early stage in their adult life. People really respond to that.

 

“The issue involves being the first point of contact, helping people with their symptoms and picking up on things that need a referral, but it is also partly about educating people about how to use the service and how to practise appropriate self-care and look after themselves.

 

“I am an independent prescriber and, in my pharmacy’s consultation room, I have two pads on my desk: a prescription pad and a pad of TARGET—treat antibiotics responsibly, guidance, education, tools—self-care leaflets that explain to people common symptoms of illnesses, how long they should last, when it is necessary to see a doctor and why it is not appropriate to take antibiotics. I tear more sheets off the self-care leaflet pad than the prescription pad. That is where we need to be.”

 

George Adams probed to confirm on the question of information sharing;

 

Are you saying that, in order to make everything work, information sharing is the number 1 priority, so that you guys can ensure that you have the access that you need when you and the patient need that to happen? That is a pretty basic question, but I want it on the record.

 

Jonathan Burton “Yes”

 

Matt Barclay “Yes”

 

David Stewart MSP asked about workforce planning;

 

How effective is workforce planning in your occupations?

 

“I recognise many of the challenges that my colleagues from dentistry and optometry have highlighted. Pharmacy is no different in that regard. We are not a controlled profession—our numbers are not controlled in the way that happens for medicine, teaching, nursing and so on—so it is difficult to plan.

 

“Jonathan Burton mentioned that we have run a couple of workforce surveys in community pharmacy, to try to get an understanding of the numbers of pharmacists and support staff out there. That has presented a few challenges, and we realise that we need to do more work to understand the numbers a bit better, because the surveys have not given us a clear picture. Pharmacists and technicians have been moving to the new roles that were created as part of the pharmacotherapy element of the GP contract, which is a priority area. The intention is for about 600 pharmacists to do that over six years, and the moves started three years ago.

 

That is putting a strain on the community pharmacy workforce, which we need to understand more.

 

“As my colleagues described, people have different expectations. For example, pharmacists want to undertake portfolio working and take on different roles in different areas. That can bring benefits, but it can also present a challenge when we are looking to provide continuity and quality of care in certain sectors. There are opportunities. Like Jonathan Burton, I see the move to have pharmacists in GP practices, as advocates for the profession and to work with GPs and nurses, as positive. We can use that approach in a positive way. However, there are a number of challenges for the workforce.”

 

Would it help if your occupation were to be a controlled occupation? What would the steps be to get more sophisticated workforce management in the future?

 

Matt Barclay commented;

 

” I am not sure that the universities would thank me for saying anything about that. I think that they like how it sits at the minute. Being a controlled occupation may help because if we could control the numbers nationally and the funding was there to support that, a controlled intake to support the needs of the modern pharmacy workforce would seem to make sense.

 

“We are undergoing a review of the pharmacy undergraduate course, which involves looking at everything from recruitment and admissions to a lot of the points that David Quigley has raised, such as whether we are getting the right people into the profession through to funding, quality and governance. We are doing that review in the background, hand in hand with all the stakeholders.”

 

Jonathan Burton added;

 

“To answer the initial question, a lot of workforce information gathering is going on, but not as much planning. Obviously, information is needed before we can plan, so that is understandable in a way. With the development of the GP contract, fantastic work is being done by pharmacists, who are being parachuted into practices that are struggling, to be frank. They are putting their full expertise into helping those patients get a good standard of care. Our colleagues are doing some really great work. However, it is a pressured environment.

 

“The Royal Pharmaceutical Society gets feedback from all sectors of the profession, and the feedback from our members who are working in GP practices.

 

The pharmacotherapy component of the GMS contract has brought them some significant challenges with regard to whether their time is being used in the best way possible for patient-facing care or in a more technical, administrative sense to keep practices functioning smoothly.

 

“We need to be mindful of those issues, which are all about making sure that people are doing the best job that they can with the skills and knowledge that they have—we are not quite achieving that yet. We have spoken before about the negative impact on the rest of the service of a possible lack of planning around the sheer numbers of pharmacists and technicians that we need in order to provide great care in those practices.”

 

“We are talking about primary care, but the impact is in local communities for small teams in community pharmacies, and we are also talking about the expertise to which junior and senior doctors and patients have access in our hospital service, where people are really poorly and need secondary care. The issue affects the whole system, and we need to plan better how we use pharmacists across the piece.”

 

David Stewart MSP asked about remote and rural working;

 

Do other witnesses have comments to make about rural practice?

 

Matt Barclay replied;

 

“We are hearing from rural members about the workforce challenge of getting people to work in practices, too. I see, through correspondence among the professions, that really good innovation is happening in remote and rural areas.

 

NHS Highland’s NHS near me project is an excellent example of that. Clare Morrison, who is a pharmacist, is leading on that work and is developing virtual consultations with remote patients in a very different way.

 

“A lot of things can be taken from that innovation and used elsewhere. In general, we are certainly hearing that workforce challenges are the main concern for some of our members in remote and rural areas.”

 

Sandra White MSP asked about new applications for community pharmacies in Scotland;

 

In my Glasgow Kelvin constituency, I see a lot of requests to open up community pharmacies, opticians and other services. Most of the requests are to open up pharmacies. A number of them get refused—I do not know why, but they do. We have a lot more students in Glasgow, so we need more pharmacies and doctors, particularly for the universities. Why do those requests get refused? Is there a limit on how many community pharmacies, opticians or dentists there can be in an area? Who blocks the requests?

 

“I can certainly talk for community pharmacies. A control-of-entry system operates. A person cannot open up a pharmacy anywhere—they need to demonstrate whether a pharmacy is necessary or desirable in a given area. A legal test is applied as part of a pharmacy practice’s hearing. Those involved in the hearing will be the applicant and perhaps those who do not want the pharmacy to open. A system is in place to control the numbers in pharmacy. Opening up the system to the free market might have an impact on service provision. We have members who can invest in their premises and in their staff in Glasgow, for example, simply because they know that another pharmacy will not be able to open in a street in their area. Those members put resource back into their business as a result of having that comfort. However, there is a process through which an application for a new pharmacy can be made. If the legal test is passed, pharmacy contracts are granted.”

 

Sandra White probed the witnesses on the topic of awareness-raising amongst the general public in terms of the services provided and how to seek appropriate help for a given ailment;

 

Is there enough awareness among health and social care professionals of what is happening on the ground? Do they need to be educated and made aware of what exists, so that people do not need to turn up to their GP?

 

Jonathan Burton commented;

 

“A lot of it comes down to communication and how we all link up. As I said, we can help patients on their journeys, but those journeys need to be smooth. We need reassurance that, when we refer somebody, a good process is in place.

 

In our submission, we mentioned the possibility of more interaction with school-age children on healthcare and self-care, so that we help people from an early age to have a bit more knowledge about the system and the expectations.

 

“We need to look at our undergraduate training and at opportunities for postgraduates to link up with other professions. It was only during my clinical skills training, which I did as part of my common conditions clinic offering, that I really started to appreciate the impact of community optometry on eye care. That understanding has substantially increased the number—and, I hope, the quality— of referrals. I am sure that there are opportunities to get such messages across earlier in people’s careers.”

 

Matt Barclay added;

 

“It is about self-care and people having a good start by knowing a little, not necessarily about a particular profession but about the NHS more generally, so that they can look after themselves.

 

David Torrance MSP continued the line of questioning about awareness-raising amongst the general public;

 

Community pharmacies are often integral to small communities. Are they better placed than the Government to educate the public about the services that are out there? Everyone says that the Government should advertise services, but should community pharmacies do that? What role does social media play in that regard? Many small towns and villages have a Facebook page and are quick at posting about the good things that are happening locally.

 

Matt Barclay responded by saying;

 

“Jonathan Burton talked about how the best advert for any profession is how the professional deals with the patient who is in front of them, whether they help the patient at the time or signpost them to another service. Maybe we could shout a bit more about what we do in our local communities. Some of our members do that, to be fair.

 

“However, there needs to be an overarching message from the centre about the policy intent and the various strategy documents—we have one in pharmacy. If there is to be a fundamental change in how primary care is delivered, we need that message, to support the professions. For example, Community Pharmacy supports encouraging people to go to the right person at the right time—the pharmacy first message. That message can be put out through pharmacies. Social media has a large role to play. There is a positive message to put out about what all the different professions can do. To answer your question, we need a mixture.”

 

Alex Cole-Hamilton asked about the contractual arrangments by which community pharmacy receives remuneration;

 

I want to ask about the culture in pharmacy. If someone presents with a long script of medications and they tell the pharmacist why they have been prescribed all those medications, what happens if the pharmacist thinks that there is a simpler way of dealing with the issues, which does not involve so many medications? What happens if the pharmacist disagrees with the GP and thinks, “If you have this condition, that medication won’t do you any good at all”?

 

Matt Barclay commented;

 

“I will allow Jonathan Burton to speak to this as well. Certainly, if a patient came into the pharmacy in which I was a locum on a Saturday and said what you indicated, and if we are really living the values of the NHS and putting the patient at the centre, I would listen to that patient. I would work with that patient to understand what their understanding was and what better solution there could be. I would then have a conversation with the patient and the GP to try to get the prescription amended. It is an interesting question, because an element of our contract involves the chronic medication service—I will call it that as I think that most of the committee will be familiar with that name, although it actually has a new name—whereby we support people with long-term conditions around their prescriptions in order to reduce waste and ensure that they get the best from their medication and have the lowest number of side effects.

 

As we know, the more medications that people are on, the more at risk they can be from side effects.

 

“We have to work with that and contractualise it more in a community pharmacy context. It is certainly the job of my organisation to work in partnership on that and build on what we have started. The answer to Alex Cole-Hamilton’s question is that we would deal with a patient’s query because the patient’s needs are paramount. However, we need to have that recognised in a contractual sense in order to move it on.”

 

Alex Cole-Hamilton sought clarification;

 

But you need to make a direct referral back to the GP if you disagree with the patient?

 

Matt Barclay continued;

 

“Yes, that is ultimately what we have to do at the minute. Jonathan Burton and I are both independent prescribers; I do not practice, but Jonathan does. If we have independent prescribing authority, we could decide to prescribe. However, many pharmacists will not do that if the patient’s condition is not within their area of competence, because they need to be professionally competent. Jonathan Burton is a great example of what we tend to do as generalists, as he uses in communities his generalist knowledge in the area of common clinical conditions and pushes that on.

 

“However, for diabetes and cardiovascular conditions, for example, we would need a certain level of expertise before making any decisions. That is not something that a pharmacist would take on at the minute. It is about having a chat with the patient, understanding their needs and then referring back to the GP and having a conversation with them to get the changes that the patient desires if that is appropriate.”

 

Jonathan Burton commented;

 

“Again, it is about making the best use of people’s skills wherever they practise.

 

As a community pharmacist, I am good at making lots of high-quality, brief interventions—that is the utopia for me.

 

“I am a spotter and I can spot things because I know patients. I can see patterns and see when something is not quite right. However, I do not always have the time, or sometimes might not have the expertise, to deal fully with the issue that I have recognised. That goes back to transformational change and looking more at the package of care rather than just a package in terms of contract remuneration and the structure of the service.

 

“I would like to see more partnership working through our pharmacist colleagues working in GP practices and, indeed, with GPs, because there are a number of magic ingredients there. I am the guy who knows the patient well and can spot where there is an issue or possibly one on the horizon; I can communicate with my GP practice colleague and they could do, on my advice, a more in-depth review of that patient’s medication. I could liaise closely with them, and we should be working together on those problems.

 

“As I said, my expertise is being a spotter, dealing with acute conditions, having a public health role and being able to make appropriate referrals where needed. Where my GP practice colleague will come in is where a deep dive into a patient’s complex medication history is needed, for example, and the pharmacist can work shoulder to shoulder with the GP on that. That is a good combination if we are looking at tackling medicines-related harm and unwanted prescriptions.

 

“The core of Alex Cole-Hamilton’s question is how we deal with prescription items that slip through the system but probably need what we would call a bit of deprescribing attention. However, it is not just about stopping things; it is about ensuring that we make the right decisions and that patients are on board with that. That needs a bit of teamwork, which means that we have to be linked up. It all goes back to the sharing of records and being able to share messages and have conversations easily.”

 

Alex Cole-Hamilton asked about social prescribing;

 

Do you feel encumbered by a sense that you are there to provide one service, which means that engaging in social prescribing would be an overreach?

 

Matt Barclay responded;

 

“We have a public health element to our contract, regarding things such as smoking and sexual health, but what you are describing probably goes a step further. We have those conversations as part of the short, sharp interventions that Jonathan Burton talked about, but I think that I would probably echo what the others have said: that is not something that is measured or recorded. The issues can come up informally as part of a wider discussion but, if we want to bring that in, it would involve ensuring that we had the capacity to do that, as it would probably involve longer consultations and so on.”

 

Jonathan Burton commented;

 

“There are two aspects to the issue of what could be labelled social prescribing. One involves a question of whether we need more structure and regulatory back-up for that sort of activity, and the second involves the fact that we would need more time and space to develop those relationships with the patients whom we look after, because there is an issue of trust involved- people need to trust you if they are going to listen to you. That trust sometimes takes a little time to build, so having supportive practice structures that enable practitioners to stay in one place for a significant amount of time and develop those relationships—and having contractual arrangements that give us that little bit of extra time with our patients—could be impactful, whatever label you want to use for that.”

 

Brian Whittle MSP returned to the workforce question;

 

How on earth can we have an effective workforce plan if we do not know the numbers that are involved in clinical activities and cannot take everything into account?

 

Matt Barcley answered with the following;

 

“David McColl just reminded me of something. Jonathan Burton mentioned earlier the information gathering that we have had through a couple of iterations of workforce surveys in community pharmacy.

 

“However, in the past, the concept of a performers list has also been mooted, which we at Community Pharmacy Scotland are supportive of. It is well known in GP land as well and might help us to understand, to a degree, who can do what and where they are. At the minute, we do not have anything like that at health board level.

 

The movement of pharmacists and technicians across the interfaces and within primary care means that it is difficult to get a handle on exactly what we need.

 

“However, to go back to David McColl’s point, it can be done.”

 

Jonathan Burton added;

 

“It is fair to say that the change in the workforce in pharmacy is very rapid at the moment, which is, in itself, one of the issues. It is quite obvious that we are in an information-gathering stage, but there is very little planning for after that. We need to consider not only how many people we have and where they are, but what they are doing.

 

“My working day has changed immensely over the past three or four years.

 

We operate a mixed consultation/dispensing model.

 

“The more complexity we see, the more unpredictability there is, and the more time we spend with the patient sat in front of us. What exactly are my colleagues in GP practices doing? Is it administrative; is it technical, around prescribing; or is it clinical review? How does that picture look at the moment? We need a lot more granularity and detail.”

 

The final question in the session came from Emma Harper MSP who asked about those patients outwith the healthcare system;

 

What about the folk who do not access healthcare? There is another challenge when we consider poverty, health inequality and the folk who really need healthcare. I am thinking about the inverse care law. How do we help those people to get the support that they need?

 

Jonathan Burton responded;

 

“If we look at community pharmacies across Scotland, we see that they are distributed more heavily in areas of deprivation. There may be underlying historical reasons for that, such as higher dispensing volumes, but there is a real opportunity, which is being partially exploited at the moment.

 

When we look at the ease of access to services such as the minor ailment service, and the number of children who are treated through those services, we see that there is a massive opportunity to interact with families who are in low-income brackets.

 

We also have pharmacists who work with the homeless and we have a long history of close working relationships with substance misuse clients and services. We are in the trenches on this one.”

 

The enquiry continues.

 

The full report of the meeting in which Jonathan and Matt gave evidence can be viewed here.

 

Below is a schedule of sessions that have been held, and will be held at the Scottish parliament when key primary care stakeholders will give evidence to the committee.

 

24 September 2019 (click on the date to view meeting summary)

 

  • Allied Health Professionals.
  • Multi-disciplinary teams.

 

1 October 2019 (click on the date to meeting summary)

 

  • Primary Care professionals.
  • General Practitioners.

 

8 October 2019

 

  • Local Primary Care planning.
  • Voluntary sector and Primary Care.

 

5 November 2019

 

  • Technology and information sharing.
  • The Cabinet Secretary for Health and Sport.

 

19 November 2019

 

A selection of attendees who were involved in the public panels will be invited to discuss the evidence presented to the Committee in phase two of the inquiry.