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New customers: new education

Published on 16/02/05 at 04:36pm

Doctors have for a long time been the primary influencers of prescribing and chronic disease management. For pharma companies, that has meant putting the full weight of marketing and education campaigns behind GPs.

This started to change with the arrival of the NHS Plan and the government's new vision for healthcare which essentially shifts prescribing and the managing of medicines to community pharmacists. For pharma companies this presents a new opportunity to strengthen communication with these new prescribers. Although in the past pharmacists have been mainly targeted through PR and doctors through medical education (med ed), there is a specific place for the pharmacy education (pharm ed) element within the marketing mix.

Med ed vs pharm ed

One definition of med ed is that it is about developing an integrated, science-based, communication programme, using different media to spread information about a medical product or therapeutic area.  

The needs of pharmacists are different to those of GPs. Pharmacists work in the community, across both the prescription and OTC medicines sector and have the mixed roles of prescribing, OTC recommendation, health promotion, medicines management and concordance. Pharm ed therefore has to meet the standards and education needs required to help them provide these services and medicine supply functions.

That means developing pharm ed in line with med ed, so that there is a greater emphasis on therapeutics and evidence-based education together with practical support for pharmacists delivering new professional services, such as medicines use review, prescription intervention and supplementary prescribing. There will also be a need for information on rational prescribing and interpreting medical data and clinical trials.

As independent prescribing by pharmacists becomes established, pharm ed can then be used to target pharmacists earlier on in the marketing programme, in other words at the pre-launch stage, as is currently the case with med ed.

Communicating with this new and influential audience requires an understanding of:

  • the environment they work in
  • their unique position on the 'high street' and within the community
  • their relationship with PCTs
  • their relationship with GPs and other healthcare professionals
  • the 'language' used within the profession
  • business and professional concerns (eg, mandatory CPD, funding of professional services)
  • the role and needs of their support staff

Factors fuelling pharm ed

Pharmacists' role in managing chronic disease and increasing access to medicines has been recognised by the Department of Health. The NHS Plan (July 2000) wanted health services to be shaped around the needs of patients. That meant an NHS that offers patients fast and convenient access to high quality services, informed choice and a real voice in the design and development of healthcare. For pharmacy in particular, the government has a number of goals.

Meeting the changing needs of patients:

  • Ensuring people can get medicines or pharmaceutical advice easily and conveniently
  • More support in using medicine
  • Building on the trust and confidence that people place in pharmacists and pharmacy services

Responding to a changing environment:

  • A more competitive retail environment for community pharmacy
  • Arrangements for securing and paying for generic medicines
  • Electronic ordering and home delivery

Maintaining professional standards:

  • Tackling things that go wrong in a modern, open and transparent process
  • Professional education and training that meets the needs of tomorrow's world
  • Ensuring pharmacists keep their skills up to date

One of the significant outcomes of the NHS Plan has been the role redesign of healthcare professionals to make better use of skills. For pharmacy this has meant a greater involvement in making medicines safer and more accessible to patients. Both the GP general medical services contract and the new pharmacy contract have provided the underpinning framework for delivering these new services.

The new pharmacy contract

The new pharmacy contract will be implemented from April 2005 and will see pharmacists take on their first clinical roles.

The New Framework Contract for Community Pharmacy aims to:

  • Provide clear minimum standards for community pharmacy, to meet the needs of Pharmacy in the Future - implementing the NHS Plan
  • Provide clear and fair rewards for high quality services and promote best value for money
  • Harness the skills of community pharmacists and their staff, to deliver better primary and community care services to patients by developing opportunities and rewards for integrated working
  • Minimise bureaucracy for pharmacy/PCTs

Pharmacists will be rewarded for offering a range of professional services. Under the old contract, such services were delivered as a goodwill gesture by a few pharmacists.

Structure of the contract

The new pharmacy contract mirrors the GP contract and consists of three different levels of services: essential services, advanced services and enhanced services. It is likely that the contract framework will develop over time to keep pace with the changing needs of patients and the NHS. For example, some enhanced services may become part of the essential services category.

Essential services: The new contract expects all community pharmacy contractors to provide these services. Essential services will be 'nationally agreed' and will not be open to local negotiation and include:

  • Dispensing
  • Repeat dispensing
  • Signposting patients to other healthcare providers
  • Clinical governance requirements, which include: Standard operating procedures;  Adverse incident reporting to National Patient Safety Agency; Evidence of pharmacist continuing professional development (CPD); Service audits and patient questionnaires; and Intervention monitoring
  • Public health - healthy lifestyle promotion, including: Opportunistic one to one counselling on smoking cessation; Opportunistic one to one counselling of patients on CHD risk factors; Promotion of lu vaccination uptake in at risk groups; Educating the public on the appropriate use of antibiotics, particularly their minimal effectiveness in coughs and colds
  • Medication waste disposal

Advanced services: Pharmacists offering these services will need to be accredited by the PCT (or equivalent) to ensure a good standard of service and premises. In time, it is hoped that all contractors will provide the service as part of the gradual contract development. Advanced services include:

Medicines Use Review (MUR):

  • Pharmacist undertakes medicines use review to meet the requirements of the elderly (NSF) and for other patient groups
  • Face to face meeting with patients
  • A concordance centred review, which assesses patient problems with current medication and its administration
  • Patient knowledge of medication regimen is assessed and developed
  • Report is fed back to patients' GP

Prescription Intervention Service (similar to the MUR service):

  • Pharmacists highlighting problems with prescriptions, or improvements to therapy which require a review of the patient's medication regimen
  • Interventions may include dose optimisation and synchronisation, suggestions for therapeutic substitutions based on local protocols, recommendations of changes to help with patient concordance

Enhanced services: These services will be commissioned locally by PCTs. PCTs will also be able to develop other local services to meet their specific needs. PCTs will also have the option to use local pharmaceutical services (LPS) arrangements to deliver these local services. Enhanced services may include:

  • Minor ailments management
  • Disease specific medicines management services
  • Emergency hormonal contraception service
  • Concordance services
  • Smoking cessation service
  • Diabetes screening
  • CHD screening/Healthy Living
  • Palliative care services
  • Full clinical medication review
  • Prescriber support services (medical practice based)
  • Head lice management service

Pharmacy prescribing

Pharmacists, who have always been the experts on drugs and their use, are now being encouraged to make better use of these skills. The new approach is for doctors to diagnose and for pharmacists to use the diagnosis to prescribe treatment for an individual patient.

The supply of medicines by pharmacists has been pushed forward by the arrival of specific mechanisms:

  • patient group directions
  • minor ailment schemes
  • POM to P switches
  • supplementary prescribing

Each of these has its unique place in patient care and in the NHS Plan's aims to increase patient access to medicines. Supplementary prescribing paves the way for full independent prescribing that is being introduced this year and will prove to be a hot topic for 2005.

Supplementary prescribing

The first qualified pharmacist supplementary prescribers were introduced in 2004. The definition of supplementary prescribing is 'a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient's agreement.'

In this case an independent prescriber would be a clinician who is responsible for the assessment of patients with an undiagnosed condition and for decisions about the clinical management required, including prescribing. The supplementary prescriber would be the person who takes over the continuing care of a patient, which may include prescribing, after initial assessment by an independent prescriber.

Funding

The NHS is sponsoring pharmacists to attend supplementary prescribing courses. Pharmacists need to apply to their local PCT for consideration. Another avenue that is being explored is sponsorship by pharmaceutical companies. Some pharma companies already sponsor nurses to become specialists in particular therapeutic areas.

Formulary

There is no specific formulary for supplementary prescribers to use. That means all prescription only medicines (POM) and general sales list (GSL) and pharmacy (P) medicines can be prescribed. Appliances, devices, foods and other borderline substances can also be prescribed. The exceptions are controlled drugs and unlicensed drugs unless they are part of a clinical trial but there are plans to extend the prescribing rights of supplementary prescribers to include unlicensed medicines supplied as specials and extemporaneously dispensed medicines.  

Access to patient records

The biggest challenge to community pharmacists becoming supplementary prescribers has been access to medical records. This has not be an issue for pharmacists running clinics from GP surgeries or who are situated adjacent to a surgery, but for the majority of community pharmacists who work remotely the problem will need to be addressed through the DH National Programme for IT (NPfIT).  

Independent prescribing

Independent prescribing by pharmacists is expected to be introduced later this year. There are several issues that need to be resolved in the meantime, such as whether they will be restricted to a formulary, but there are likely to be two models: a pharmacist diagnosing and prescribing for minor conditions; and a pharmacist prescribing for a more complex condition that was diagnosed by a medical practitioner. Independent prescribing may occur following a medication review.

Some experts believe there is a place for both independent and supplementary prescribing, the former for acute conditions and the latter aimed at the management of chronic conditions.

Pharm ed for support staff

The Royal Pharmaceutical Society of Great Britain (RPSGB) has recognised that for pharmacists to meet  NHS needs, the support staff need to be properly trained and developed.

Many of the roles that pharmacists are now expected to perform, such as medication review, chronic disease clinics and supplementary prescribing, will require a re-organisation of tasks and responsibilities within the pharmacy team to free up the pharmacist's time. That means delegating some of the routine pharmacy functions to technicians and pharmacy assistants, such as the 'final check' in the dispensary and the sale of Pharmacy medicines without the need for pharmacist supervision.

Pharma companies need to recognise the contribution that support staff make to patient care and medicines management. With the deregulation of medicines from POM to P there is an opportunity to help them apply an evidence-based approach to OTC dispensing.

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