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Medicines optimisation — can the current contractual framework deliver?

Is the current community pharmacy contractual framework holding pharmacists back in terms of delivering medicines optimisation? Maybe it is time for a new approach

By Peter Magirr

Is the current community pharmacy contractual framework holding pharmacists back in terms of delivering medicines optimisation? Maybe it is time for a new approach

Peter Magirr, FRPharmS, head of medicines management, NHS Sheffield

Medicines optimisation is perhaps the clearest attempt to date to make explicit what we all know very well. This is that medicines are an excellent technology but that patients do not, in many cases, derive the maximum possible benefits from their use. Medicines optimisation is what we want; it is not by any stretch of the imagination what we have at present and getting there is now a major challenge for the pharmacy profession. Pharmacy leaders like Keith Ridge have spelt out the message clearly: the professions — and the pharmacy profession in particular — must get their act together on this and do more, much more, working with each other and with patients to achieve this outcome.

Nothing in the above is controversial, nor is it likely to be news to any reader of Electronicjuice — but bear with me.

The vast majority of medicines in the UK are prescribed and dispensed in primary care. The costs of these medicines represents a major element of healthcare spending — a really big ticket item for the NHS that is behind staff costs but pretty much in front of everything else.

Breakdown of costs

And the breakdown of these costs is fairly interesting. Primary care prescribing costs for the four biggest categories — circulation, respiratory, endocrine and mental health — rose on average by only 3 per cent between 2007–08 and 2010–11. In many primary care trusts the cost growth was less than this; in getting on for 20 per cent of PCTs the costs actually decreased. To some degree this reflects the efforts that PCTs have devoted to managing prescribing cost pressures and, in particular, the agenda on which they have focused their medicines management teams. Although there may be a debate on whether this has been at the expense of other work such teams could have done, the effect on prescribing cost containment is clear.

The picture with regard to dispensing cost is an interesting contrast. Here the bill is going up, fuelled by increasing numbers of pharmacies (particularly new 100-hour contracts) and increasing items of prescriptions for a population that is living longer with a variety of long-term conditions.
Funding for community pharmacy has increased from just under £2,000m in 2007–08 to £2,525m in 2011–12. In context this means it now costs almost 29 per cent of the drug cost to fund the dispensing and other services provided under the community pharmacy contractual framework.
So with drug costs stable or even decreasing and increased funding going into community pharmacy, the sector should, whether the economy can afford it or not, be upbeat. It does not, however, appear to be as simple as that. Independent contractor colleagues appear to be struggling while some multiple pharmacy groups are reporting good results and the Boots/Walgreen scenario suggests that the sector retains value.

One contributory factor to this good outlook (for shareholders) is cost containment — static or falling wages for pharmacists due to increasing numbers of graduates and EU pharmacist availability. Locum pharmacist costs are also being contained, the current hourly rate being more or less the same as it was a decade ago.

The result of all this is that we have an extensive network of pharmacies, highly efficient (for the large scale operators) and making use of pharmacists (a legal necessity) to supply medicines to patients. But what we do not seem to have is a practice setting and a contractual framework that adds value to the supply function by making use of pharmacists’ skills and knowledge to support patients to optimise their medicines.

What I think makes this of more than academic interest is the economic position and outlook. It seems highly unlikely that any commissioner will continue to pay more and more without getting better outcomes; indeed the challenge now via the QIPP (quality, innovation, productivity and prevention) agenda and other initiatives is to get better outcomes more cost effectively.

Acute challenge

This challenge is likely to get ever more acute as funding for the NHS remains under pressure and, ultimately, if community pharmacy cannot deliver on medicines optimisation within the context of the current contracting arrangements new ones will be needed. These may involve separation of the supply function from the optimisation work. This might mean large scale, low cost suppliers employing relatively few pharmacists and an extensive network of community-based pharmacists — working closely with GPs and other primary healthcare clinicians — to support patients in getting the best out of their medicines, and in doing so improve their quality of life, avoiding admissions to hospital and the myriad of other demands on healthcare provision that come with poor medicines optimisation.

Such a model could liberate the clinical potential within the community pharmacy workforce which is, sadly, in many cases being wasted at the moment and in addition reduce demand on other parts of the healthcare system. With sensible procurement and commissioning arrangements it could also cost less than the current £2,525m that we currently spend on the service.

Offering better outcomes for patients, better value for money, a reduction in demand on secondary care and a more clinically focused career path for pharmacists working in the community — is it not time for some bold thinking on how we can achieve medicines optimisation?
And, if the current, tired contractual framework is holding this back, is it not time for a totally different approach?

Citation: Electronicjuice URI: 11104002

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