Scottish Government

Main Findings

• There was broad support expressed for the draft proposals for the new contract, and in particular the key aspects of the core service outlined and the notion of locally negotiated services.
• Dominating issues raised were that dispensing should remain a key activity, the new contract should not be overly prescriptive as to stifle innovation, and a greater clarity of detail was required on the proposals.
• Overall, there was much support for the general aims of the proposals for NHS Board planning and provision of pharmaceutical care services with many respondents welcoming in particular the proposed shift from a reactive model of provision to one of greater pro-activity.
• Many respondents expressed their clear support for the proposals to extend the listing arrangements to pharmaceutical non principals with a variety of advantages cited.
• Overall, there was much support for the proposal to allow for a more liberal interpretation of pharmacist supervision. However, whilst this was viewed as freeing up pharmacists' time for more direct patient care in theory, most consultees perceived obstacles to realising this aim in practice.
• Few responses were clear cut in supporting or opposing the proposals for cross border and distant provision of pharmaceutical services with many respondents appearing to welcome innovation but cautioning that developments should not jeopardise existing effective and valued practice. Innovation was seen as both a tool and a threat.
• Many respondents urged that the level of funding available for implementing and exercising the new contract should be sufficient to support an effective service. Respondents stressed that funding was required not just for financing the service to patients but also for the administration of the service and supporting the transition to the new system.

Context

The Scottish Executive's strategy for pharmaceutical care in Scotland, The Right Medicine (2002), followed the publication in 2001 of the Scottish Health Plan, Our National Health: a Plan for Action, a Plan for Change. The consultation document contained proposals for legislation that will allow for the delivery of objectives set out in the strategy. The overall aims of the proposed changes are to improve patient care and to better utilise the skills of community pharmacists and their support staff to meet local needs.

Full implementation of the proposals would require a combination of both primary and secondary legislation and administrative direction. The implementation of any primary legislation requirements would be subject to a suitable legislative vehicle arising.

At the time of going out to consultation, the new contract was still in the course of negotiation between the Scottish Executive Health Department and the Scottish Pharmaceutical General Council. The consultation sought views on enabling provisions that future legislation might need to support delivery of the new contract rather than the detail and operational aspects of the new contract per se.

The Consultation

The consultation on Modernising NHS Community Pharmacy took place between 6 March 2004 and 1 June 2004. Over 5,000 copies of the consultation paper were distributed to a wide range of people and organisations in the public, private and voluntary sectors. In addition to the official launch of the consultation paper, a series of consultative fora, including meetings with key stakeholders also publicised the consultation and served to encourage informed responses.

The consultation paper highlighted specific issues on which views were invited. These were:

• provisions to enable the implementation of a New Community Pharmacy Contract;
• new requirements for NHS Boards with regards to planning and securing the provision of pharmaceutical care services in their respective areas;
• a requirement for all registered pharmacists providing community pharmacy services to be entered on a NHS Board's pharmaceutical list;
• an amended definition for "supervision" of pharmaceutical services so that it follows the approach taken in the Medicines Act 1968;
• powers for NHS Boards to secure the provision of pharmaceutical services from outwith their area; and
• a power that would enable Ministers to designate which elements of community pharmacists' remuneration should be paid from NHS Boards unified budgets.

Ninety-one responses were received from a wide range of professional organisations and individuals.

Aims and Objectives

The aim of the research was to analyse the comments contained in written responses to the consultation on Modernising NHS Community Pharmacy, to present the findings of the analysis and to identify any gaps in respondent sector.

Methodology

Responses to the consultation were sent to the Scottish Executive consultation team either in hard copy or via e-mail. The consultation team sent copies of each response to The Research Shop for analysis. The consultation attracted a relatively moderate number of responses but represented a broad range of stakeholders with individual pharmacists and community pharmacies comprising the largest group of respondents. No particular gap in respondent sector was identified.

An electronic Excel database was used to store and assist analysis of the responses. Most of the analysis was qualitative in nature although where scope for quantitative analysis existed, this was exploited.

Introduction of the New Community Pharmacy Contract

There was broad support for the draft proposals for the new contract although respondents recommended that the new contract should not be overly prescriptive as to stifle innovation. A common request was for local negotiations to take place against the backdrop of a national framework of benchmark tariffs and standards for locally agreed services. Many respondents sought clarification on which organisation(s) would be responsible for developing protocols, setting standards and enforcing these. Calls were made for a clear definition of standards relating to premises, and in particular, private consulting rooms/areas.

Several consultees stressed what they saw as the need to address the training requirements of pharmacy support staff. Some questioned what funds would be available to support such training.

General support was expressed for the proposals for reporting of adverse incidents and near misses although more detail was requested on what was to be reported and the reporting processes.

Most respondents (64%) favoured patient registration with a community pharmacist and a further 16% of consultees saw both pros and cons to the arrangement. Respondents raised the need to consider applying the proposals to dispensing doctors, the need for guidance on action/powers required by the NHS in cases of non-compliance and the need to consider effective ways to cross-transfer clinical patient data perhaps via NHSnet.

Planning and Provision of Pharmaceutical Care Services

There was much support for the general aims of the proposals with many favouring the proposed shift from a reactive model of provision to one of greater pro-activity. Respondents were almost evenly split between those supporting the need to replace the "necessary and desirable" test of control of entry and those who opposed it. The planning process was viewed as an inclusive approach with respondents stressing the necessity of defining statutory consultees in legislation.

The definition of "over-provision" was seen by many as likely to be controversial with a salient view that this should be left to self-regulate by means of market forces. A recurring theme was the perceived need to provide a national framework or template for Health Boards to use in constructing their plan. Respondents called for the planning process to be conducted in a transparent fashion on the basis of robust information and criteria. There was opposition to short-term planning which was viewed as promoting instability in service and acting as a disincentive to investment.

Long term financial support was requested to underpin relocation and recommendations were made for a review of the current Essential Small Pharmacy scheme in order to ensure its maximum effectiveness. No support was expressed for the proposal to introduce "holding contracts" with most expressing strong opposition to the concept.

The introduction of an appeal procedure was seen as a priority especially in view of the plans for rationalising and relocating businesses and changing the control of entry mechanism. Alternative models suggested included partial contracts, mobile pharmacies and consortium working.

Pharmaceutical Lists

There was much support for the proposed extension to the pharmaceutical list to include non principals. Three-quarters of those who commented favoured placing the contract with the contractor rather than with a named individual pharmacist. Respondents requested that national accreditation criteria be applied to local training schemes so that training in one Health Board area can be readily recognised by and transferable to another area.

Concerns were raised over the possible increased funding and administration required for the upkeep of the list. A recurring theme was the need for a fast-track registration system in order for locums to provide cover in emergency situations.

A few respondents were concerned that the proposals would serve to restrict what they saw to be current flexible practice by introducing barriers where previously these had not existed. Many suggested that the list be maintained at a national level in order to address possible boundary restrictions.

Persons Authorised to Provide Pharmaceutical Services

There was much support for the proposal to allow for a more liberal interpretation of supervision. However, whilst this was viewed as freeing up pharmacists' time in theory, most consultees perceived obstacles to realising this aim in practice. It was commonly thought that pharmacists would be able to devote more time to direct patient care only if they were supported by more highly trained staff. One main concern was that funding should be made available to support the training required.

A recurring comment was that even though pharmacists may delegate dispensing tasks in future, they should still retain the key responsibility for service provision. Robust standard operating procedures for dispensing were called for to contribute to the future security and safety of staff and patients.

A common view was that pharmacists should always be available for patient consultation and absences away from the pharmacy should be an exception and perhaps regulated. A recommendation was for pharmacists to be responsible for only one named premise at any one time.

Cross Border and Distant Provision of Pharmaceutical Services

Many respondents appeared to welcome innovation but cautioned that developments should not jeopardise existing effective and valued practice. Innovation was seen as both a tool and a threat. Calls were made for any innovations to be supported by a robust IT network and piloted prior to any national roll-out.

Many respondents called for new forms of control to accompany new powers to encourage and allow for innovation. A priority for some was that security and safety of pharmacists and patients should not be compromised. Several consultees cautioned against permitting innovation which may adversely affect the business viability of current community pharmacies.

A common theme was that whatever innovations developed, there remained a need to maintain a face-to-face local community pharmacy service. Many respondents supported the notion that prescriptions should be presented initially at or through a pharmacy contractor who provides a full pharmaceutical service under the national contract.

Funding of Pharmaceutical Services

Many respondents urged that the level of funding available for implementing and exercising the new contract should be sufficient to support an effective service. Respondents stressed that funding was required not just for financing the service to patients but also for the administration of the service and supporting the transition to the new system.

Some respondents agreed that a robust national formula was needed on which to base funding allocations to Health Boards. There were mixed views on the suitability of existing public health indicators in this respect with some consultees calling for new research to develop a more appropriate, customised formula for the pharmaceutical context.

A common concern was that in practice Health Boards were seen as likely to have little room to manoeuvre over pharmaceutical service provision and budgeting but would be held to account for over-spend and under-spend.

Many sought clarification on the proposed arrangements in the case of Health Boards over-spending and under-spending on their respective pharmaceutical budgets. One-third of those who commented on funding recommended that Health Board budgets for core pharmaceutical services should be ring-fenced.

Many respondents commented that the suggested pace of change model over a 10-year period would be beneficial.