Section 3 Supporting delivery of CMS
3.1 Introduction
Each of the four core elements of the new community pharmacy contract in Scotland have been designed on the basis of the results from research evidence and tested through pilots and early implementation sites. For CMS this means building on previous policy initiatives such as the CRAG framework, Clinical Pharmacy Practice in Primary Care, serial (repeat) dispensing studies and trials and the Pharmaceutical Care Model Schemes ( PCMS) initiative. In addition, when considering the CMS generic framework, any precedents in terms of implementing similar models of practice across the rest of the UK and elsewhere have been reviewed and lessons learned have been taken into account. This approach consolidates existing good practice and utilises methods that appeared to be successful in other similar programmes of work.
3.2 Supporting implementation
The areas that need to be considered in order to support the successful implementation of CMS can be summarised under the following categories:
- communications
- inter-professional working
- education and continuing professional development ( CPD)
- governance
- wider integration.
- Communications
Good communication is critical to the successful implementation of CMS. In order that patients understand how the service works, they should be provided with a specific CMS information leaflet advising about the service and explaining the implications of sharing relevant clinical data between GPs and community pharmacists, including associated aspects of consent. These leaflets should be available both in GP practices and community pharmacies.
Additional awareness raising and communication materials should be considered in order to target patient group associations (such as the Long Term Condition Alliance and Scottish Patient Association) and other NHS organisations (such as the NHS Help Line). These materials should also cover patient information about their disease condition/s, advice on taking their medication and any other pertinent issues. Experience from NHS 24 has demonstrated success in standardising information and advice given to patients and carers. This also helps ensure that the information given to patients is consistent across the whole healthcare team. NHS 24 has a dedicated, maintained website, - www.NHS24.com - containing relevant information that can be used by patients or healthcare professionals.
It is important that GPs and community pharmacists are clear about their own roles throughout the patient journey of care in order to support delivery of the service, prevent any overlap or duplication of actions and also to clarify appropriate referral pathways and criteria. This includes the role of the secondary care team who may receive referrals from pharmacists.
- Inter-professional Working
In order to support GPs and community pharmacists in the successful implementation of CMS, including the IT underpinning the service, it would be beneficial for NHS Education Scotland ( NES) Pharmacy to provide a CMS implementation resource pack. This could act as a quick reference to the service, the underpinning software support and housekeeping requirements. This approach has been used for other elements of the new community pharmacy contract - see www.nes.scot.nhs.uk/pharmacy/newcontract - and has received very positive feedback from community pharmacists. To date, these NES packs have only been provided to community pharmacists. However with the introduction of CMS it would now seem logical to extend provision to GP practices.
Previous lessons learnt have identified the importance of GPs and community pharmacists being able to start working simultaneously. If one group is ready ahead of the other it becomes a rate limiting step to progressing new ways of working. A patient must be registered for CMS at a community pharmacy in order for a GP to be able to generate a serial prescription. It is important therefore that there is no time delay in patients being registered which means that an opportunity is lost for a GP to instigate a serial prescription. It may therefore be beneficial for GPs and community pharmacists to consider, in advance of the service starting, a list of suitable candidate patients to be registered for CMS. This means that once systems are enabled community pharmacists will have a list of patients to register and GPs can produce serial prescriptions for eligible patients.
Once CMS is live, community pharmacists are well placed to register suitable patients from existing repeat dispensing episodes. In addition, appropriate patient support materials can be used to raise awareness of the service. Pharmacy Patient Medication Record ( PMR) systems may also be able to highlight patients on regular repeat prescriptions and flag them as potential CMS patients. In turn, GPs can use routine patient appointments and chronic disease management clinics to identify, for serial prescriptions, suitable patients who are stable on their medication. Community pharmacy referrals, specialist referrals and individual patient requests may also trigger requests for consideration for serial prescriptions.
- Education and Continuing Professional Development ( CPD)
To ensure that newly qualified pharmacists are suitably equipped to provide CMS, it is important that relevant competencies are incorporated into both the undergraduate and pre-registration training programmes. From an undergraduate perspective continued close working by both Scottish Schools of Pharmacy should facilitate this. NES Pharmacy oversees the Scottish Pre-Registration Training Programme and should be able to incorporate any necessary requirements. In addition, a range of continuing education options are already available to support community pharmacists providing CMS including NES Pharmacy Core Chronic Disease materials.
A quality system promotes and assures consistent service provision to an appropriate standard. CMS must be founded on evidence-based practice. It should also have governance arrangements in place that ensure continuous quality improvement, including a system that supports regularly measuring and evaluating practice (audit) and peer review.
The new community pharmacy contract will be underpinned by a quality framework. Whilst it will cover all aspects of practice, CMS will be a key element and there will be a number of process and outcome measures which could contribute to the development of a quality framework. eLearning will also be a useful resource in terms of supporting CPD. As many community pharmacists may work in relative isolation from other professional colleagues, a process of peer review can help test and develop individual competence, support CPD via reflective practice and sustain quality assurance.
CMS will be underpinned by eCMS, which replaces most paper-based reporting systems with electronic reporting. As a result administrative arrangements for CMS will be kept as straightforward as possible and rely principally on IT rather than paper-based systems. eCMS will deliver electronic feedback on both dispensing and other activities undertaken by the pharmacist as well as facilitate regular communication between the GP and the community pharmacist. There may however be other databases and services provided by secondary care practitioners which may benefit from secure information exchange with CMS. Any such exchange will be according to agreed and verifiable protocols - and on the basis of a defined need.
As CMS offers the opportunity to develop a patient version of the pharmaceutical care plan this could in the future be hosted electronically as part of the Scottish eHealth programme developments - www.ehealth.scot.nhs.uk/. These aim to provide individual patient health plans for example through a patient access portal or an extension of the emergency care summary record, and be used collaboratively by patients and their NHS clinicians.
3.3 Summary
Some common themes regarding delivery have emerged when considering existing best practice and lessons learnt in implementing similar programmes of work elsewhere. Addressing these in good time, prior to introduction and throughout the implementation programme for CMS, should provide a sound foundation on which to build this new service. Following the launch of CMS, there is a requirement for ongoing review of progress to robustly address any additional issues that may arise over time.