APRIL,Edition # 23, 2001

Pharmacy in Britain seems to be on a roll into the new millennium.
As an equal partner in the NHS plan, it is being accorded a status equivalent to the real resource worth of a pharmacist.
Pharmacist underutilisation has finally been recognised by government, and new plans are in progress to harness this newly recognised pharmacy resource for the benefit of all participants.
While there are some similarities to components of what is happening here in Australia (and Australia is ahead in some areas), the difference is that the British NHS are working to a formal business plan, communicated in an unambiguous manner, and demonstrating a clear role for pharmacists at a level commensurate with ability.
By comparison, the Australian scene does not appear as cohesive or decisive.
While the NHS Plan involves all major aspects of pharmacy, some significant and major areas have been set aside for consultant pharmacists (known as Practice Pharmacists in Britain), and it is these specific activities (dependent and independent prescribing) where "catch up" is required.

It is worth examining the core principles of the British NHS:

"1. The NHS will provide a universal service for all, based on clinical need, not ability to pay.
2. The NHS will provide a comprehensive range of services.
3. The NHS will shape its services around the needs and preferences of individual patients, their families and their carers.
4. The NHS will respond to different needs of different populations.
5. The NHS will work continuously to improve quality services and to minimise errors.
6. The NHS will support and value its staff.
7. Public funds for healthcare will be devoted solely to NHS patients.
8. The NHS will work together with others to ensure a seamless service for patients.
9. The NHS will help keep people healthy and work to reduce health inequalities.
10. The NHS will respect the confidentiality of individual patients, and provide open access to information about services, treatment and performance."

After many interviews with patients regarding the type of service they required, and with pharmacists, who stated what they were capable of delivering, the British government drafted, in July 2000, their vision of a universal public health service. By November 2000, basic agreement had occurred between all involved parties, and the real work began.
It was comment made by the general public that awoke the government to the fact that pharmacist skills and expertise could be put to a better and expanded use.

The first objective set for pharmacy was to ensure that the changing needs of patients were met. Medicines and pharmaceutical advice should be obtained easily, and preferably at a time and place of patient choosing. The second objective set was to give more support in the use of medicines, providing help to keep people from becoming ill because of noncompliance, thus eliminating waste.
As one method of meeting these needs, the NHS is looking at funding a wide range of generic medicines. Pharmacists will be expected to support NHS services with face to face contact and any hi-tech support which would enhance a service. Information backup would be provided by NHS Direct, a phone-in information service as to where the nearest pharmaceutical service would be available to a patient, plus NHS Direct Online, an Internet version providing a similar range of information.
Through pharmacists, the NHS will ensure:

* patients will be able to access an expanding range of OTC medications from pharmacies.
* patients will be able access medicines after hours without impediment.
* by 2002, people requiring help from NHS Direct will be able to be directed to their nearest pharmacist for help, no matter where they live.
* by 2004, 500 primary care centre will be established and will involve direct investment by the NHS. These facilities will approximate Australian medical centres with access to doctors, nurses, pharmacists dentists, allied health, social workers and other support services, all under the one roof.
* by 2004, repeat dispensing will be established (N.B. no repeats are currently allowed for British NHS prescriptions. At least Australia is well ahead in this regard).
* by 2004, electronic prescribing will be in place to reduce errors and to allow e-pharmacies to enter fully into online dispensing.
Official pharmacy in Australia will have to sort out their priorities before this can occur locally, either as a mail order service or an Internet supply service.
The British government has come out strongly in support of both types of distance supply services, and believes their laws permit their sale, provided normal safeguards are met i.e. supervised by a pharmacist and supplied from an approved pharmacy site. The British government further states that there is no reason, in principle, why medicines should not be sold or dispensed electronically and has strongly recommended that e-pharmacy be a choice for patients requiring NHS medications. It goes further, to state that a review of current NHS rules will be undertaken, to remove all impediments and obstacles for pharmacists wishing to provide this service.
All this will be routine both for community and hospital pharmacies, and electronic prescriptions will have the same legal force as handwritten prescriptions.
Note that the process to utilise e-pharmacies is government driven and they do not see a problem with the pharmacist not being face to face. In fact, they point to the rapid advances in information technology as a means of bridging gaps e.g.such a possibility has emerged with the recent development of virtual image technology. Online, generated images of people make you feel you are in the same room -you are able to converse and even to see around corners!
* action teams are being trained to help pharmacists develop a range of medicine management services. They will involve leaders from pharmacy and medicine, NHS managers, patients and carers and the system is designed to develop a cadre of people with expertise in setting up medicine management services and capable of passing on their expertise to others.

A payment system is also being developed to reward pharmacists providing high quality services such as medication reviews. Those pharmacists willing only to provide basic services will be paid appropriately at a lower rate(this is a similar process occurring within Australia at the moment, with dispensing fee increases being diverted for clinical services).
Changes will be brought into public hospitals to ensure a pharmacist intervenes when a patient is admitted, and ensure medication is appropriate at the commencement of treatment, following the process throughout the stay and having appropriate discharge medications available (and being empowered to write the discharge prescriptions) in a timely fashion as the patient leaves. This process to be accompanied with appropriate patient education and support information, and liaison with their community pharmacist to ensure a seamless service.
Note that this already occurs in Australian hospitals in part, but lack of funding for hospital pharmacies quite often means that the service is not spread evenly over all patients.
Patients will be encouraged to bring their own medications into the hospital setting (Australia currently discourages this procedure), to avoid wastage. Systems of self administration for patients will also be developed, reducing nursing times for medicine administration.

The big change envisaged for pharmacists is that they will be able to prescribe NHS medications for patients. As noted in the first article appearing in this newsletter, regarding Australian consultant pharmacist structure, pharmacists have always prescribed, but have never been able to prescribe schedule 4 medications or NHS medications.
The British system envisages practice pharmacists initially becoming "dependent" prescribers i.e. prescribing under strict protocols or having a doctor sign off on a prescription.This eventually leads to "independent prescribing" after a period of two years.
In August 2000 the British government introduced legislation to establish "patient group directions" as an alternative way of authorising the supply of medicines. These directions are drawn up by a doctor and countersigned by a pharmacist to establish a strict protocol, where a named professional can supply medicines without the need for an individual prescription. Under this new British NHS system, pharmacists will be encouraged to lend their expertise in managing specialist programs, such as for emergency hormonal contraception; smoking cessation, utilising nicotine replacement and Zyban; and drug misuse programs such as the methadone program.
At all stages of the NHS implementation, patients will be empowered to take an active role in managing their own care, which requires the patient to be fully informed and be a full partner in their medicine taking.

To have prescribing rights in Australia will require a big shift in doctor thinking, but it seems inevitable that those doctors who do not become active partners in this process, will be left behind as service payments are manipulated to ensure an appropriate outcome.
Accredited Australian consultant pharmacists will certainly be the group selected to provide this service at the appropriate time.
Nurse practitioners, both in Australia and Britain, have already demonstrated that non doctor prescribing is both safe and more easily accessed by patients.
The British NHS plan makes it very clear that patients should not be constrained by rigid demarcations between professions.

By April 2003, all NHS employees, pharmacists and pharmacy support staff, will be expected to be accredited and to have embraced a lifelong learning program of continuing education i.e. a system of practice certificates.
This has already been foreshadowed in Australia, and the Pharmacy Guild and the Pharmacy Society have been stressing for quite some time, that non participants will be financially disadvantaged if they do not embrace this process at individual and practice levels.
Pharmacy support staff and technicians in the British system are to have better training and their status enhanced, also by accreditation processes, so that better use can be made of this resource.

Many of the emerging NHS services will be contracted individually through local community pharmacies, tailored for the local environment, and proposals by local pharmacists will be encouraged, if a need is identified. These schemes will not be limited to dispensing and will embrace medication management services, health promotion and disease prevention. The contracts will focus on outcomes and the quality of the service provided. Contracts can be made with employee pharmacists or pharmacy owners. The issues that need to be initially addressed under these contracts include the clinical quality of services, their speed and efficiency, the standard of premises, the provision of private consultation areas, good record keeping, quality information for patients all underwritten by continuing professional development of pharmacists and staff.

The British system appears to be imaginative and meets in full, the wish list prepared by pharmacists during the development of the NHS Plan.
This initially surprised official pharmacy.
The new services create a "fit" for pharmacists that is recognised by government and backed by legislation. In reality, it endorses what has always been pharmacist traditional roles,simply expanding the processes and protecting the pharmacist from interprofessional friction.
By blurring the barriers and demarcations, the British government can look forward to future years of enhanced health delivery services, in an innovative and cost effective manner.
end

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