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Climb every mountain

Practical challenges, including building closer relationships with GPs, will need to be overcome if the recommendations in the Murray review on community pharmacy are to be implemented successfully.

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The imposition of cuts to NHS funding for pharmacy services in England in 2016 went against the grain of what had appeared to be the government’s direction of travel for pharmacy. Pharmacy was supposed to expand its role in service provision for patients with chronic conditions or who required urgent care for minor conditions. Much was therefore riding on NHS England’s ‘Community pharmacy clinical services review’, commissioned from Richard Murray, director of policy at the think tank The King’s Fund, by NHS England (The Pharmaceutical Journal online, 22 February 2017).

The review was charged with recommending how to integrate pharmacy better as part of the primary care team, and best utilise pharmacy skills within evolving new models of care and the sustainability and transformation plans (STPs) (The Pharmaceutical Journal online, 14 February 2017) being developed across England. Most importantly, the review’s recommendations are expected to shape how the pharmacy integration fund (The Pharmaceutical Journal online, 21 October 2016) is spent and, ultimately, what services local commissioners might look to pharmacy to provide.

On first glance, the final recommendations, published in December 2016, did not disappoint, describing a vision for pharmacy services in line with the profession’s own and with obvious synergies with the ‘Community pharmacy forward view’, published in August 2016 as the profession’s response to the looming pharmacy cuts. The challenges are set to be implementation, funding, and engaging the support of other health professionals and the public.

Many of Murray’s recommendations are intertwined and interdependent, so there is a danger that cash-strapped NHS England will see the report as a pick-and-mix menu and opts not to implement the vision as a whole. Not only would this make the review’s recommendations more difficult to implement, it would not achieve the best outcomes for patients and most efficient use of resources possible. Murray himself admits that “it would be a great pity to see the recommendations in isolation” and, specifically, that the redesigned medicines use reviews (an advanced pharmacy service in England) “would be difficult to do as full medication reviews given the current state of access to patient records and independent prescribing”.

In terms of access to patient records, the new quality pharmacy payments framework (The Pharmaceutical Journal online, 21 October 2016) is well placed to set the ground work for connectivity by requiring pharmacies to be connected to NHS mail and using the electronic prescription service, and rewarding steps towards greater use of patient summary care records. Alastair Buxton, director of NHS services at the Pharmaceutical Services Negotiating Committee, which negotiates the pharmacy contract in England on behalf of contractors, says that although “NHS mail and summary care records are both somewhat limited in their value, if you look at the pharmaceutical perfection that we may hope for in the future… it’s a good starting point”.

“They can help with a cultural change in relation to IT in pharmacy,” he explains, by “breaking down that IT isolation that we have within the sector”. Unfortunately, pharmacy IT systems have been slower to evolve compared with general practice; meanwhile, independent prescribing rights for pharmacists would require legislative change.

One of the toughest challenges will be improving relationships between GPs and pharmacy, which Murray recognises as “weak” and “under developed”. But tackling this is paramount because not only do many of Murray’s recommendations require a close working relationship, local GP commissioners will have a big influence on whether pharmacists are commissioned to provide clinical services in the first place, and their advocacy will be vital in encouraging patients to engage with such services.

Murray’s report says that local relationships between GPs and pharmacists must be fostered, “based on trust and not competition” and efforts to do this must be driven centrally and enabled locally, and led by NHS England in collaboration with the pharmacy and GP representative bodies. With not just Murray’s recommendations, but so much NHS reform through the vanguards (partnerships of NHS, local government, voluntary, community and other organisations that are implementing plans to improve the healthcare people receive) (The Pharmaceutical Journal online, 18 August 2016) and STPs reliant on improved relationships, this is something that NHS England could and should begin to act on now ahead of its formal response to the review.

Murray is optimistic this will happen, telling The Pharmaceutical Journal that he is “not unduly concerned about the risk of treating pharmacy in isolation” because “NHS England was very alive to the changes going on elsewhere in the NHS”. However, with no additional funding to help drive the recommendations made by Murray, it appears there are mountains to climb before the aspirations will be achieved.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2017.20202365

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