Andrew Evans has been chief pharmaceutical officer for Wales since July 2016; prior to that, he was principal pharmacist for Public Health Wales.
The Welsh government has invested heavily in healthcare IT in recent years, particularly so in the award-winning Choose Pharmacy IT application. Choose Pharmacy, a service in which pharmacists take responsibility for managing a range of minor ailments, was introduced in 2013 and has since been rolled out across Wales. Welsh community pharmacies are also offering an increasing range of services including the Discharge Medicines Review Service, which provides community pharmacy support to patients transferring between care settings and has been estimated to save the NHS £4 for every £1 spent on it.
At the eighth annual Welsh Medicines Safety Conference, held at the Radisson Blu Hotel in Cardiff on 22 November 2018, The Pharmaceutical Journal spoke to Evans about the Welsh pharmacy industry’s preparations for Brexit; preparations for the Falsified Medicines Directive (FMD); the roll out of Choose Pharmacy, and the Welsh government’s move towards a service-based pharmacy contract.
How are Welsh pharmacists and patients feeling as Brexit approaches?
It’s really important that people are given confidence that there are plans in place to manage any risk associated with leaving the EU. We’re working with the UK government on plans to stockpile medicines with wholesalers and marketing authorisation holders. This is a big part of our strategy, so we’re not looking to do anything different. We’re telling the NHS, and asking community pharmacies, not to do anything irresponsible around stockpiling but to listen to the government’s messages and make sure that the UK supply chain is as robust as it can be.
Where our hospitals are using medicines and where there are national contract frameworks for medicines, we’re making sure that we can guarantee the availability of the medicines used routinely in our hospitals.
So you don’t think patients are particularly worried at the moment?
Well, I know patients are worried about it. We are often asked questions about this sort of thing. We need to have confidence that the Department of Health and Social Care and the UK government are doing work to look at the risks associated with Brexit. Where people can be confident is that we’re looking across the NHS in Wales. Where our hospitals are using medicines and where there are national contract frameworks for medicines, we’re making sure that we can guarantee the availability of the medicines used routinely in our hospitals.
Is Wales ready for the Falsified Medicines Directive? Wales may have a slight advantage in that Welsh pharmacists are already used to scanning prescriptions.
Each community pharmacy in Wales already uses a 2D barcode scanner for scanning prescriptions, so hopefully that’ll make it a relatively smooth transition to using Falsified Medicine Directive scanners
I think that experience with scanning will help massively. Each community pharmacy in Wales already uses a 2D barcode scanner for scanning prescriptions, so hopefully that’ll make it a relatively smooth transition to using FMD scanners. In our hospital sector, the NHS informatics service in Wales has been doing a huge amount of work with hospitals to make sure they’re prepared.
Are pharmacists worried about reimbursement of the costs of becoming compliant with the Falsified Medicines Directive?
I think they are. I know there are discussions ongoing across the UK around the implications of the FMD and the costs of meeting that. Overall, the costs are likely to be low. We’ve seen the impact assessment from the EU about implementing the FMD … it’s something we need to work through with contractors, to really understand the costs of compliance.
Russell Goodway, chief executive of Community Pharmacy Wales, said at an All-Party Pharmacy Group meeting on 31 October 2018 that in the Welsh pharmacy contract there can be a “perverse incentive” to keep dispensing. Do you see the contract moving from a quantity to a quality, service-based one?
I think we’re already doing that. To clarify Russell’s point, while he was talking in a Wales context, the “perverse incentive” exists around pharmacy contractual arrangements in all parts of the UK. Pharmacists are dependent on volume of prescriptions for their income. That balance needs to change. We need to make sure we’re not disincentivising people to put quality into their interactions with patients. We’re on a journey to resolve that in Wales. Over the past two years, we’ve been repurposing funding within our contractual arrangements to take an incentive out of dispensing to, in effect, drive efficiency in the dispensing process. But we’re reinvesting that money in the clinical services that we want pharmacies to offer.
Over the next five years, I think we’ll really see a focus where there is much less incentive to drive prescribing volume, and a much greater focus on quality and clinical services.
Wales has just rolled out a sore throat testing service and is about to start a blood-borne virus testing service. Can you provide an update on that?
The sore throat test-and-treat service went live in 60 pharmacies in Wales on 16 November 2018 and there have been four consultations so far — so I’ve been told. None of those has resulted in antibiotics being prescribed and one of them has used the point-of-care rapid antigen test that we’re rolling out to diagnose where the patient has a streptococcal infection or not. In this case, it turns out there wasn’t.
While pharmacists involved in this service are able to clinically assess people, they’re also responsible for the use of antimicrobials and we’re really hopeful that this service will improve antimicrobial stewardship. It should also take pressure off GPs; something like 180,000 GP consultations take place in Wales each year for sore throat. If we can move a fair proportion of that to community pharmacy then that would be a good thing. We’re going to evaluate the sore throat service over the course of the next 12 months.
What about blood-borne virus testing?
We’ve tried blood-borne virus testing in some health boards and we’re now expanding it to two others. That’s because we’re committed as a government to the World Health Organization strategy for eliminating hepatitis C. Part of this strategy is about treating people and we’re already making access to hepatitis C drugs widely available. But the trick is being able to identify people who’ve got hepatitis C: they’re not always known to health services. Community pharmacies offer a great opportunity to interact with people who don’t usually interact with the rest of the NHS; to test them and then get them into services where we can treat them and hopefully eradicate hepatitis C.
At a meeting in 2017, I heard a GP say that some patients use Choose Pharmacy to get a prescription for something they could get over the counter. Do you think that happens often and, if so, is it a contributor to the expensive Welsh medicines bill?
I don’t think this happens often. What we’ve actually seen in the roll out of the common ailments service (CAS) in Wales, which began in 2013, is that pharmacists are judicious in who they treat. We’ve designed the service so that it’s difficult to abuse it. You’ve got to have a consultation with the pharmacist that involves going in to a consultation room, creating a record and registering with that pharmacy. It’s not that you can walk into a pharmacy and ask for a bottle of paracetamol suspension and simply get it for free instead of having to buy it or see your GP.
Data suggests that 85% of consultations in the common ailments service report that those patients would have gone to see their GP or used an out-of-hours service had they not visited the pharmacy
What we also know is that pharmacists are really sensible about diverting people to the CAS. If people want to self-care, then we are seeing that pharmacists continue to let them self-care. Data we’re collecting suggests that something like 85% of consultations in the CAS report that those patients would have gone to see their GP or out-of-hours had they not visited the pharmacy.
There is a broader point as well: for many people, particularly in deprived communities, buying medicines is a difficult choice. So they will turn up to their GP and that’s entirely appropriate because it would have been a significant economic burden to them to have had to go to a pharmacy and purchase a medicine. And some patients may not have the skills to self-care.
In England, minor ailments services have been decommissioned in many areas, unlike Wales and Scotland where they have been rolled out nationally. In light of Wales’s success, do you have any message or advice for your counterpart in England?
[Laughs] I don’t know whether it’s my place to give the NHS in England any advice.
What might seem like a nominal cost of medicine to us might actually be a significant proportion of somebody’s disposable income
Do you have any experience you can share, then?
Our experience is that if you design it well, then actually it can improve access to services and divert people from other, less appropriate parts of the NHS. In all parts of the UK, it is difficult for some people to choose to self-care. What might seem like a nominal cost of medicine to us might actually be a significant proportion of somebody’s disposable income.
It’s been said that healthcare in Wales can suffer from ‘pilotitis’, where a service is piloted, does well, and then funding dries up so the service is not commissioned. Is that a fair thing to say?
I think historically it might have been fair, but we’ve worked really hard to try to resolve that.
We’ve moved from a position where services are now available in each pharmacy, rather than being available in some health boards and not in others, or in some pharmacies but not others
The contractual change we’re making is putting ringfenced money into health boards to support pharmacy service commissioning. In the past where we may have had pilots funded from slippage at year end, or the odd small amount of grant funding to stimulate those projects, we’re now able to put in place a consistent, recurrent revenue stream. This has prompted health boards to be able to say that they want pharmacies to help them solve some of the problems the NHS is facing, and there is now a direct way to fund those pharmacies. As a result, we’re seeing a much greater collaboration between the health boards and much greater consistency in the availability of these services. In the past two years, we’ve moved from a position where services such as smoking cessation, emergency contraception and flu vaccination are now consistently available in each pharmacy, rather than being available in some health boards and not in others, or in some pharmacies but not others.
How significant is the Royal Pharmaceutical Society Wales’s new palliative care policy and how hopeful are you that the recommendations will be taken on board?
The policy not only makes recommendations for others, but it recognises that there are improvements needed within pharmacies themselves. The Royal Pharmaceutical Society (RPS) is setting the standard for what each pharmacy should be able to offer in terms of a high-quality palliative care service, whether that’s providing a service that is specifically about palliative care or whether it’s just about providing care for somebody who has palliative care needs more generally. Greater awareness and understanding of palliative care is something we want to reinforce, so we’ll be talking to various parts of the NHS, education providers and so on, to look at how we can take forward some aspects of the palliative care policy that the RPS has launched.