New care models: the role of pharmacy in vanguard pilots

In October 2015, a plan emerged for Salford clinical commissioning group (CCG) to build a business case for a team of 23 pharmacists to work across the 46 GP practices within Salford, which went out to tender in December 2015. Salford Royal Hospital – which is an acute and community services provider – put together a bid with a GP practice, Salford Health Matters, and won a five-year contract with the option to extend for two years.

The contract was awarded in February 2016 and started two months later. Since then, Salford Royal’s director of pharmacy Lindsay Harper and her team have set about recruiting pharmacists, developing training packages, establishing a project board, meeting with GPs, talking to lawyers about indemnity, and working with the academic health science network to think through electronic referral systems between healthcare providers and pharmacies.

The contract forms part of Salford Royal’s work as a so-called ‘vanguard pilot’, 1 of 50 sites given government funding to develop new models of care as part of NHS England chief executive Simon Steven’s vision for a sustainable NHS.

Published in October 2014, Steven’s ‘Five year forward view’ indicated the ways that pharmacists could play a broader role in preventing ill health, supporting healthy living and self-care for minor ailments, reviewing and reconciling medications for people with long-term conditions, and working as team members in more integrated local care models.

Discussions with some of the lead pharmacists in the vanguards reveals more detail about what they are up to, and just how complex some of the initiatives are turning out to be.

The recruitment challenge

“It’s a huge challenge to recruit a team of 23 pharmacists in one go,” says Harper. “We have seen a real mix of experience, with people recruited from backgrounds in hospital, CCG, community and one from mental health.”

The plan is for the practice pharmacy team to have an overall team leader, at band 8b on the NHS agenda for change pay scale, for which the salary range is £46,625 to £57,640. This role will be supported by 5 team leaders at band 8a (salary range £40,028 to £48,034), each managing a locality, and 18 band 7 practice pharmacists (salary range £31,383 to £41,373). All posts apart from 8 band 7 pharmacists have been appointed to start in September and October 2016.

Most of the band 7 pharmacists are likely to spend half the week in the hospital and the other half of the week in the community while they undergo a bespoke training programme.

The big benefit of having the service based in the hospital is that the primary care pharmacists will have a working relationship with the specialist hospital pharmacists

“I think the junior pharmacists are nervous but very excited about developing the new role because they are going to get the benefit of learning about secondary and primary care simultaneously,” explains Elizabeth Lamerton, principal clinical pharmacist at Salford Royal, who is in charge of developing training for the junior pharmacists. “The big benefit of having the service based in the hospital is that the primary care pharmacists will have a working relationship with the specialist hospital pharmacists. If there is a patient with very specific needs, for example in respiratory care, we will be able to provide specialist pharmacy input from the acute trust.”

The service is a way of delivering care closer to home and ensuring that patients are always the focus, she explains.

“[Pharmacists] see this as a chance to get involved in the whole patient pathway and influence who is coming into the hospital as much as what happens when people get home,” adds Lamerton.

A project board is overseeing the development of the pharmacist project within the vanguard, with input from the medical director of the Salford Health Matters GP practice, and links to the CCG and the local pharmaceutical committee (LPC).

“The GPs want the pharmacists yesterday,” says Lamerton. “One of the first things for the project board is to meet with GPs and find out what their priorities are for the practice pharmacists.”

Initially, the idea was that GPs would employ the practice pharmacists. But that changed after the complexity of the task ahead became clear.

Harper explains. “When we were planning for the vanguard, it was clear from mortality reviews that [polypharmacy was a contributing factor and] one of the needs was for pharmacists to do medicines reconciliation within practices, particularly when patients were transferred between care settings.”

The integrated care organisation gives us an opportunity to look at how we handle medicines right across the patch

This was significantly different to the medicines management and cost control role that had been taken to date by the CCG pharmacy team. Beyond this, there was a need to integrate medicines policies and standards across acute, community and mental health care and care home providers involved in the vanguard alongside Salford Royal.

As Harper says: “The integrated care organisation gives us an opportunity to look at how we handle medicines right across the patch. We want one single medicines policy and feel that this is something that would help to address the confusion that currently exists and improve medicines safety across Salford.”

In the meantime she is wrestling with thorny issues such as indemnity. “One of the concerns is that we will be asking these pharmacists to amend prescriptions and prescribe in primary care while they are employed by Salford Royal. We are talking to our legal department about indemnity and the need for joint procedures and policies.”

It is too early for Salford to report on any results – but certainly there has been some learning.

Lamerton spells it out. “If I was talking to someone starting out on this journey, I would say it is important to manage expectations from the start,” she says. “It is important to be clear about moving from medicines management to medicines optimisation, medicines safety and medicines reconciliation.

“I’d say that having a GP on the project board is also essential to ensure support from GPs and ensure that the team can collaborate effectively.”

The challenges of recruiting the right people for these new roles comes up again and again with vanguard pharmacist leads.

Alan Bloomer is lead pharmacist at Blackpool Teaching Hospitals, where an extensive care service at Fylde Coast multispecialty community provider (MCP) began in June 2015. It’s targeted at people with multiple comorbidities who often experience fragmented pathways with all the medication risks that implies.

Patients referred to the service receive a comprehensive assessment by a multidisciplinary team, including a band 8 pharmacist who has access to the primary care record and the authority to change medications. The multidisciplinary team develops care plans and goals for self care. In October 2015, the service recruited a pharmacist to carry out home visits for housebound patients.

“It’s about reducing [inappropriate] polypharmacy and looking at adherence,” says Bloomer. Early data show it is achieving a reduction in polypharmacy, outpatient appointments and attendance at A&E departments, although the service is now paused to allow for a re-evaluation.

This new role requires a very particular kind of pharmacist, says Bloomer. “It’s incredibly hard to find the right candidates.”

That’s not a surprise to Clair Huckerby, pharmaceutical adviser at Dudley CCG, home to Dudley’s MCP. She has been a practice pharmacist for 17 years, leading a team of practice pharmacists across the city for 13 years. Her team has expanded to 24 members through the MCP and includes pharmacists in specialist roles, such as respiratory medicine, care of older people and neurology, as well as generalists.

A crucial factor has been development of a service specification. “We are very proud of it,” she says. “It means we can take pharmacists from a variety of backgrounds and from interns up to the most highly qualified and train them.”

But she adds: “I am very picky about recruiting people with the right skills. They need to have advanced clinical skills and communication skills.”

To those who might be starting on this journey, she’s clear about her learning and says: “Get advice from someone who has done it on the skills and skill mix needed and have a governance plan. I am very comfortable with our governance processes at Dudley CCG, but I think GPs’ expectations need to be managed so that they are clear about what individual practice pharmacists can manage.

“I have seen GPs putting practice pharmacists in very compromising situations where they are working outside their competence and they are unable to get insurance.”

Creating new roles

Northumberland primary and acute care system (PACS) is taking time to implement ambitious plans for new roles for pharmacists across hospital, community and primary care settings, as Wasim Baqir, lead pharmacist, explains.

In 2015, pharmacists joined consultant-led multidisciplinary teams working at a newly established emergency care hospital. More recently, Baqir has developed a new community-based specialist pharmacy service that uses a risk stratification model to identify people who could benefit from more intensive pharmacist involvement. The first team members started in June 2016 so it is early days.

“It’s a small team that will go home by home or practice by practice,” says Baqir. “It’s a bit like painting the Forth Bridge in that once we have been round, it will be time to start back at the beginning again.”

He has recruited a team of 15 pharmacists ranging from band 8 independent prescribers down to band 6 training roles and has developed a brand new education programme that will see the band 6 pharmacists training in both primary and secondary care.

“The reality is that 15 pharmacists are not going to make much of a dent so we are going to be working with community pharmacy,” says Baqir. “We know that many of the interventions we will make are not very complex and can be picked up by community pharmacy.”

Northumberland PACS is also ramping up pharmacist involvement in primary care with the creation of a new hub to improve primary care access in four practices and one community hospital covering a population of 38,000 people.

The hub will have a team of professionals, including pharmacists, who will be asking whether patients requesting a GP appointment need a GP – or whether they could be seen by another team member.

Hospital pharmacists are already used to working in complex situations and I do not think it is beyond us to extend that into primary and community care

It’s too early to report any data either from the new service or the community hub. But there are some broad lessons – one of which is how well GPs understand pharmacists’ potential.

Baqir says: “Hospital pharmacists are already used to working in complex situations and I do not think it is beyond us to extend that into primary and community care. But we need GPs to understand what we can and cannot do. There is a risk that we take the more routine stuff – but that should be done by community pharmacy. We should be picking up the more complex stuff.”

Community pharmacy: the missing link?

Mark Spencer, a GP in Fleetwood and chair of the NHS Alliance, has worked alongside pharmacists for many years in urgent care and general practice, and believes that there are significant roles for pharmacists to input into the new models of care at scale. “If you look at the general practice ‘Five year forward view’ you might think that pharmacists are the cavalry, set to ride in to rescue general practice.”

To an extent he agrees with Baqir. “The majority of pharmacists coming into general practice require a significant amount of training,” he says. “They are mainly dispensing pharmacists who have had very little exposure to clinical medicine and their ability to reduce workload in general practice is limited in the short term. I think it will be 12–18 months before they are delivering any productivity gains.”

There is a danger that the concentration on new models of care could destabilise what is a very valuable part of community health – high street pharmacy

But he is wary too of the impact of new models of care on high street pharmacy and is keen to see the vanguards make better use of this existing resource. “There are only so many pharmacists available,” he points out. “There is a danger that the concentration on new models of care could destabilise what is a very valuable part of community health – high street pharmacy.”

Elizabeth Wade, director of policy at Pharmacy Voice, an association of trade bodies representing community pharmacy in England, is concerned that some of the vanguards have failed to involve community pharmacy in their plans. This is a mistake, she says. “Our expectation would be that community pharmacy has a contribution to make. There is definitely good involvement and engagement in a couple of the vanguards but again it is not as extensive or as in depth as we would have hoped in most of them.”

Alastair Buxton, director of NHS services at the Pharmaceutical Services Negotiating Committee, agrees: “The vanguard sites represent an important opportunity for the NHS to think about new ways of shaping community pharmacy services for the benefit of patients and to ease pressure on other local services,” he says. “LPCs have been working hard to engage with local vanguard teams, but they have had varying levels of success.”

Seeing the benefits

NHS England, meanwhile, is clear that the work with and by pharmacists in the new care models vanguards is already having benefits for patients. A spokesperson cites East and North Hertfordshire’s care home vanguard where the medicines optimisation team had, by June 2016, visited 14 care homes and made changes to the medication of 437 residents. This included 1,188 interventions, reviewing 3,649 medicines, and stopping 453 medicines – 70 of which were linked to an increased risk of falls. The team so far has made estimated savings of £54,528 in drug costs, or approximately £125 per resident.

Early data from Dudley’s MCP indicate more than 1,000 hours of GP time saved and more than 10,000 interventions by practice pharmacists. Similarly, West Wakefield MCP’s data from six weeks worth of interventions by practice pharmacists from early May 2016 to mid-June 2016 show that collectively the practice pharmacists made more than 7,500 interventions – of which only 3% went back to the pharmacist – and saved nearly 1,000 hours of GP time.

NHS England is working out the best way to share the lessons learned. One part is the forthcoming publication of frameworks that describe the core components of the new models and that will enable their spread through the sustainability and transformation planning process now underway. The ambition of NHS England is that by 2020 50% of the population will be covered by new models of care, compared with the 9-10% (5 million people) now.

The NHS England spokesperson says: “The frameworks will not be prescriptive, but will outline the key features of each of the care model types. Pharmacy is an important partner and provider in many of the vanguards, and we expect it would have a similar role in many new care models across the country.”

The lead pharmacists at the forefront of developments are all passionate about the potential of these new models of care but are acutely aware that time is pressing. Baqir sums up: “I think this is very exciting – but we only have two years of funding and that gives us some urgency. I am really concerned that we put in place an integrated service – and that it will become common sense to keep it going.”