There are mixed feelings among pharmacists about what the recent NHS reforms in England have meant for their working practices. Debbie Andalo spoke to some of them

Pharmacists caught up in England’s NHS reforms have mixed feelings about their roles in the new organisations that kicked off last month. Some have found themselves in clinical commissioning groups (CCGs) and others have moved to commissioning support units (CSUs), which are to be run commercially.

There is some concern that the new structures have diminished the opportunities for them to share best practice and innovation, but there is also cautious optimism. It is clear that pharmacists are going to have to take the initiative if they want to make sure their voice is heard in the new NHS.
Duncan Petty, chairman of the Primary Care Pharmacists’ Association has this advice: “Pharmacists need to speak to their local CCG and local government people about how they can help with their agenda. I think a lot of them are so used to change that they accept it as something which happens to them. But my advice would be to maintain their professional networks with colleagues locally and nationally, look for opportunities to meet face- to-face and share ideas and good practice.”

On 1 April 2013 the NHS commissioning landscape in England was transformed: out went 152 primary care trusts and in their place 211 CCGs were created holding a budget of £65bn. Local authorities, for the first time in decades, took back responsibility for public health with every top tier or unitary authority having its own local health and wellbeing boards sharing a budget of £2.7bn. NHS England — the renamed NHS Commissioning Board — took on a £13bn budget for commissioning primary care services.

Jigsaw fragmenting

The commissioning jigsaw has fragmented pharmacy services, which some former PCT pharmacists who have gone to work for the new CCGs regret. Paula Wilkinson, chief pharmacist for Mid-Essex CCG, says: “A lot of people working in the NHS are very upset about this reorganisation. They have successfully destroyed, made worse and made considerably more difficult what was a relatively simple structure.”

Helen Liddell, head of medicines management at Leeds South and East CCG describes the changes as the “biggest reorganisation I have lived through since 1982”. Ms Liddell, who until April was head of medicines management for a practice-based commissioning group in Leeds, says there is a different “ethos” in the CCG.

“Everybody knew each other before but now it’s a much bigger organisation with lots of new people and functions,” she says. The new CCG, she feels, has more authority than her previous employer, which was more “practice facing”, but with that comes increased governance and responsibility. She says: “Before I didn’t have to worry about applications for prescription pads and freedom of information requests and all that day-to-day stuff. There is no admin support for our team and I feel there are a lot of gaps and hiccups to get over.”

Pharmacists working in the new CCG environment bemoan the loss of the autonomy they used to have for medicines management. Under the new system responsibility for medicines management, the previous preserve of PCTs, has been broken up. Dr Petty says: “The feedback we are getting [regarding] medicines management is that community pharmacists are ringing up and the CCG heads of medicines management are having to say ‘Sorry I can’t help you with that — you have got to go to NHS England’ and they aren’t comfortable with that but they are having to learn to say ‘no’.”

His views are borne out by Ms Wilkinson, who feels disempowered in the new system: “I feel like I have lost power as I no longer lead on everything to do with pharmacy and medicines management in the locality. I think that is a great shame and doesn’t augur well for pharmacy going forward.”
Ms Liddell agrees: “In the practice-based commissioning group there was a strong medicines management commitment at senior level, but here from the stuff I have seen it seems more like an add-on.”

Despite the thumbs down for the changes made to medicines management, pharmacists employed by CCGs are happy about working more closely with GPs. Zahra Irannejad officially became chief pharmacist at Sunderland CCG on 1 April after being head of prescribing for North Tyne NHS.

Although she is still getting her head around working for a commissioning-only organisation as opposed to an NHS provider, she enjoys working for the CCG because it is clinically led. She says: “I feel that the clinicians are really involved, I have GP clinical leads whom I work with and my line manager is a GP.”

Greater customer focus

Gillian Eddy was head of medicines management for NHS Norfolk and Waveney PCT cluster until 1 April when she became head of medicines management for her local CSU. She moved across with her whole team and finds the changes “refreshing”. She says: “The job has changed in as much as it’s about supporting five different CCGs that have different agendas and different budgets. But it’s actually quite refreshing having a new focus and trying to do things from a slightly different perspective.”

Ami Scott is commissioning pharmacist for NHS Central Southern CSU. She took up the role after being specialist pharmacist for commissioning at Berkshire West PCT. The CSU covers seven counties but she is only responsible for medicines optimisation services for four CCGs — all in West Berkshire. She says: “They are the only CCGs to have bought medicines optimisation services from us so in many ways my job is very similar to what it was.”

Her new role is more “customer-focused” and the introduction of performance indicators keeps her on her toes: “It’s also been a new way of thinking for me because, not only do I have to make sure that I deliver on my key performance indicators, but it’s also about making sure I deliver a service which is good enough so that when the contract is up for renewal I will get the work. I think we will achieve more in the new system and I will have more career options.”

The elections to the Royal Pharmaceutical Society’s national pharmacy boards, even though you may not vote just yet, can be considered to be under way now that the names of the candidates have been published. Election papers will be sent out in May but, in the meantime, candidates can send two letters of up to 400 words to The Journal for publication between now and our issue of 25 May 2013. Candidates ought not to waste the opportunity.

Funding for community pharmacist practitioner champions in Scotland will be continued in 2013-14.

An NHS circular, published this week (19 April 2013), states that the existing arrangements for champions will continue, with funding remaining at the same level as the last financial year.

Champions are expected to support the roll-out of serial prescribing and dispensing, maximise the use of electronic claiming in the acute medication service, and support the use of the high risk and new medicines tools in the Pharmacy Care Record.

Aspects of professional ethics have always been troublesome. This week, Joy Wingfield, an eminent pharmacy ethicist, suggests that the General Pharmaceutical Council, as it reviews its “Standards for conduct, ethics and performance”, may find particularly troublesome revision of the conscience clause inherited from the Royal Pharmaceutical Society of Great Britain’s pre-separation, 2007 Code of Ethics.The conscience clause allows pharmacists who have strong religious or moral beliefs to refuse to provide treatments or procedures with which they disagree.

However, such pharmacists are meant to signpost patients to other pharmacists who do not hold such convictions. What is the ethical difference between providing a service and, in effect, procuring it? Is this the pragmatic compromise that Professor Wingfield describes?

One area where conscience clause application could cause difficulties is employment. What happens if it turns out an employee pharmacist does not share the convictions and beliefs of his or her employer? Could such a scenario be grounds for dimissal, especially if it came to light only after employment had been taken up? Might there be a case for officially disclosing one’s ethical beliefs before accepting offers of employment so that accommodations might be made? Or could that fall foul of antidiscrimination law?

The views of the public may be instructive. Take this comment from the US website “Feminists for choice”. We have paraphrased it, but it remains uncompromising: “If you own the pharmacy, you should be able to do what you please. If you don’t want to dispense birth control or emergency contraception, then fine, don’t. However, if you work for me at my pharmacy and refuse to dispense it, I should be able to fire you. If you’re vegetarian, you can open a vegetarian restaurant. You can’t take a job at my steakhouse and then refuse to serve steak based on an ethical problem with meat. If you don’t like it, get out of the business entirely.”

Clearly, since pharmacists’ professionalism means they are meant to serve the public interest and not necessarily their own, the GPhC will have its work cut out.

Keele University School of Pharmacy has launched a website providing guidance on medicines optimisation for patients with dysphagia.

The website is aimed at healthcare professionals and includes links to additional tools, publications, guidelines and educational materials.

The site — which is supported by an unrestricted grant from Rosemont Pharmaceuticals — covers subjects including dysphagia, the assessment and management of patients, medicine administration, unlicensed medicines, specials, tablet splitting and imported products. Of particular use to pharmacists is a search function which gives information about the available formats of medicines.

The Medicines Manager software, which enables pharmacists to see a full list of a patient’s repeat medicines held on the GP system, was originally tested by one pharmacist and two GP practices in Plaistow, East London, last year.

But now software providers Rx Systems and EMIS have announced they are extending the pilot to independent community pharmacies, and small and large multiples across England.

Jignesh Patel, community pharmacist at Rohpharm, who was involved in the original pilot, said: "It’s now easier for us to respond to patient requests and we can communicate directly with the GP — for example, to query a prescription. The GP can also contact us — for example, asking us to only fill part of a script because the patient is overdue a review."

The latest phase of the pilot means that the electronic link can be tested in an electronic prescription service release 2-enabled environment.

GSK has added QR (quick response) codes to the packaging of its Seretide Accuhaler (salmeterol xinafoate/fluticasone propionate) device — indicated for both asthma and chronic obstructive pulmonary disease — to aid compliance. When scanned with a smartphone, the barcode directs patients to a website demonstrating how to use the inhaler.

This is the first GSK inhaler product to include a QR code on its packaging. A GSK spokeswoman said: "As far as we know, this is a first . . . for inhaled medicines generally."

MMR vaccination programme to target one million

One million children and teenagers in England are to be targeted in a national MMR vaccination catch-up programme, announced today (25 April 2013).

Public Health England, NHS England and the Department of Health have launched the programme — to be administered by local health teams through GP surgeries and schools — following the recent outbreak of measles in the Swansea area of Wales, which has now reached 942 cases since November 2012. In addition, new figures published today (25 April 2013) by PHE show 587 confirmed measles cases in England in the first three months of 2013 and a record annual high of almost 2,000 cases in 2012.

According to PHE: “There are approximately one third of a million 10-16 year-olds [in England] who are unvaccinated and another third of a million who need at least one further dose of MMR to give them full protection. It is also estimated that there are around another one third of a million children below and above this age band who need at least one further dose of MMR. The target population for this catch-up programme is therefore of the order of one million doses.”

Only 16 cases in Scotland

Scotland, on the other hand, has seen just 16 cases of measles since the beginning of January 2013, with Scotland’s chief medical officer Sir Harry Burns saying: “While measles will continue to circulate throughout the UK, risks in Scotland are much lower due to our higher uptake rates and the work already undertaken over the last 18 months [to ensure that children between 10 and 17 were given a further opportunity to have the MMR vaccination]. However, in view of the significant circulation of measles in Wales and England, NHS boards will now write to parents of all unvaccinated or partially vaccinated children aged 10-17 with an invitation to attend for vaccination over the next few weeks to ensure they are protected.”

PHE has developed a ready-reckoner tool for public health teams to estimate MMR coverage by age, current measles susceptibility, and the number of unvaccinated children aged 10-16 years.

Paul Cosford, director for health protection at PHE, said: “We believe this national framework for a catch-up programme sets out an appropriate response to the situation in England, using the range of expertise and skills across the new public health system. We are confident that local teams have the resources to identify and vaccinate those children most at risk, and that the NHS has sufficient vaccine to cover the approaches described in the action plan.”

See also:
MMR advice issued for England as Welsh outbreak continues
Measles and the symptoms to look for

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Caption: Teenagers and children will be targeted in the catch-up programme
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Innovation in community pharmacy will be easier to spread because of the new NHS structure in England, according to Deborah Jaines, head of primary care and commissioning outcomes at NHS England.

Speaking at the Pharmaceutical Services Negotiating Committee conference yesterday (24 April 2013), Ms Jaines said that there are real opportunities offered in the new NHS structure.

"If you think about how primary care trusts were configured in the past; now we have 27 out posts of a single organisation [NHS England] so getting the message out and getting the spread of best practice out, will be more efficient and direct and less cumbersome than getting around . . . PCTs," she said.

She added: "We’ve also got some really good examples of emerging good practice; the healthy living pharmacy project has just published its evaluation and we are eagerly awaiting the new NMS evaluation. It feels like pharmacy is aligning well with this productivity agenda."

Take a leap of faith

Also speaking about innovation, Clare Howard, deputy chief pharmaceutical officer and medicines optimisation lead at NHS England, said pharmacists must take a leap of faith and get engaged with local intiatives, such as healthy living pharmacies. In the future, just handing over the medication is not going to cut it, she said.

"Medicines optimisation is about optimising the outcomes that patients receive from their medicines, and that’s a really important statement. With 50 per cent of patients not taking their medicines as intended and when waste is as it is, and with patients being admitted to hospital [for medication incidents], well actually we’re not optimising that benefit.

"If we’re still here in five to 10 years with patients still only taking their medications correctly 50 per cent of the time, there will be some significant questions that the pharmacy profession will have to stand up and answer," she said.

Mrs Howard recommended that pharmacists engage with patients to make sure they are creating the services patients want and need to enable them to take their medicines correctly.

Investment in new medicines is falling as a proportion of total NHS spend — a “crude” savings approach that may be damaging patient care, the Association of the British Pharmaceutical Industry has warned.

Furthermore, the UK spends less on new medicines (7p per head of population per day) and on medicines overall (74p per head of population per day) than other developed countries, including Germany (21p/£1.11, respectively), France (22p/£1.40, respectively) and the US (36p/£2.21, respectively).

ABPI chief executive Stephen Whitehead said: “Our healthcare system needs to focus much more on caring for patients in their own homes and much less on treatment in expensive hospitals. Investing in new, innovative medicines will be absolutely key to this.”

He added: “It is particularly frustrating that we still struggle to get new medicines to patients when . . . the UK has amongst the lowest prices in Europe, and the NHS will save over a billion pounds every year until 2015 as medicines lose their patent.”

The ABPI’s 2013 conference took place this week (25 April 2013) in London.

Waste water has been analysed as a way of measuring population compliance with antiviral therapy. The results suggest that only around 50 per cent of the oseltamivir (Tamiflu) that was collected by patients during the 2009 influenza A pandemic was actually taken.

Researchers from the Natural Environmental Research Council in the UK predicted consumption of oseltamivir by measuring the level of the drug’s active metabolite (oseltamivir carboxylate) in the influent of two waste water treatment plants (one rural and one urban) in Oxfordshire over 24 hours during the peak of the pandemic. 

These figures were compared with National Pandemic Flu Service data on oseltamivir supply, leading to an estimated compliance rate of 45 to 60 per cent.

The authors note that use of antivirals is central to pandemic preparedness plans and say there is a clear need to alter public health messages to improve compliance. They suggest that “waste water forensics” can be a valuable tool in monitoring population behaviour and that near real-time estimates of drug compliance in specific catchment areas can potentially help public health messages become more targeted (PLOS ONE, 2013;8: e60221).

Lessons learned from antibiotic stewardship systems in secondary care now need to be supported and extended into primary care, according to Keith Ridge, chief pharmaceutical officer for England.

In his keynote address at the opening of The Clinical Pharmacy Congress in London today (26 April 2013), Dr Ridge acknowledged the input that primary care pharmacists have already had into antimicrobial stewardship. He reminded those now working in clinical commissioning groups and commissioning support units to continue to play a key role in preventing antimicrobial resistance, encouraging them to act as “local guardians of antibiotics”.

“Pharmacy teams are critical and essential in multidisciplinary clinical teams that are delivering antibiotic stewardship,” said Dr Ridge. He reminded delegates of the “immense threat” of antimicrobial resistance and stressed that more needs to be done to combat the problem.

Dr Ridge explained that part of the solution is in the development of new antibiotics, but that preserving existing antibiotics is also important, which is where pharmacists can make a difference. “I need you to be even more vigilant about enforcing antibiotic stewardship systems,” he said.

The Professional Records Standards Body (PRSB) was launched last week (16 April 2013) to deal with all matters relating to health and social care records.

Its purpose is to ensure that the way in which patient records are kept reflect the best practice of that organisation and enable good outcomes for the patient. The PRSB will therefore advise statutory, voluntary and professional bodies and associations on record structure and content.

Founding members include the Royal College of Physicians and the Royal College of Nursing. The Royal Pharmaceutical Society is eligible to apply to become a member.

Combining the new anticancer drug pertuzumab with trastuzumab and docetaxel improves survival for patients with metastatic human epidermal growth factor receptor 2 (HER2)-positive breast cancer, results from a phase III trial show (published online in Lancet Oncology, 18 April 2013).

The primary results from this trial (the CLEOPATRA trial) showed improved progression-free survival with the pertuzumab regimen compared with trastuzumab and docetaxel alone (PJ 2013;290:329). An interim analysis of overall survival, a secondary endpoint of the trial, has now been reported.

After a median follow up of 30 months, survival was significantly improved in the pertuzumab group (hazard ratio for mortality 0.66, 95 per cent confidence interval 0.52-0.84, P=0.0008). Kaplan-Meier survival curves showed an early separation between the two treatment regimens.

Serious adverse events were reported in 36 per cent of pertuzumab patients and 29 per cent of patients taking trastuzumab and docetaxel alone. Addition of pertuzumab did not increase the rate of left ventricular systolic dysfunction.

The study authors describe the new regimen as a “substantial improvement on the standard of care for this population of patients”.
The National Institute for Health and Care Excellence’s appraisal of pertuzumab is expected to be published in November 2013.

A restriction on the use of strontium ranelate has been backed by the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP), following recommendations made by the Pharmacovigilance Risk Assessment Committee. 

An increased risk of heart attack was found in post-menopausal women taking strontium ranelate (Protelos) during a routine risk assessment by the PRAC. Now that the PRAC’s safety recommendations have received the backing of the CHMP, they will be sent to the European Commission for endorsement. In the meantime, it is advised that only patients with severe osteoporosis are treated with strontium ranelate and patients with high blood pressure should not be given the medicine.

Smoking cessation and emergency hormonal contraception services should no longer be referred to as enhanced services, the Pharmaceutical Services Negotiating Committee has clarified in a document about England’s new enhanced service commissioning arrangements.

These services — along with screening (eg, for chlamydia), supervised administration and needle and syringe exchange services — are now commissioned by local authorities as public health services. They no longer fall under the legal definition of enhanced services, which can only be commissioned by NHS England, the PSNC explains.

In certain circumstances, local authorities might ask NHS England to commission these services on their behalf, in which case they will be treated as enhanced services. “A contractor or applicant wishing to provide a public health service should contact the relevant local authority to establish to which organisation they should apply,” the PSNC advises.

Pharmacies that before the NHS reforms were directed to provide certain enhanced services will still be required to provide those services that fall within NHS England’s commissioning remit. But they will no longer be legally bound to provide the services that are now commissioned by local authorities, and therefore no longer classed as enhanced services, the PSNC explains.

Full details of the essential services that contractors are required to provide are set out in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013.

Enhanced and advanced services that may be commissioned from contractors are listed in the Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013.

The European Medicines Agency has published its initial list of medicines subject to additional monitoring as part of the new EU-wide “black triangle” monitoring scheme. The scheme rolls out from 1 September 2013 and will replace the Medicines and Healthcare products Regulatory Agency’s black triangle scheme from that date.

However, during the transition period the MHRA is advising healthcare professionals to be aware of some differences between its own, latest black triangle list published 19 March 2013 and that of the EU additional monitoring list published on 25 April 2013, which only includes products meeting the “mandatory” reasons for inclusion.

The agency also points out that an “optional” scope list of further medicines that need additional monitoring, according to competent authorities, will be published later this year, adding: “Marketing authorisation holders should be aware that products which are not currently included in the initial EU additional monitoring list may be reinstated from the UK black triangle list later in 2013 once the final list is agreed by the Pharmacovigilance Risk Assessment Committee.”

The MHRA invites healthcare professionals with any questions about the scheme to email them to blacktriangle@mhra.gsi.gov.uk

An electronic system that allows hospital pharmacists to send medicines information to community pharmacists is being developed by East Lancashire Hospitals NHS Trust.

The initiative was revealed by the trust’s clinical services lead pharmacist, Alistair Gray, during the Clinical Pharmacy Congress, which took place at the Excel Centre in London on 26–27 April 2013. It is intended to let community pharmacists know about changes to patients’ medication and to identify those who are suitable for the new medicine service or a targeted medicines use review.

Once consent is obtained from patients, hospital pharmacists will be able to make the referrals using tablet devices at the patient’s bedside at any time during admission. When the patient is discharged, a community pharmacist (of the patient’s choosing) will be sent a message to inform them of the referral with a copy of the patient’s discharge letter attached.

Potentially, the patient could also be sent a text to confirm that the referral has been made. The system could also make referrals to the local domiciliary medicines management team, which conducts medicines reviews in patients’ homes.

“The [scheme] is just a way of getting patients an MUR or new medicine service review,” Mr Gray explained. “These are evidence-based interventions, which have been shown to make a difference to adherence, outcomes and, ultimately, to reduce readmissions to hospital. It’s in everyone’s interest to do that.”

Launch of the system is planned for later this year (2013). Mr Gray confirmed that the trust would be reviewing outcomes to determine whether the system affects hospital readmissions rates.

The scheme is one of several initiatives being carried out by the hospital to improve the quality of discharge information. Other initiatives include a checklist carried by nurses during ward rounds that prompts a standardised approach to care and documentation. Doctors are expected to document the patient’s admitting diagnosis on ward round entries — to make it easier for discharge letters to be written. This task is expected to take place the day before discharge, at the same time that a discharge prescription is written. Doctors are also prompted to document an expected date of discharge during every ward round, to allow other healthcare professionals to plan ahead.

In addition, drug charts have been redesigned to contain a designated space for documenting:

• Whether a drug is new, or prescribed prior to admission
• The drug’s indication
• Whether a dose has been increased or decreased

Mr Gray estimated that writing discharge information in advance reduces the average length of stay for most patients by half a day.