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Pharmacy: Health Services

Volume 488: debated on Wednesday 25 February 2009

To ask the Secretary of State for Health (1) what recent estimate he has made of the proportion of pharmacy consultations which result in referral to other healthcare services; (255442)

(2) what estimate he has made of the proportion of pharmacies which provide an influenza vaccination service;

(3) what progress his Department has made towards applying world-class commissioning competencies to the commissioning of pharmaceutical services, as referred to on page 23 of his Department's White Paper, Pharmacy in England, Cm 7341;

(4) what progress his Department has made in discussions on appropriate measures to support adherence to medicines, as referred to on page 33 of his Department's White Paper, Pharmacy in England, Cm 7431;

(5) what progress his Department has made on research to establish the extent to which medicines are not used, as referred to on page 32 of his Department's White Paper, Pharmacy in England, Cm 7431;

(6) what methodology was used to calculate the figure of £100 million for the costs of unused and unwanted medicines referred to in his Department's White Paper, Pharmacy in England, Cm 7431; and what estimate he has made of this cost in the last 12 months;

(7) what progress his Department has made in developing further incremental implementations of repeat dispensing, as referred to on page 31 of his Department's White Paper, Pharmacy in England, Cm 7431;

(8) which primary care trusts commission services from community pharmacies to stock medicines that people may need at the end of their life, as referred to on page 36 of his Department's Pharmacy White Paper, Pharmacy in England, CM 7431;

(9) what reasons he has identified for the decline in the number of local enhanced home delivery services commissioned by primary care trusts in England between 2006-07 and 2007-08, as referred to in table 6 of the General Pharmaceutical Services in England and Wales 1998-99 to 2007-08 bulletin;

(10) if he will place in the Library a copy of the Public Health Leadership Forum for Pharmacy's work programme for 2008-10, referred to on page 52 of his Department's White Paper, Pharmacy in England, Cm 7431;

(11) what progress has been made by NHS Connecting for Health in scoping arrangements for electronically capturing information about (a) interventions made and (b) advice given by pharmacists in promoting health lifestyles, as referred to on page 53 of his Department's White Paper, Pharmacy in England, Cm 7431;

(12) what progress his Department has made in incorporating minor ailments schemes within the community pharmacy contractual framework since 3 April 2008;

(13) what assessment he has made of the extent to which pharmacies have been included in local schemes to help reduce unintended pregnancies, as referred to on page 56 of his Department's White Paper, Pharmacy in England, Cm 7431;

(14) what contributions which pharmacies can make to the care of people with diabetes have been identified to date by the National Clinical Director for Diabetes and the Chief Pharmaceutical Officer, as referred to on page 58 of his Department's White Paper, Pharmacy in England, Cm7431;

(15) what progress has been made in introducing a support service for people who are newly prescribed a medicine to treat a long-term condition within the community pharmacy contractual framework, as referred to on page 65 of his Department's White Paper, Pharmacy in England, Cm 7431;

(16) what steps he is taking to develop (a) professional and (b) contractual arrangements to ensure that people with symptoms from cancer are efficiently referred onwards by pharmacists, as referred to on page 67 of his Department's White Paper, Pharmacy in England, Cm 7431;

(17) on what dates in 2008 the working group on pharmacy medical and public representatives referred to on page 74 of his Department's White Paper, Pharmacy in England, Cm 7431, met; if he will place in the Library a copy of the (a) agenda for and (b) minutes from each of the meetings; what progress the working group has made in promoting more effective professional relationships between pharmacists and other healthcare professionals; and if he will make a statement;

(18) what progress he has made in planning communications which will (a) highlight the breadth of services and skills available in pharmacies, (b) illustrate the role that pharmacies can play in promoting good health, (c) raise awareness of the knowledge of the role that pharmacies can play in managing long-term conditions and reducing health inequalities and (d) increase the use of pharmacy services, as referred to on page 72 of his Department's White Paper, Pharmacy in England, Cm 7431; what the target audience is for each strand of communications; what further qualitative research he has commissioned to develop a better understanding of the particular needs of these audiences as referred to on page 72 of the White Paper; when he plans to introduce the communications programme; what expenditure he estimates his Department will incur on the communications programme in (i) 2008-09, (ii) 2009-10 and (iii) 2010-11; and if he will make a statement;

(19) what research the National Institute for Health Research has undertaken into pharmacy since its establishment; and what priorities have been identified for research into pharmacy by the Chief Pharmaceutical Officer, as referred to on page 78 of his Department's White Paper, Pharmacy in England, Cm 7431;

(20) what steps he is taking to utilise the pharmacy network to promote pharmacovigilance, as referred to on page 79 of his Department's White Paper, Pharmacy in England, Cm 7431;

(21) what assessment his Department has made of the availability of specialist pharmacy services across England; and if he will make a statement;

(22) if he will place in the Library a copy of the workforce planning for pharmacy undertaken to inform the NHS Next Stage Review, as referred to on page 99 of his Department's White Paper, Pharmacy in England, Cm 7431;

(23) what progress is being made in reviewing the requirements contained within pharmaceutical needs assessments, as referred to on page 106 of his Department's White Paper, Pharmacy in England; when he expects the review to be completed; whether the results of the review will be piloted; if he will make it his policy to ensure that primary care trusts are judged to be competent in conducting pharmaceutical needs assessments prior to doing so; and if he will make a statement;

(24) from what date his Department intends to include directed enhanced services within the community pharmacy contractual framework, as referred to on page 109 of his Department's White Paper, Pharmacy in England; what progress has been made in deciding which services to include in directed enhanced services; whether he plans to introduce an enhanced services expenditure floor for pharmacy services; and if he will make a statement;

(25) what arrangements his Department has put in place to (a) identify and (b) address unwarranted variations in standards and quality of pharmacy service delivery, as referred to on page 111 of his Department's White Paper, Pharmacy in England, Cm 7431;

(26) what the outcomes were of the annual pharmacy-based audit, as referred to on page 112 of his Department's White Paper, Pharmacy in England, Cm 7431 in each year since it became operational; what progress has been made in strengthening the clinical audit of pharmacy services; and if he will make a statement.

Good progress is being made in implementing the White Paper “Pharmacy in England: Building on strengths—delivering the future” to achieve the Government's future vision for pharmaceutical services in this country. The two national clinical directors for pharmacy have been appointed to champion the development of pharmaceutical services and help deliver the White Paper's objectives.

As chapter 3 of the White Paper sets out, we are keen to improve the way medicines are accessed and used. Research has been commissioned from the universities of York and London to examine the scale and cost of medicines wasted, as well as the complex and varied reasons why people do not take their medicines as intended. The findings are expected later this year and will inform policy development for influencing both health professionals and members of the public to reduce the amount of unwanted medicines and provide value for money for the national health service. The figure of £100 million for the costs of unwanted and unused medicines in the White Paper is no more than a cautious estimate. The 2000 Spending Review stated that “various small scale studies have suggested that the value of medicines returned to pharmacies amounts to 1.5-2 per cent. of the overall drugs bill”, which was £5,160 million in 2000-01. No estimate has been made of this cost in the last 12 months.

The research on the extent and reasons why medicines are not used will also inform measures to support adherence to medicines. These measures will be subject to discussions with key stakeholders and interested parties, taking into account guidance, such as the recently published report from the National Institute for Health and Clinical Excellence (NICE) “Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence” published in January 2009, as well as local enhanced services already being commissioned by primary care trusts (PCTs).

Information on the services PCTs commission from community pharmacies to stock medicines that people may need at the end of their life—a local enhanced service termed ‘on demand availability of specialist drugs—is contained in table 6 of “General Pharmaceutical Services in England and Wales 1998-00 to 2007-08” and a breakdown by PCT is in its online appendix—both of which were published by the Information Centre for health and social care in November 2008. Copies of the documents have already been placed in the Library. Home delivery services are commissioned by PCTs according to patients' needs locally. Many pharmacies voluntarily provide such a service.

Pharmacists have been established reporters to the yellow card scheme since 1998. They have a particularly important role in detecting and reporting suspected adverse drug reactions (ADRs) in association with over the counter medicines including herbal products and newly reclassified medicines. By the end of January 2009, the Medicines Healthcare products Regulatory Agency (MHRA) had received in excess of 20,000 reports from the profession, contributing 13 per cent. of all yellow cards annually.

The MHRA recognises that pharmacists have a crucial role to play in pharmacovigilance, not just in the submission of suspected ADR reports, but also in raising public awareness of patient reporting. Following a successful national campaign to raise awareness of the yellow card scheme in community pharmacies during 2008, there was a 50 per cent. increase in patient reporting and a doubling in online reporting.

The MHRA is now exploring further use of the pharmacy network in conjunction with the chief pharmaceutical officer for England. To recognise the important role pharmacists play in pharmacovigilance, specific information pages for pharmacists are being launched on the MHRA website at the end of February 2009. These will provide up to date information and guidance on ADR reporting.

A wider range of services is being commissioned from pharmacies according to local need. Some PCTs are commissioning community pharmacies to provide seasonal influenza vaccination following training and accreditation, to help GPs attain their targets. Information on the proportion of all pharmacies providing this service is not collected centrally. In many parts of the country, pharmacies are one of the main sources of access to emergency hormonal contraception, either through over the counter sales or through the use of patient group directions. In addition, a total of £26.8 million of additional funding has been allocated in 2008-09 to special health authorities (SHAs) and PCTs to improve women's knowledge of, and access to, the full range of contraception, to help reduce the number of teenage pregnancies and abortions. It is for SHAs and PCTs to determine how to use this funding most effectively to meet the needs of their local populations. SHAs have been working with PCTs to agree local action plans to develop innovative schemes, including pharmacy-based schemes, to improve awareness of and access to all types of contraception. The extent to which pharmacies have been included in local schemes to help reduce unintended pregnancies has not been assessed.

Many pharmacies are already providing services to people with diabetes—ranging from blood glucose testing and carrying out blood pressure measurements to providing healthy lifestyle advice. The Department is working with the Royal Pharmaceutical Society of Great Britain and the National Pharmacy Association to develop resources to support the further integration of pharmacy into the care of people with diabetes, which will be endorsed by the national clinical director for diabetes and the chief pharmaceutical officer for England. These resources, expected to be completed by autumn 2009, will identify how pharmacy can play its part in the integrated care of people with diabetes to help ensure that patients get seamless care.

Pharmacists also have an important role in raising awareness of symptoms of cancer. The Department has funded leaflets containing key messages on lung cancer awareness, which will be distributed to all community pharmacies shortly. The Department will be discussing with key stakeholders and interested parties, how best to incorporate referral systems for people with symptoms indicative of cancer, within the community pharmacy contractual framework. The Department is also considering how to engage pharmacists further in raising awareness of other cancers and referring on to other healthcare professionals, where appropriate.

The introduction of a support service for people who are newly prescribed a medicine to treat a long-term condition will be informed by ongoing discussions with key stakeholders and interested parties, as will the incorporation of minor ailments schemes within the community pharmacy contractual framework. Both services will take account of local enhanced services already being commissioned by PCTs, research into public awareness and knowledge, and will be subject to further negotiation. Similarly, the use of directed enhanced services within the community pharmacy contractual framework is subject to further discussions and negotiations taking into account local enhanced services already being commissioned by PCTs.

No estimate has been made of the proportion of pharmacy consultations, which result in referrals to other healthcare services, as this information is not collected centrally.

In keeping with the NHS next stage review, pharmacy has an important role in prevention, as well as treatment. The public health leadership forum for pharmacy has identified its work programme for 2008-09 as the development of educational resources on sustainable development, sexual health and mental health for distribution to all community pharmacies in England. Resources for sustainable development were published and distributed in September 2008. The resources for sexual health and mental health are expected to be published by the end of 2009. The Forum has agreed that its programme of work for 2009-10 will consist of:

developing a model for healthy living centre pharmacies, which will identify the services that might be provided as well as what such pharmacies might look like;

taking steps to enable pharmacy staff to become health trainers; and

facilitating the development of a plan to develop leadership training for senior pharmacists working within PCTs so they can influence commissioning decisions.

Initial scoping of the extent of the provision of specialist pharmacy services across England has been completed and advice is being sought from the specialist commissioning group directors network and the national specialist commissioning group on the commissioning of these services.

These developments need to be underpinned by effective professional relationships, communications and information technology. The Department asked NHS employers in 2008 to convene and lead a working group of pharmacy, medical and public representatives to formulate a series of actions to promote more effective professional relationships. Further details of the working group are held by NHS employers. One aspect of the group's remit was to identify and agree mechanisms that can support further incremental implementation of repeat dispensing. In January 2009, the working group published “Guidance for the implementation of repeat dispensing” for general practices, to support this. A copy has been placed in the Library. In addition, the working group have published guidance for general practices on the medicines use review service, and have issued a joint letter to community pharmacists, general practitioners and their local representatives to help facilitate discussions between general practitioners GPs and pharmacists on key work areas including repeat dispensing. The three documents can be found at:

www.nhsemployers.org/pay-conditions/primary-211.cfm.

To support communication planning the Department commissioned an extensive qualitative research programme in September 2008 that was completed, as scheduled, in December. The research identified key segments within the population and gave insight into their differing uses of, and attitudes towards, pharmacy. The Department is considering the implications of these findings for the communications programme and expects to publish the research together with an outline communications plan later this spring. Further qualitative research is being commissioned by the Department on the opinions of the pharmacy profession towards delivering the services outlined in the White Paper. This research will be completed by this summer. £65,000 has been spent in 2008-09 to date on the research to support the communications programme. Estimates for future years' expenditure are not yet available.

A pharmacy information technology programme is being established by the Department and NHS Connecting for Health. One of its first responsibilities will be to progress the White Paper commitment to electronically capture information about interventions made and advice given, by pharmacists.

Structural and legislative reform is also needed and the Department consulted on a number of proposals in autumn 2008, including PCTs assessing pharmaceutical needs. A preliminary report of the outcome of that consultation on those elements which require changes to the primary legislation was published on 16 January 2009 alongside the Health Bill 2009. The Bill proposes placing a requirement on PCTs to undertake and to publish their assessments of pharmaceutical needs. Subject to parliamentary approval, regulations would then set out the structure and content of these assessments, how PCTs should carry them out and the requirements for publication. The Department expects to work closely with interested parties, including NHS and contractors' representatives, on drafting the regulations. At this stage, the Department does not propose to pilot these requirements, but to roll them out across PCTs with appropriate support and training programmes.

The Department asked NHS Employers to set up a short-term working group in 2008 to review the structure of, and data requirements for, PCTs’ pharmaceutical needs assessments and to develop a support programme so that these assessments will be an effective and robust commissioning tool, which support local decisions. NHS employers published the first element of this support programme—“Guidance for PCTs on pharmaceutical needs assessments (PNAs) as part of world class commissioning”, which has been prepared to dovetail with the world-class commissioning programme—on 7 January 2009. A copy has been placed in the Library. It is available at:

www.nhsemployers.org/PNAguidance.

Further resources will be published later this spring. These will include guidance on how to commission pharmaceutical services and more detailed advice on the information these needs assessments should contain. These resources are designed to provide a comprehensive support programme for PCTs to achieve the necessary capability to be world-class commissioners of high quality pharmaceutical services.

The Department is committed to continuing to work with the NHS and the Pharmaceutical Services Negotiating Committee to devise proposals to ensure that effective arrangements are in place to address unwarranted variations in standards and quality of pharmaceutical service delivery. Following consultation last autumn, provisions in the Health Bill 2009 will, subject to parliamentary approval, introduce new powers to enable PCTs, through regulations, to issue remedial notices to contractors or to withhold payments due to them. These new powers will form part of the Department's programme to ensure appropriate discretionary levers are available to PCTs to secure quality pharmaceutical services and to manage contractors' performance. Subject to discussions with key stakeholders and negotiation, this will be supported by strengthening the clinical governance requirements of the contractual framework which already require amongst other things, contractors to carry out an annual patient survey and one pharmacy-based and one multi-disciplinary audit. These audits are undertaken locally and no data is held on them centrally.

Research to inform future developments and an appropriate pharmacy workforce are also important. Research into pharmaceutical services is a relatively new area. Its focus has largely been on the acceptability and uptake of services by the public and on perceptions of the profession and their job satisfaction. Measures to date have largely been expressed in terms of inputs and outputs, rather than in terms of service quality, outcomes and relative cost effectiveness.

Therefore, chapter 6 of the White Paper sets out action by the chief pharmaceutical officer for England to convene an expert panel to advise on research priorities to improve the evidence base underpinning the value and effectiveness of pharmacy services.

This will be informed by:

the extensive and ongoing qualitative research programme commissioned through the pharmacy White Paper;

the ongoing composite review of the relevant research literature on the contribution of community pharmacy to improving the public's health, covering the period 1990-2007, which will be completed and published in due course; and

the outcome of an event hosted by the Pharmacy Practice Research Trust, held on the 5 and 6 November 2008, to which the chief pharmaceutical officer for England contributed. The event was designed to begin to develop a UK wide research strategy for pharmacy and brought together key stakeholders across pharmacy and academia to initiate discussions around the concept of an overarching profession led UK wide research strategy for pharmacy.

Pharmacy workforce planning forms part of the arrangements to strengthen workforce planning for all professions set out in “A High Quality Workforce”, published in July 2008. A copy has been placed in the Library. The chief pharmaceutical officer for England has established the modernising pharmacy careers programme board to provide professional advice and scrutiny on workforce plans where these concern pharmacists and other pharmacy staff (for example pharmacy technicians) providing NHS services. The pharmacy professional advisory board will work closely with Medical Education, England, which will provide professional, high level scrutiny of and advice on the quality of workforce planning at a national level for doctors, dentists, pharmacists and healthcare scientists. Arrangements are in place for the modernising pharmacy careers programme board's first meeting in February 2009