MURs should evolve into full clinical medication reviews using independent prescribing

The Community Pharmacy Clinical Services Review examines the evidence for pharmacy services and suggests how to make the most of their potential

An independent review commissioned by NHS England recommends renewing efforts to make the most of clinical services provided through pharmacy, and doing so at pace.

The Community Pharmacy Clinical Services Review, carried out by Richard Murray, director of policy at the King’s Fund, was commissioned by Chief Pharmaceutical Officer Dr Keith Ridge in April 2016 following the publication of NHS England’s Five Year Forward View and the General Practice Forward View – both of which set out proposals for new models of NHS care.

• Electronic repeat dispensing to become the default for repeat prescribing.
• MURs redesigned to include ongoing monitoring and regular follow up, eventually evolving into full clinical medication reviews using independent prescribing.
• Smoking cessation services to become part of the national contract.
• Existing Vanguard programmes and resources used, in conjunction with the Pharmacy Integration Fund, to develop the evidence base for pharmacists in new models of care.
• NHS England and its national partners should consider how best to support STPs to integrate community pharmacy into plans.
• Pharmacy professionals to have read-and-write access to clinical records.
• Registered technicians able to work under PGDs.

Change will require action both through the national contract as well as locally, and it also needs pharmacy to be integrated into evolving models of care, says the review. This should include enhancing pharmacists’ role in long-term condition care and in public health.

The review recommends making full use of the electronic repeat dispensing service. And that, except for patients not yet stabilised on their medication, this should become the default for repeat prescribing and its use should be incentivised both for community pharmacies and for GPs.

Medicines use reviews should be redesigned to include ongoing monitoring and regular follow-up as an element of care pathways. Such a service should be able to use transfer of care and referral schemes, as well as electronic repeat dispensing.

It should focus on patients at high risk and those with multiple comorbidities, as well as those with single priority conditions such as diabetes, hypertension and COPD. Pharmacists should be able to adjust prescription duration to optimise outcomes and convenience for patients.

MURs should ultimately evolve into full clinical medication reviews using independent prescribing as part of the care pathway. For these to be safe and effective, pharmacists would require access to patients’ full medical records.

NHS England should explain how it intends to deliver on its commitment to a locally commissioned minor ailments scheme across England by April 2018. This should include testing models that use patient registration to enhance take up, building on the experience in Scotland. While this could take place within the Vanguard programme as new care models develop, progress toward the April 2018 commitment needs to happen sooner.

The Clinical Services Review recommends that smoking cessation services become part of the national contract.

Vanguard schemes

Pharmacy needs to play its part in the NHS Five Year Forward View and be a core part of the integrated, convenient services that people need but, “to some extent, pharmacy has been left as an outsider”. The new Vanguard programme launched by the Five Year Forward View looks to develop practical exemplars for these new models of care and community pharmacy needs to be fully integrated into these new models.

There are five new care models being developed in the Vanguard programme, of which four are particularly relevant for community pharmacy:

• Integrated primary and acute care systems (PACs) that are joining up GP, hospital, community and mental health services
• Multispecialty community providers (MCPs) that are moving specialist care out of hospitals into the community and establishing better out-of-hospital integration
• Enhanced health in care home Vanguards that are offering older people better, joined up health, care and rehabilitation services
• Urgent and emergency care Vanguards that are supporting new approaches to improve the coordination of urgent and emergency care services and reduce the pressure on A&E departments.

While several MCPs have community pharmacists as part of the team, across the Vanguards as a whole, community pharmacy is more noticeable by its absence or by the relatively minor role it plays. “This risks being a great lost opportunity, not least as there are exciting examples of the expanded roles pharmacists are taking on in England outside of the Vanguard programme.” 

• Poor integration with other parts of the NHS – hindered by the lack of interoperability between digital clinical systems.
• Issues around behaviours and cultures – including sometimes weak relationships between GPs and pharmacy, which in turn inhibit better integration.
• System design issues – including the existing contractual mechanisms for pharmacy, mechanisms that are complex and poorly understood. 

STPs

Sustainability and Transformation Plans (STPs) – being developed across 44 `footprints’ in England – involve bringing together health and care stakeholders to develop ‘place-based plans’ showing how local services will evolve and become sustainable over the next five years. “At their best, STPs offer the opportunity to provide a coherent strategy toward the commissioning of pharmacy services. However, they also represent a challenge.”

Community pharmacy has sometimes struggled to be seen as part of the NHS `family’, says the review. And there is a risk that pharmacies may also be inadvertently left out of STP plans. Public Health England and the Pharmacy and Public Health Forum intend to publish a suite of quality-assured case studies to support the mobilisation of pharmacy for public health delivery. But renewed efforts will be needed to ensure the potential for community pharmacy to help improve the sustainability and transformation of services at local level is not lost from STPs as they develop.

“Only by engaging with these strategies and the general direction of travel from national to local commissioning, will the visions outlined in the 2008 White Paper and a variety of reports produced by the profession themselves eventually become a reality and pharmacy take its proper place within an integrated NHS.”

Over time, STPs may provide the vehicle to ensure that community pharmacy is ‘at the table’ as a matter of routine. However, STPs are at an early stage of development and have an “already daunting to-do list”.

• Poor take-up of repeat dispensing in England, despite supporting evidence
• Beyond MUR and NMS, evidence supports a wider role in supporting patients with long-term conditions
• Evidence supports minor ailments services delivered by community pharmacy
• There is support for a wide range of public health services
• Evidence for, or against, specific clinical services is sparse.

The evidence base

Existing Vanguard programmes and resources should be used, in conjunction with the Pharmacy Integration Fund, to develop the evidence base for community pharmacists within new models of care. This applies to all community programmes, but they should specifically include:

• Integration into long-term condition management pathways using medicines optimisation principles for care home residents
• Pharmacist involvement in case-finding programmes for conditions such as hypertension where they can deliver interventions to prevent progression
• Using existing contractual levers and developing new ways of contracting to mitigate conflicts of interest while incentivising faster uptake of independent prescribing.

Public Health England already plans to present the evidence base for action to local government and STPs. More widely, NHS England and its national partners should consider how best to support STPs to integrate community pharmacy into plans and overcome complexities with commissioning.

Digital maturity and connectivity should be improved to facilitate effective and confidential communication between pharmacists and other healthcare professionals. This should include read-and-write access to clinical records.

Regulations should be amended to allow registered pharmacy technicians to work under patient group directions to allow better use of skill mix when delivering clinical pharmacy services.