Tees LPC Pharmacy funding Where are we now

Tees LPC Pharmacy funding Where are we now and what next?

Agenda 1. 2. 3. 4. Department of Health’s view Reaction from the profession Reaction from the press The LPC’s plan

INTRODUCTION The role of community pharmacy Community pharmacy already plays a vital role in: - Dispensing medicines Advising on medicines use Promoting good health and supporting the prevention agenda Supporting people to look after themselves Key facts and figures 1. 6 million visits to community pharmacy every day, of which 1. 2 million are for health reasons Around 1 billion medicines dispensed in community pharmacy every year £ 8 billion spend every year in primary care on NHS medicines 2. 5% current yearly rate of prescription growth But it could play an even greater role, as part of more integrated local care models, in: - Optimising medicines usage Supporting people with long term conditions Treating minor illness and injuries Taking referrals from other care providers Preventing ill health Supporting good health DH - Leading the nation’s health and care Medicines optimisation Up to half of patients don’t use medicines in the way intended; many are simply thrown away 1 in 7 over 75 s are admitted to hospital because of incorrect medicines use 70% of people in care homes may be at risk from medication errors 9

PHARMACY AT THE HEART OF THE NHS Pharmacy at the heart of the NHS The vision is for community pharmacy to be integrated with the wider health and social care system. T help relieve pressure on GPs and Accident and Emergency Departments, ensure optimal use of medic will mean better value and patient outcomes. It will support the promotion of healthy lifestyles and ill h prevention, as well as contributing to delivering seven day health and care services. - Pharmacists enabled to practise more clinically - irrespective of setting and including in community pharmacy - and optimising medicines in a way which puts patients at the centre of decision making, with regular monitoring and review. - Clinical pharmacists in GP practices, able to prescribe medicines and working side by side with GPs, supporting better health and prevention of ill-health. - Clinical pharmacists working in care homes, working with residents and staff to make the most of medicines. - Clinical pharmacists helping patients who have urgent problems, at the end of the phone - for example via the 111 service or on the internet. - Easier for patients to get their prescriptions, for example via the internet where a patient feels this would be more convenient for them. - Pharmacists freed up to support patients to make the most of their medicines, promote health and provide advice to help people live better, harnessing the skills of the wider pharmacy team to support and deliver high quality patient centred health and care. The direction of travel around strengthening clinical practice and medicines optimisation is in keeping with what is expected of hospital pharmacy. DH - Leading the nation’s health and care 10

EFFICIENCY IN COMMMUNITY PHARMACY NHS funding for community pharmacy Amount (£ million) - - The NHS has committed £ 2. 8 bn in 2015/16 on remuneration funding for community pharmacy. £ 2 bn in fees and allowances, with a further £ 800 m distributed through margin on drug reimbursement. 1. 4% 0. 9% 4. 3% 4. 9% Practice payments (£ 633 m) Dispensing fees (£ 869 m) 13. 5% Directed Medicines Use Reviews and other advanced services (£ 86 m) Electronic prescription allowance (£ 28 m) 43. 5% 31. 7% Repeat dispensing annual payments (£ 17 m) Special fees and other allowances (£ 97 m) Establishment payments (£ 270 m) - The median average pharmacy receives £ 220, 000 a year in NHS fees and allowances (including margin). - In the context of the NHS needing to deliver £ 22 billion in efficiency savings by 2020/21, we have to examine community pharmacy and the contribution it can make to this challenge. DH - Leading the nation’s health and care 13

EFFICIENCY IN COMMUNITY PHARMACY Efficiency in community pharmacy - - There are 11, 674 pharmacies in England (at 31 March 2015 ) This is an almost 20% increase since 2003, when there were 9, 748. 14, 000 12, 000 10, 000 8, 000 The NHS funds this growing estate while there is low uptake of digital channels - out 6, 000 of step with how other public sector services 4, 000 have developed over the past 10 years. 2, 000 - - 40% of pharmacies are in clusters of 3 or more meaning that two-fifths of pharmacies are within 10 minutes walk of 2 or more other pharmacies, each being supported by NHS funds. 0 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Number of community pharmacies Average monthly items per pharmacy Number of pharmacies and average monthly items dispensed in England, 2003 -2015 Source: Prescriptions Dispensed in the Community, Statistics for England - 2003 -2013 [NS] Technology is increasingly being used to assemble prescriptions, in individual pharmacies, in small hubs by small groups, and by large organisations, but the current rules mean some forms of technology cannot be accessed by all pharmacies. DH - Leading the nation’s health and care 14

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Remuneration funding for community pharmacy in 2016/17 Spending on health continues to grow, and the Spending Review announced a £ 10 billion real terms increase in NHS funding in England between 2014/15 and 2020/21, of which £ 6 billion will be delivered by the end of 2016/17. In the Spending Review, the Government also re-affirmed the need for greater efficiency and productivity, and the need for the NHS to deliver £ 22 billion efficiency savings by 2020/21, as set out in the NHS’s own plan, the Five Year Forward View. Community pharmacy must play its part in delivering those efficiencies. The Government believes these efficiencies can be made without compromising the quality of services or public access to them because: there are more pharmacies than are necessary to maintain good patient access most NHS funded pharmacies qualify for a complex range of fees, regardless of the quality of service and levels of efficiency of that provider more efficient dispensing arrangements remain largely unavailable to pharmacy providers In 2016/17, the total funding commitment for pharmacies under the community pharmacy contractu framework (essential and advanced services) will be no higher than £ 2. 63 bn, compared to £ 2. 8 bn in 2 The Government is consulting on proposals to realise its objective of a more clinically focussed, modern and efficient pharmacy sector, delivered within the £ 2. 63 bn of funding under the Community Pharmacy Contractual Framework. DH - Leading the nation’s health and care 15

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Proposals for change in community pharmacy 17 December 2015 marked the start of our consultation with the PSNC, other pharmacy bodies and others, including patient and public representatives, on changes to community pharmacy, achieved within the £ 2. 63 bn funding cap described previously. Our aim is that these changes will: - Integrate community pharmacy and pharmacists more closely within the NHS, optimising medicines use and delivering better services to patients and the public. - Modernise the system for patients and the public - making the process of ordering prescriptions and collecting dispensed medicines more convenient for members of the public by ensuring they are offered a choice in how they receive their prescription. - Ensure the system is efficient and delivers value for money for the taxpayer. - Maintain good public access to pharmacies and pharmacists in England. The following slides provide more information on our proposals to achieve these objectives on which we would welcome your views. DH - Leading the nation’s health and care 16

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Bringing pharmacy into the heart of the NHS Pharmacists’ skills make them invaluable to patients and the public, but too often those skills are not used effectively, resulting in avoidable hospital admissions, medicines wastage and sub-optimal care. NHS England has taken important steps to integrate pharmacy into the NHS and the Government would like to make further progress. We will work closely with the PSNC, other pharmacy bodies and others, including patient and public representatives, on how best to introduce a Pharmacy Integration Fund (Ph. IF). This will be the primary means of driving transformation of the pharmacy sector to embed medicines optimisation and the practice of clinical pharmacy in primary care, bringing clear benefits to patients and the public. The proposal for year one will be to focus particularly on the key enablers to achieve integration of community pharmacy. It will be spent primarily on supporting the deployment of clinical pharmacists in a range of primary care settings, including GP practices, multi-speciality community providers, urgent care hubs, care homes and NHS 111. We believe this will be fundamental to fully integrating community pharmacy into the NHS through the creation of clinical and professional links to community pharmacists, together with referral pathways. In addition, it is envisaged the fund will support a range of activities, including: - Developing the delivery of high quality, clinically focussed pharmacy services that are integrated within wider primary care, including community pharmacy; - Integration of the seven principles of medicines optimisation into care pathways for long term conditions such as diabetes, COPD, asthma and hypertension including opportunities for health improvement and wellbeing; - Developing, collaboratively with Health Education England, the whole pharmacy workforce to make patient facing roles the norm; - Supporting the development and implementation of digital technologies for community pharmacy so that it has the infrastructure to achieve integration with clinical pathways and medicines optimisation for patients; - Developing clinical pharmacists working in GP practices, care homes and primary care urgent care hubs (e. g. NHS 111); - Evaluation of innovative clinical pharmacy services, including those already provided by community pharmacies and those developed through the Ph. IF; - Working with Public Health England to develop the value proposition for community pharmacy to encourage the commissioning of local health and wellbeing services by local authorities with a focus on the Healthy Living Pharmacy model. DH - Leading the nation’s health and care 17

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Bringing pharmacy into the heart of the NHS (2) We welcome views on these proposals, and further proposals from the pharmacy sector, and others, including patient and public representatives, on bringing pharmacy into the heart of the NHS to deliver better quality services to patients and the public. What are your views on the introduction of a Pharmacy Integration Fund? What areas should the Pharmacy Integration Fund be focussed on? How else could we facilitate further integration of pharmacists and community pharmacy with other parts of the NHS DH - Leading the nation’s health and care 18

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Modernising the system to maximise choice and convenience for patients public Online ordering, click and collect and home delivery are all growing significantly in other sectors and online retail sales grew by 16% in the UK in 2014. However, the uptake of digital ordering, click and collect and home delivery in community pharmacy remains low. The Office of National Statistics estimate that less than 10% of adults ordered their medicines online in 2014. Because of this, the Government wants to ensure that the regulatory framework and payments system facilitates online, delivery to door and click and collect pharmacy and prescription services. These services already exist to an extent within the community pharmacy sector. As part of our consultation we want to consider how we can promote patient choice and convenience when ordering prescriptions, creating a seamless digital journey for all patients, where the choice of delivery or collection is made upfront. Specifically we want to consider proposals to: - ensure patients are offered the choice of home delivery or collection when ordering their prescription; - introduce a new terms of service for distance-selling pharmacies in recognition of the difference in their service offering, and thus differentiated payment. To what extent do you believe the current system facilitates online, delivery to door and click and collect pharmacy a prescription services? What do you think are the barriers to greater take-up? How can we ensure patients are offered the choice of home delivery or collection of their prescription? DH - Leading the nation’s health and care 19

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Making efficiencies The Government wishes to work with the PSNC and pharmacy organisations to deliver a more efficient and innovative system. As part of this, we want to consider proposals to: - Simplify the NHS pharmacy remuneration payment system. The current system is complex and does not promote efficient and quality services. For example the establishment payment - of around £ 25, 000 per year - is received by all pharmacies dispensing 2, 500 or more prescriptions a month, a relatively low prescription volume. This incentivises pharmacy business to open more NHS funded pharmacies, adding costs to the taxpayer. We therefore propose the establishment payment is phased out over a number of years. - Help pharmacies become more efficient and innovative through, for example, modern dispensing methods. We will separately consult on changes to medicines legislation to allow the ‘hub and spoke’ dispensing model across different legal entities. This could allow independent pharmacies to capture the efficiencies stemming from large-scale, automated dispensing, reduced stock holding and economies of scale in purchasing and delivery of stock to the hubs, freeing up time to concentrate in the spokes on delivering patient centred services designed to optimise the use of medicines by patients. These efficiencies could help pharmacies lower their operating costs and enable pharmacists and their teams to provide more clinical services and to improve and support people’s health. - Encourage longer prescription durations, where clinically appropriate. Where there is no clinical need for a 28 -day repeat prescription, this represents inconvenience to the patient and an avoidable cost to the taxpayer. As part of stable long term condition management, many prescribers already prescribe 90 -day repeat prescriptions where it is clinically appropriate. With a wider range of interested parties, we will be looking at steps to encourage optimising prescription duration, balancing clinical need, patient safety, avoidance of medicine waste and greater convenience for patients. The above are initial proposals. The Government is open to any proposal that will drive efficiency and innovation in community pharmacy. What are your views of the extent to which the current system promotes efficiency and innovation? Do you have any ideas or suggestions for efficiency and innovation in community pharmacy? What are your views of encouraging longer prescription durations and what thoughts do you have of the means by w this could be done safely and well? DH - Leading the nation’s health and care 20

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Maintaining public and patient access to pharmacies Access to pharmacies in England is excellent - 99% of the population can get to a pharmacy within 20 minutes by car and 96% by walking or public transport. Access is greater in areas of highest deprivation. The Government is committed to maintaining access to pharmacies and pharmacy services, and is consulting on its proposal for the introduction of a Pharmacy Access Scheme, based on a national formula by which qualifying pharmacies, according to an index based on geography and other factors, will be required to make smaller efficiencies than the rest of the sector. The proposal is for a national formula to be used to identify those pharmacies that are the most geographically important for patient access, taking into account an isolation criteria based on travel times or distances, and also population size and needs. The population needs variables that we propose should be included are as follows: · Index of Multiple Deprivation (2015) · Proportion of population >75 years who are >85 years · Proportion of population >70 years claiming disability living allowance · · · Standardised Mortality Ratios (SMR) by middle super output area Generalised fertility rate Age-sex standardised proportion non-white Age-sex standardised proportion tenure social Age-sex standardised limiting long term illness Once an index of isolation and population needs is determined, we would then need to determine the means by which pharmacies would qualify, such as a travel time threshold or similar. The index would then be combined with the chosen qualifying criteria to generate a list of qualifying pharmacies. What are your views on the principle of having a Pharmacy Access Scheme? What particular factors do you think we should take into account when designing the Pharmacy Access Scheme? DH - Leading the nation’s health and care 21

PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Further discussion Do you have other views you would like to feed into the consultation process? We welcome feedback from these stakeholder briefing sessions. Please respond to this first phase consultation by Friday 12 February 2016, which will allow us to collate all views received during this initial period and input them into the ongoing discussions with the PSNC. We are expecting individu input to the consultation via the PSNC and other representative bodies. We will then hold further stakeholder meetings during March in advance of the consultation period closing on 24 March. DH - Leading the nation’s health and care 22

Reaction from the profession https: //petition. parliament. uk/petitions/116943 Stop cuts to pharmacy funding and support pharmacy services that save NHS money 39, 889 signatures – but slowing down I am a community pharmacist! So far as part of my 9 hour shift today; I have dispensed and given out medication to 367 different people equating to 987 different items, had a consultation and supplied a patient with emergency contraception, Counselled 2 people on the…(Calum Plenderleith)

Reaction from the press One in four pharmacies on the high street face closure £ 170 m cuts could kill off a QUARTER of our chemists prompting warning of even more pressure on A&Es Up to 3, 000 pharmacies could close after government cuts, MPs warn DDA to scruitinse effect of pharmacy funding cut Many High Street pharmacies in England face closure, says minister Pharmacists were meant to be the face of the NHS - but now our jobs are at risk Sector's shock at Burt's suggestion of 3, 000 closures

What are our options? 1. Do nothing? 2. Do something…

The LPC’s plan Online & Social Media @Com. Phcy. Tees 242 followers – many not our pharmacy teams Tees LPC 57 ‘likes’ – we need more http: //psnc. org. uk/tees-lpc/ (or Google Tees LPC)

The LPC’s plan Fill in the petition https: //petition. parliament. uk/petitions/116943 (or Google pharmacy cuts petition) Write to MP’s Template for pharmacy team members Other material NPA (for independent pharmacies) Head Office (for multiple pharmacies)

The LPC’s plan Visit MP’s and other local decision makers Local press engagement Speak to the patient groups (Healthwatch) and ask for their support What other ideas have you got?

Group discussion Three ideas of how we can: 1. Get our patients’ support 2. Get other health care professionals’ support 3. Anyone else and how

PSNC proposals 10 am 9 February 2016 Proposals for Community Pharmacy review 2016/2017 and negotiation with the Do. H

Community Pharmacy Review 2016/17 A summary of PSNC’s service development proposals to the Department of Health and NHS England

Introduction On 17 th December 2015 the Department of Health (DH) and NHS England wrote a joint open letter to PSNC entitled Community pharmacy in 2016/17 and beyond. In the letter the Government announced that funding for community pharmacy in 2016/17 would be cut by £ 170 m, from £ 2. 8 bn to £ 2. 63 bn, which is a reduction of more than 6% in cash terms. PSNC is working with the other national community pharmacy organisations and the Royal Pharmaceutical Society to respond to the Government’s proposals and to coordinate a campaign against the aspects of the proposals which will have an adverse impact on patient services and access to community pharmacies. Further information on the Government’s proposals and PSNC response can be found on the PSNC website. The open letter stated: There is real potential for far greater use of community pharmacy and pharmacists: in prevention of ill health; support for healthy living; support for self-care for minor ailments and long term conditions; medication reviews in care homes; and as part of more integrated local care models. To this end we need a clinically focussed community pharmacy service that is better integrated with primary care. That will help relieve the pressure on GPs and Accident and Emergency Departments, ensure optimal use of medicines, better value and better patient outcomes, and contribute to delivering seven day health and care services. As DH and NHS England have no specific proposals on how to develop a clinically focussed community pharmacy service, PSNC agreed to submit proposals for discussion. This document summarises the proposals that PSNC has made to DH and NHS England.

The context for PSNC’s proposals When the 2005 Community Pharmacy Contractual Framework (CPCF) was introduced, there was an agreement that it would evolve to respond to the needs of patients and the NHS and to reflect the desire of the profession to build more services around the dispensing service. While the CPCF has developed with the addition of new clinical services, including the New Medicine Service and the Seasonal Flu Vaccination Service, it has not yet developed as far as pharmacy contractors and PSNC would wish. In 2012 PSNC agreed a clear Vision of its aims and aspirations for the community pharmacy service, with community pharmacy teams helping people to optimise their use of medicines, supporting their health and care for acute and long-term conditions, allowing them to live independently in their own homes and providing individualised information, advice and assistance to support the public’s health and healthy living. psnc. org. uk/vision A 2012 survey of community pharmacy contractors confirmed that the majority of the sector (98% of respondents) supported this aspiration for community pharmacy and since then PSNC has been working towards this vision by seeking to develop the community pharmacy service across four key domains: In 2015 PSNC proposed five immediate service developments that NHS England could implement in its Pharmacy 5 Point Forward Plan. Our service development proposals to DH draw on this plan. psnc. org. uk/5 pointplan

The PSNC proposals These proposals set out how the CPCF could develop in order to meet DH and NHS England’s stated aims of developing a more clinically focused community pharmacy service while also meeting the other ‘efficiency and productivity’ requirements set out in their letter of 17 th December 2015. They have been presented to DH and NHS England as outline proposals to prompt further discussions with PSNC. We will undertake further development work on the proposals, subject to the response they receive from DH and NHS England. The proposals are set out in three phases, in recognition of the need to allow the wider NHS and community pharmacy to adopt them in a controlled manner that also allows time for other enablers, such as IT, to be put in place. We recognise that implementing these service development proposals would have substantial implications for DH’s planned restructuring of funding delivery and this would require detailed consideration. PSNC is publishing this summary of the service development proposals so that contractors and their teams are kept abreast of potential development of the CPCF and have time to consider how they may impact on their practice

Phase 1 – Community Pharmacy Care Package Transfer from Repeat Prescribing to e. Repeat Dispensing (e. RD) and the development of a community pharmacy care package for patients • Use of electronic repeat dispensing becomes the default prescribing option where the prescriber wishes to prescribe on a long-term basis • The duration of each supply to the patient is determined by the pharmacist and patient, with guidance from the prescriber, in order to ensure it is based on clinical need and to seek to avoid unintended wastage of medicines • Patients are registered with an individual pharmacy to allow a patient centred/holistic approach to supporting their use of medicines/ management of LTCs • Funding mechanism for the care package must ensure there is no drive to dispense prescriptions where the patient has no need for them

Phase 1 – Community Pharmacy Care Package • Medicines optimisation support provided regularly • MUR-type conversations with the patient may be required, including at the start of the process, and NMS-type interventions would be provided as required • Synchronisation of patient’s medicines undertaken to support adherence and reduce waste • Patient Activation Measure (PAM) and adherence scores would be used to indicate the impact of pharmacy interventions, including on the patient’s engagement with their health • This will assist the targeting of pharmacy engagement with the patient to improve adherence and optimise use of their medicines, allowing the patient to set their own motivational goals

Phase 1 – Inhaler technique checks/coaching • Offer of an inhaler technique check and coaching session to patients prescribed inhalers using e. RD at least twice a year • A formal system for referral back to the prescriber would be implemented for circumstances where a referral is clinically necessary

Phase 1 – Prescription Interventions • Pharmacies already make interventions on prescriptions • These are communicated to the prescriber but are not always clearly recorded in patients’ pharmacy records • Information on the interventions is not centrally collated and therefore the value of these interventions cannot be determined • Under this proposal such interventions would now be clearly recorded using a standard classification system and the data would be centrally collated • National and local (CCG) guidance would be provided to pharmacies on target interventions • Not dispensed interventions would fall within the remit of this proposal

Phase 1 – Post-discharge MURs/ medicines reconciliation • Post-discharge MURs should continue to be provided • Numbers should increase as communications between hospital and community pharmacies improve • For some patients a full MUR may not be required, but a medicines reconciliation (conducted by support staff) would be of benefit to all patients • Further work is required to determine the optimal approach to supporting patients postdischarge and this may be a candidate for support from the Pharmacy Integration Fund

Phase 1 – Pharmacy First service Minor Ailments Advice Service & an Emergency Supply Service • To effectively implement such a service, review and implementation of amended NHS 111 referral pathways would be required in order to support the referral of more patients to the service • Further development of IT infrastructure would also be beneficial to support referrals and messaging between NHS 111 sites and community pharmacies • This is an area which the Pharmacy Integration Fund could support

Phase 1 – Public Health Campaigns • PHE and NHS England should agree up to six national campaign topics each year, utilising PHE’s portfolio of national campaigns • Each campaign could run within pharmacies for up to 2 months • This approach would allow PHE to deliver a consistent campaign message across the whole pharmacy network reaching millions of people at once

Phase 2 – Enhanced community pharmacy care package for patients All pharmacies will need to have SCR access in place and have to provide the national flu vaccination service • Building on the development of the care package in phase 1, additional elements would be provided to patients registered to receive the service • These elements would support the development of a pharmacy care plan with the aim of optimising the patient’s use of medicines, treatment of their condition and improvement of their patient activation score

Phase 2 – Enhanced community pharmacy care package for patients • Examples would include assessing CAT and ACT scores for patients with COPD and asthma, frailty and falls assessments and use of other screening tools (building on the work of the Community Pharmacy Future projects) • Use of these tools would allow the assessment of the impact of the community pharmacy support on the patient and their condition • As appropriate an annual MUR-type review may be undertaken and NMS interventions would be provided when patients commence new therapies • Most of the interventions would be provided on an ongoing and regular basis, generally as patients present in the pharmacy to obtain their next supply of medicines

Phase 2 – Healthy Living Pharmacy or equivalent accreditation • In order to support the effective provision of public health campaigns, pro-active healthy living advice and locally commissioned public health services, pharmacies will work towards achieving an HLP equivalent accreditation • The training of support staff as health champions will provide them with the skills to effectively support behaviour change by patients and the public, related to both healthy living and medicines optimisation • A deadline by which pharmacies must be accredited would be set and an ongoing requirement to ensure that accreditation is maintained

Phase 3 • During this phase the service developments proposed in Phase 1 and 2 would continue to be provided • Pharmacies would additionally provide support to specific groups of patients to manage long term conditions, e. g. hypertension and asthma, and more advanced support for frail and older people with multiple conditions • This would release further GP practice capacity but it would also require the majority of community pharmacists to be qualified as independent prescribers (or for the Alberta approach to prescribing qualification to be adopted)

Other service developments and the future DH has identified the provision of additional clinical pharmacy support for care homes as one area that needs to be taken forward. PSNC believes community pharmacy can provide some of the necessary support required by care homes and patients living within them, but the approach to team working with general practice would need to be explored in order to maximise the value provided to patients and the NHS. This is work that could initially be explored using funding from the Pharmacy Integration Fund. Overall, the outline proposals set out here represent a starting point for discussions with DH and NHS England. They describe how community pharmacy teams could make a more significant contribution to patient care. At this time of financial strain and increasing demand we believe they are ideas that DH and NHS England cannot afford to ignore.

What next? Business as usual Current advanced services Current local enhanced services Threat or Opportunity?

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