08

Making better use of pharmacy

Chair: Donal Markey, Head of Primary Care
Commissioning, NHS England (London Region)

Transforming London’s health and care together

Making the most of community
pharmacy
Donal Markey Pharmacy Advisor HLP Children & Young People
 Aim and purpose of this session

How can Healthy London Partnership:

• Support the role of community pharmacy in supporting CYP?
• Promote understanding for future workforce planning and development?
• Consider the barriers to the better utilisation of pharmacy and how to
overcome them?

1 Overview of community pharmacy

2 Examples of services commissioned in pharmacies which support CYP

Opportunities to consider community pharmacy in Out of Hospital care

3 pathways
 Overview of community pharmacy
Pharmacy services in England: Key facts 2015/16

7.8m items of Fluticasone

Propionate (inhaled) dispensed 11,688 community
pharmacies in
1.08 billion
3.3 million Medicine Use England and 1862
prescription
items 
Reviews , average of 280 in London
per annum for a London
dispensed in
Pharmacy
the community
Fluticasone
Propionate
£9.27 billion was the
(inhaled)
cost of prescriptions
dispensed in the remains the
community
34.4 m highest
Simvastatin costing 35.4% of
was the most
prescribed
medicine at items
£376m dispensed
chemical
by EPS

821,893 New Medicines Services

interventions, average 78 per annum
for a London Pharmacy
 Overview: Community Pharmacy Services
Categories & Funding sources

Service Essential Advanced Quality Enhanced Locally

Payment Commissioned
Commissioner NHS NHS England NHS England NHS England CCG or Local
England Authority
Funding Central - Central - Central – Local - NHS Local
Source Global Sum Global Sum Global Sum England Regions
Examples Dispensing Medicine Inhaler
D Minor Ailments Stop smoking
Public Use Reviews surveillance Service Sexual health
Health New NHS Choices Extended services
Campaigns medicine opening hours Screening
Audit Service Immunisation Minor ailments
National Flu Higher level
Service (+ 18 medication
years of age) review services
Urgent
medicine
supply
services
 Pharmacy Integration Fund
Support transformation in FYFV, £42m 2016-18

Integrate and develop clinical pharmacy practice in a wider range of primary care settings.
Free up community pharmacists and their teams to:
• spend more time delivering clinical services and health improvement for their patients;
• work in a variety of NHS settings
• Utilize technology.
 
The initial priorities for the fund in 2016-18 are:
Deployment of clinical pharmacists and pharmacy services in community and primary care
 including groups of general practices, care homes and urgent care settings such as NHS 111.
Development of ‘infrastructure’ through the pharmacy professional workforce, accelerating
digital integration and establishing the principles of medicines optimisation for patient-centred
care.
https://www.england.nhs.uk/commissioning/primary-care/pharmacy/integration-fund/
 
Out of Hospital care for children &
young people provided by
pharmacies

Public health campaigns & audits

Asthma Management
Children & Young People
 Highlights
Final results

1,865 1,225 65.7% 32

Pharmacies of the total boroughs
Community pharmacies responded number of (all) took Participation per
across the whole of London
pharmacies part
were invited to a take part borough
100.0%

9,690 9.4
90.0%
80.0%
70.0%
responses Average age
60.0%
of participant 50.0%
40.0%

Campaign 30.0%

extended to 10 weeks 20.0%

till 2 October 9 1 in 4 10.0%

0.0%

ey n y t s ley es th on es et ey
t
Average Entries were c kn nh
e
am ham gt o
w l in ro m
le
a m
le
Be x
ha s S H
w
m wor ut t arro am arn ing
h B r ulh
am ren
B
Ha ag Ne Is B rH T d T Ha nd
F
entry per using a smart n d
D
owe upo
n
W
an
upo
n
h
a
a T d n it
pharmacy device rki
ng
hm
on
ngs
to
er
sm
m
Ba Ri
c Ki m
Results Ha

36% 25% 48% 70% 64% 23% 96%

Did have a flu Had
Had to
to make
make an
an Do have an Had a inhaler Have a spacer Live with Do not smoke
emergency request
jab last year asthma action technique device someone who
for an inhaler in the
last 12 months plan or wheeze assessment in smokes
plan the last 12
months
 On-line Asthma Toolkit

Support across the system to improve asthma care

https://
www.healthylondon.org/children-and-young-people/london-asthma-toolkit
Oral Pain Management
Children and Young People
 Summary Headlines

65% of parents 9% of parents 66% of parents

purchasing or seeking reported that their child who reported that their
advice about children’s had signs and symptoms child had definite pain in
pain medications suggesting a dental their mouth and/or a
reported that their child emergency that required tooth had not seen a
had pain in their mouth immediate attention dentist before visiting the
and/or a tooth pharmacy

54% of children 15% of children 41% of children

who had a definite pain who had a definite pain who had a definite pain
in their mouth and/or a in their mouth and/or a in their mouth and/or a
tooth and a regular tooth had seen a GP tooth reported signs and
dentist had not actually before visiting the symptoms indicative of a
seen their dentist pharmacy toothache
 Examples of services which support CYP

Minor Ailments Service

Mixes of NHSE and CCG services in London
Present 22 boroughs in London
Support Common Ailments in CYP
• Head lice
• Nappy rash
• Cough & cold
Cited in 5YFV as a key enabler in support GP practices in capacity management
NHS England reviewing the commissioning model in 2017/18
Potential for integration with OOH pathways, NHS111

Asthma Assessment Service, Bexley CCG

Pilot scheme makes use of pharmacists’ expertise

Encourages closer working between GPs and pharmacists

Incorporating community pharmacy
It’s not working. What could we do better?

Home

Source
Source R
R Chavasse
Chavasse ,, St
St
Georges
Georges

School
Nurse

Primary Care School

2nd
nd / 3ry

Hospital Care
Plenary session: Next Steps for discussion

1 Would any of these ideas work or transfer

into your CCG or STP footprint?

2 Consider how HLP could support

Talk to the NHS England DOP team; they

3 can provide additional information on
Pharmacy

Identify locally which pharmacy leads could

4 take any ideas and opportunities forward
within the system.
 What is stopping Pharmacy being fully utilised?

“Community Pharmacy is not “Pharmacists are thought of

seen as ‘the NHS’ by the public “Pharmacists often
as a shop keeper or private
and there is a lack of patient aren’t involved in
business rather than a
understanding of the services we redesigning services”
clinician”
can offer”

“There is a lack of good “We need support

news stories about understanding the
“Some GPs do not pharmacy. future system”
understand what
pharmacists can do”

“Services are
fragmented and there
“We need support to “Community Pharmacy has
are multiple agencies –
understand what been seen as ‘less clinical’
how do we work with
commissioners want” than other pharmacists”
them all?”

“We need support to

understand how we can “Pharmacists are often left
deliver to outcomes” out of the conversations”
NHS 111 / Integrated Urgent Care:
making better use of pharmacy
Gill Chambers, Healthy London Partnership
 NHS 111 / Integrated Urgent Care Patient Flow
NHS 111 has been in place across England since 2013 to provide a 24/7 single point of access for
assessment of urgent health needs, with the aim of signposting or referring to ‘right place, first time’.
Referral to A&E, via
999 or walk-in
When you Further telephone assessment by the
have an Integrated Urgent Care clinical assessment
service, a multi-disciplinary team
urgent including a prescribing pharmacist
health Referral to a range of services including community
need … NHS Pathways pharmacy, using direct booking where available
assessment
Call closed with
advice only

Age
profile of
callers to 0-17
NHS 111 age
in group CYP
London* age
split

* Data for London NHS 111 – 1st February to 30th April 2017 (3-month period)
 NHS 111 Urgent Medication Supply Advanced Service
NUMSAS provides a convenient and cost-effective way of providing emergency supply of repeat
medication, accessed via NHS 111.
Further telephone assessment by the
Integrated Urgent Care clinical assessment
When you service, a multi-disciplinary team
including a prescribing pharmacist
have an
urgent
repeat
medication Referral to a community pharmacist near the
NHS Pathways caller’s current location
request … assessment

Analysis
of CYP use
of
NUMSAS
in
London*

* Data for London NHS 111 – 1st February to 30th April 2017 (3-month period)
 NHS 111 / Integrated Urgent Care CYP Flow
0- to 17-year-olds make up approximately 27% of calls assessed in NHS 111. A typical patient flow is
shown below.
18
Referral to A&E, via
999 or walk-in calls
When you Further telephone assessment by the
have an Integrated Urgent Care clinical assessment 60

urgent
service, a multi-disciplinary team calls
including a prescribing pharmacist
health Referral to a range of services including community 18
need … NHS Pathways pharmacy, using direct booking where available
assessment calls
Call closed with 4
100 calls advice only calls

Community pharmacy 635 cases – Potential cases for pharmacist in

CYP case 0.8% of all CYP calls to NHS 111. Integrated Urgent Care and/or
mix in Table shows breakdown by type: community pharmacy – 10% of all
London* NUMSAS 195 31% CYP calls to NHS 111.
Skin, rash 122 19% Table shows breakdown by type:
Eye, red or irritable 64 10%
Home management/self-care advice 7,226 87%
Eye, sticky or watery 53 8%
Urgent repeat medication requests 380 5%
Rectal pain, swelling, lump or itch 44 7%
Health information 374 4%
Mouth ulcers 28 4%
Medication enquiry 268 3%
Other 129 20%
Emergency contraception 50 1%
Toxic ingestion/inhalation 16 0%

* Data for London NHS 111 – 1st February to 30th April 2017 (3-month period)
Innovations in community
pharmacy
Amit Patel, CEO Pharmacy London
Vision

 The ability to promote self care and prevent

escalation of LTCs through easily accessible
services
 Understanding local patient populations and
their intricacies
 The ability to work with a diverse set of partners
Opportunity

 1.8 million patients walk through community

pharmacy a day
 Being able to truly employ family based care
 Early intervention and prevention, using
childhood obesity as an early indicator
 Working with voluntary sector to look at social
issues
 Vitamin D promotion
 Young patient education
Business Case

 GP visit (11.7min) - £45

 GP telephone consultation(7.1min)- £27
 GP home visit (23.4min) - £114
 Nurse Consultation( 15min) - £13
 A&E visit - £138
 Outpatient attendance - £117
 Pharmacy Cost- £1.50 to £2 per minute
• Large savings to be made
• Increased ability to see more patients
• Less pressure on A and E and the rest of the system
• Increases ability for GPs to see the patients that really need to see them.
• The ability to seamlessly join services and manage patients holistically ie. Whole care
needs planning, Family care planning and education, accessible to all, ability to
manage discharge and reduce chances of readmission
• But this only happens if CFS is funded!!!
Positivity with meaning
Questions?
CAMHS & Community Pharmacy
Innovative Partnership Project

Dr Subha Muthalagu, Ray Lyon

Project Lead, Chief Pharmacist,
Strategy,
Consultant Child & Sussex Partnership
Adolescent Psychiatrist, NHS Foundation Trust
Sussex Partnership NHS
Foundation Trust
 Funded by

A Health Foundation Innovating for

Improvement Award – Round 3
 CAMHS Context
• Increasing referrals, complex presentations, inadequate
resources
• Expectation to maintain service safety and quality
• CYP on ADHD medications require regular physical monitoring
• Compliance with NICE guidelines
• 3 monthly BP and HR measurement, plotting on centile charts*
• 6 monthly weight and height measurement, plotting on growth chart
• Regular monitoring of side effects and review of ADHD progress

*Local agreement that once the medication was stable this could be undertaken 6 monthly
 Framework used

• Needs of the patient and their family at the centre of

the innovation
• Co-designing the project with key stakeholder
involvement throughout:
• Stakeholder engagement events - design the patient
journey
• Lymington Mini-Pilot – testing patient journey
• Learning and making continuous improvements with
feedback
 Care Pathway

• Family consent to participate

• CAMHS register patient on to PharmOutcomes and refer them

to their chosen pharmacy

• Pharmacy staff book appointment - enter measurements on

PharmOutcomes

• CAMHS team review results and communicate to GP and

family and amend the care plan is necessary
 Key Achievements

• Trained 60+ community pharmacy staff to carry out W, H, BP,

HR checks in CYP
• 15 community pharmacies currently involved in the project –
independents, Boots, Day Lewis and Lloyds pharmacies
• Developed ADHD clinic database; 83% of patients were
deemed eligible; 94% (142) have consented to participate
• 116 have had at least one check; 33 two checks; 3 > three
checks
 Key Achievements

• 100% of families said it saved them time with no additional

costs to them; 97% want the project to continue in the future
• More than 20 patients will now have annual reviews instead
of 6 monthly reviews at the clinic
• Established weekly multi-disciplinary ADHD team meetings,
reflect on clinical and operational process and make
continuous improvements
• Developed an ADHD therapy group for CYP and currently in
the process of setting up a 2nd group
• Clinic is more compliant with ADHD care pathway and NICE
guidelines
 Feedback from a parent

“Happy with the new service of visiting the chemist

for the physical checks. I know the staff there and it
was bit more personal when I went for the check for
my son - Lot easier and less stressful, unlike at the
doctors where they could be running late and
everyone looking at me and my son and wondering
why he is getting stressed.“
 Feedback from children & young people

“Closer to home. I don’t have to get in a car”

“Long trip Ashurst. Short trip pharmacy”

 Feedback from a community pharmacist

“Engagement in the CAMHS-Pharmacy project has

been a positive experience for me and the pharmacy
team. The children appear to be relaxed about
coming into the community pharmacy to have their
measurements taken and their parents/carers
appreciate the convenience of both the location and
flexibility of appointment times”.
Feedback from a general practitioner (GP)

“More accessible for patients and family … No delay

in scripts as we have the measurements all sent
through to us before the scripts are requested …
much easier for family than having to make
appointment at surgery”.
 Feedback from CAMHS staff

“I have been able to make adjustments to medication

more confidently over the phone …[and] Young
people and families don’t have to wait for a face to
face clinic appointment [or] take time off from
work/school for having physical checks or have to
attend clinic every 6 months to have these done
(many now have annual clinic appointments)”.
 Economics

• The clinic is estimated to make a saving of at least 40% of its

resources with the new service model
• Resource saved will be used to reduce waiting lists, respond in a
timely way to those who need specialist help, liaise with partner
agencies and develop better therapeutic support for CYP and their
families
• CYP and their family also save money, time and inconvenience
• Reduced carbon foot print
 Key Benefits
For service users For CAMHS clinic For Community
Pharmacy

Timely physical Timely physical Formally included in the

monitoring and improved monitoring and improved patient care pathway
access to care access to care

Receive regular repeat Reduction in missed, Greater job satisfaction

prescriptions delayed or non-attended
appointments

Minimal disruption to Compliance with NICE New business

school, work and family standards opportunities
life

Saving in travel costs, Freed up clinical time -

time and inconvenience reduce waiting lists

Expert advice on Greater use of

medication technology –
PharmOutcomes, emails

Reduced stigma Enhanced quality of care

Particular Thanks To …

Paul Bennett
Richard Edgeworth,
Chief Officer,
Consultant,
Hampshire & IoW
Springfield Consultancy
Local Pharmaceutical
Working with The
Committee
Health Foundation
The Health Foundation ‘Innovating for Improvement Award’ -
Partners involved
1. Sussex Partnership NHS Foundation Trust (SPFT, Lead organisation)
2. Hampshire & Isle of Wight Local Pharmaceutical Committee (LPC)
3. Children and Maternity Collaborative Hampshire Five CCGs (hosted
by North East Hampshire & Farnham CCG)
4. Strategic Clinical Network for NHS England (Wessex) for Maternity,
Children and Young People
5. Wessex Academic Health Science Network (AHSN)