What’s happening in Wales
Written by Steve Simmonds   
The past year has been yet another challenging one for the NHS in Wales and for community pharmacy contractors as they come to terms with the new contract. In this article I will look at some of the highlights, starting with higher-level issues affecting the NHS in Wales and then looking at issues that will have affected members in Wales more directly. St David’s Day 2006 was a great day for Wales, when HM the Queen officially opened the Senedd, the new Assembly building. A new national mood of optimism has to a large extent been based on the publication of the long-awaited White Paper on future powers for the Welsh Assembly – The Government of Wales Bill, which received Royal Assent in July 2006. This gave Wales greater powers over healthcare legislation and will no doubt bring with it changes to the healthcare system in Wales and further divergence of health policy.

In preparation for greater devolution, the Devolution Concordat on Health and Social Care was agreed. Without close co-operation between all four UK administrations there is the risk that developments in one administration may inadvertently constrain or put pressure on policy or finances of the other administrations. The Concordat is intended to provide a framework for co-operation between the Department of Health (DH) and the departments or directorates concerned with health and social care in each of the devolved administrations.

Over the past year the Welsh Assembly Government (WAG) has launched a number of key policy documents and consultations. One is the 26 Week Patient Pathway Consultation. This consultation started the ball rolling on achieving the target, in the Designed for Life strategy, of reducing the patient pathway (waiting list time) to 26 weeks from referral to treatment. It opens opportunities for community pharmacy to contribute in terms of the effective and optimum management of medication, the reduction of medicines-related admissions and the management of long-term conditions in the community.

Another opportunity for commissioning new community pharmacy services comes on the back of the three key regional draft strategies, Designed to Deliver, in which the regions are each looking at how acute hospital services can be provided more effectively through the transfer of services from secondary care to primary care. Community pharmacies have a huge potential to increase primary care capacity and to increase patient choice; they cannot afford to be overlooked.

Other consultations that may impact on NPA members include the Wales Agreement to Share Personal Information. This confidentiality code of practice will provide comprehensive guidance on sharing patient personal information for those who work within or under contract to the NHS.

The National Assembly was given a free vote on the recommendations of the Committee on Smoking in Public Places. After a year of deliberation and consultation it was agreed that “the National Assembly for Wales should press the UK Government for the powers that would enable it to introduce a ban on smoking in enclosed workplaces and enclosed public places (with specified exceptions) within a timescale of two to three years.” The target date has been announced as 2 April 2007.

The National Smoking Cessation Service has swung into action with a television campaign highlighting the support available to those people who want to quit, and successful lobbying of the National Public Health Service has resulted in some of the local health boards (LHBs) in North Wales commissioning a community pharmacy smoking cessation enhanced service.

Finances


In financial terms the NHS in Wales has faired better than the NHS in England. Although the NHS expenditure is over budget the deficit appears to be more manageable. Welsh NHS organisations predicted an aggregate deficit of £32 million for 2005–06. The principality’s health service met its financial targets in 2004–05 only after receiving an additional £82 million to cover historical deficits and it has been accepted that there is a need for better management in order to meet budgets. Stricter performance management regimes are now being implemented through the three regional offices.

Over the past year the NHS in Wales has published three key national service framework documents, namely the Children’s, Young Persons’ and Maternity Services NSF, the NSF for Older Persons and the Revised Mental Health NSF. At the time of writing (summer 2006) the NHS was publishing a series of Service Development and Commissioning Directives to cover each of the main chronic diseases. The first was on arthritis and chronic musculo-skeletal conditions. Each of these key documents opens up significant opportunities for greater community pharmacy involvement and all the pharmacy bodies in Wales are lobbying strongly.

NHS staff in Wales have been congratulated for their hard work in ending long waiting times. The end-of-year waiting times show that Trusts across Wales met the target that no patient should wait over 12 months for inpatient treatment or a first outpatient appointment. This is a record achievement.

It will also be reassuring for members to know that, despite pressures to the contrary, the Health Minister believes the principles of a local response to healthcare provision and a joined up approach between health and social services still holds good and that changes to LHB structures would only result in instability and loss of focus. This contrasts sharply with the restructuring of primary care trusts in England and the period of uncertainty that will follow.

The WAG is moving forward on its flagship policy of free prescriptions in Wales by April 2007. Strategies have been put in place to prevent prescription tourism by restricting the fees to Welsh prescriptions issued by Welsh GPs. The final stage, which occurred in September 2006, was the introduction of an Entitlement Card for Welsh residents who are registered with a GP practice in England and which provides the evidence needed for pharmacists to charge the Welsh amount. Despite the increased GP workload that free prescriptions are likely to generate, there is still no appetite at the WAG to introduce a national community pharmacy minor ailment scheme.

Two further announcements were of particular importance. The first was the extension of independent prescribing rights to nurses and pharmacists. This is an exciting development and a project group and reference group are taking this item forward. It is anticipated that the first pharmacist independent prescribers will be practising before Christmas 2007.

The second was that the Council of the RPSGB decided to establish a National Pharmacy Board in Wales. The new board will take the lead in promoting pharmacy to government and its agencies, NHS bodies, and other health and social care organisations, and will support the membership through the Society’s branches.

At the time of writing, the Chief Pharmaceutical Adviser was planning to update Remedies for Success, the pharmacy strategy for Wales. It is widely believed that this new strategy will not be uni-professional and will look instead at how community pharmacy can contribute to the delivery of Designed for Life as an integrated member of the primary care team.

Over the last year we have also seen some positive moves in terms of the primary care IM&T strategy. WAG has established the Primary Care IM&T Programme to deliver corporate policy for all primary care contractor professions in Wales. Early priorities are to support the IM&T requirements, both clinical and administrative, for the general medical services, community pharmacy and dental contracts. A Community Pharmacy IM&T Project Board has been established, a project manager appointed and a reference group (including the NPA) established.

In addition, community pharmacists in Wales are being provided with access to the Health of Wales Information Service website where they can access a range of health publications through the e-library initiative. Informing Healthcare has also awarded OVID Technologies a major contract to supply 90 full-text online journals for health professionals including pharmacists across Wales.

Community progress


Having looked at the NHS and political environment we can now turn to the key developments in community pharmacy. Despite some financial and operational challenges, it would be fair to say that the new contract has been successfully implemented in Wales. In financial terms £142 million has been set aside as the equivalent global sum to fund the new contract in Wales, with £3 million of the funding set aside for advanced services and a further £4 million for IT developments.

Contractors in Wales were generally slow in taking up accreditation training and investing in consultation areas for advanced services. Figures provided by the Business Services Centres (BSCs) indicate that medicines use review (MUR) payments claimed in Wales during the first full year of the contract were around 7,000. With just over 700 contractors in Wales, this equates to an average of 10 MURs per contractor and 5 per cent of the 200 MUR Welsh contractor allowance.

The July 2006 figures showed that around 55 per cent (398) of premises were accredited and only 23 per cent of the community pharmacy workforce in Wales (598) had registered their accreditation with the BSCs. Although there is a strong indication that numbers of MURs are now rising steadily there is still likely to be a significant under-spend on the advanced services budget again this year.

This situation prompted the NPA to conduct a survey of its members in Wales to identify the problems and how the NPA could support its members. In April 2006, amid great controversy, the Health Minister indicated to Community Pharmacy Wales that the remainder of the budget would be unlikely to be carried over and would be used to offset other areas of overspend. During the year ahead there are a number of issues to address if the service is to become a success story. Chief among these is the need to promote the service to patients and the need to secure GP buy-in.

LHB monitoring of the new contract implementation in Wales has gone well, with most LHBs adopting a supportive partnership approach and providing additional help and training for pharmacists when required. As well as LHB inspection some community pharmacies experienced their first inspections by the Community Health Councils (CHCs) under their new powers to inspect NHS premises. CHCs have been looking from a patient’s perspective at staff appearance, access, signage, information, cleanliness, tidiness, the standard of decoration and the level of privacy.

In terms of the commissioning of enhanced services it has been a ‘curate’s egg’ across Wales. Whereas all LHBs are facing financial pressures, the majority have still found the funding to commission one or two enhanced services. The main services have been care home support, minor ailments, emergency hormonal contraception, syringe and needle exchange and supervised administration of medicines.

In addition some innovative services have been commissioned such as flu vaccination uptake in Torfaen and out of hours palliative care in Gwent. Over the year ahead I would expect a few LHBs to look at the potential to commission warfarin monitoring and chlamydia screening from community pharmacy.

At a national level CPW agreed with WAG that there would be three types of enhanced services in Wales, namely local, national and directed. Although it remains quite a battle to get these services off the ground, draft service specifications have been agreed for four national enhanced services and CPW is working with LHBs to agree indicative prices. Although there were no directed enhanced services to date, it was expected that the first would be the Essential Small Pharmacy Scheme.

One of the more difficult areas in the new contract implementation has been the interpretation of community pharmacy’s role in providing monitored dosage (MDS) containers under the Disability Discrimination Act. A large number of patients and their carers, both in the community and in care homes, who had received MDS support over many years no longer qualify. GPs who had traditionally supported the service by issuing seven-day scripts are reluctant to continue with this additional workload and have stopped this support for new patients.

One area of significant focus has been the transfer of the portable oxygen service to Air Products who were awarded the contract to supply all patients in Wales. The resultant chaos was well documented but community pharmacy contractors across Wales responded magnificently and earned nothing but praise from politicians, the media and the NHS. This will have done nothing but good for the profession.

New contract applications


While the DH looks at how the implementation of changes following the Office of Fair Trading report have affected the pharmacy market, Wales has also been active on this front. Health and Social Care Ministers for Wales rejected the OFT’s recommendations for liberalising pharmaceutical services in the UK because of concern over the impact on small pharmacies, particularly in socially disadvantaged and rural areas.

CPW, the NPA and the Company Chemists’ Association responded to a WAG consultation on application and appeal processes and advocated that: 

  • Prejudice applies to the full range of pharmaceutical services including enhanced and advanced services.
  • GP services are funded through nGMS funding and therefore their services cannot be prejudiced by the opening of a community pharmacy.
  • Prejudice should not apply to community pharmacy applications.
  • The opening of a community pharmacy in a controlled locality would be automatically desirable.
  • The GP dispensing contract should be relinquished following the granting of a pharmacy contact.

The pharmacy bodies asked WAG to be bold and to address many long-standing issues. The response also stated that the rural agreement as negotiated in England should be the minimum acceptable position. At the time of writing we were awaiting the outcome, which could have a significant impact on the pharmacy market in Wales in the year ahead.