Start of a long journey

The publication of the Scottish Executive’s document Delivering for Health marked the start of a long journey that will transform the way health services are provided in Scotland. As the Executive’s response to the Kerr report into service redesign, it signposts the direction of travel for the NHS and outlines a strategic, long-term programme of action and a framework for service change across NHS Scotland.

The key goals, in effect, change the way we think of the health service. Rather than an NHS that reacts to patient demand, the new approach takes as a key aim the improvement of health among the population as a whole, using a full range of both existing interventions and those in development. Earlier identification and more effective interventions will ease the stress on the acute sector, so the NHS of the future will achieve greatly increased levels of productivity and will improve the quality of care delivered.  

This new, integrated model of health service delivery will provide care to patients as locally as possible. It will provide this care over an extended period, as patients with long-term conditions receive the support they need to manage their conditions successfully. Part of that support will include support for their carers, who provide the great bulk of community care and whose needs have too often been underestimated in the past. The change in emphasis, from the reactive treatment of sick people to the proactive promotion of health through providing anticipatory and targeted care to those at greatest risk of ill health, will in turn result in better management of hospital admissions and discharges.

Implementation of Delivering for Health will transform the NHS by further improving quality and efficiency, and by promoting further integration of services. As part of the implementation process, the Health Department issued a letter (HDL) on 28 February 2006. The guidance in this HDL describes what needs to be done, by whom and by when. It identifies major milestones, defines responsibilities for ensuring that the necessary tasks are undertaken and completed, and defines accountability arrangements for the performance of NHS Boards to ensure that momentum is maintained.

The Scottish Executive Health Department (SEHD) gives top priority to actions that will help achieve the shift in the balance of care required, from reactive to proactive care. These will in turn be given priority by local health boards. Because many of these actions will be based in the community, they will be led by Community Health Partnerships (CHPs). The desired outcome is a whole-systems approach to rebalancing the service in favour of community-based care and active management of patients with long-term conditions. This will require the full engagement, across the entire care spectrum, of local partners. Boards will be expected to work collaboratively either in their regional planning groups or on a national basis with support from SEHD. The key performance targets and measures to be included in each Board’s Local Delivery Plans are aligned with the direction set out in Delivering for Health, and will be closely monitored.

How will this affect community pharmacists? Well, after years of discussion of the wider role they could play in delivering care in the primary sector, the next steps are laid out in the HDL. Under “Local level actions” in Appendix 1, community pharmacy and its role in shifting the balance of care is mentioned specifically. The required action is the production of a plan to extend local care through enhanced primary medical services and community pharmacy.

Figure 1

At national level, the key action in shifting the balance of care is implementation of the community pharmacy contract – along with the eHealth commitment to deliver the ePharmacy Program to support the community pharmacy strategy. It’s no exaggeration to say that the new contract will be central to the redesign of health services in the community.

New contract development

2006–07 heralds the start of the implementation of the new pharmacy contract in Scotland. The decision to bring in the four core services by a process of evolution will allow review and fine tuning so that the contract is implemented soundly rather than quickly.

The minor ailment service (MAS) has new eMAS software underpinning the electronic registration and payment system. MAS allows patients who are exempt from prescription charges the opportunity to receive treatment for a range of common clinical conditions, free of charge, direct from their community pharmacist. To access the service, patients must register with an individual pharmacy, using their community health index number (CHI). This registration is managed in a national electronic database, the Central Patient Registration System (CPRS). Pharmacists are paid a capitation fee for the number of patients registered and reimbursed for any medicines dispensed. In order to remove any incentive to prescribe, no dispensing fee will be paid.

eMAS patient registration process
The Public Health Service (PHS) also started in summer 2006 and did not require any new IT. PHS has the enormous potential to make better use of pharmacies in improving the health of Scotland’s local communities. Although beginning in a modest fashion with community pharmacy supporting local and national public health campaigns, ultimately it is hoped that this service will be developed to optimise the strategic locations of community pharmacies as NHS healthy living walk-in centres.

In 2007 the Acute Medication Service (AMS) is scheduled to be rolled out, providing the underpinning IT support is in place. Patients will still receive a paper prescription but it will contain a barcode. By printing the prescription, the GP will send the prescription to a central e-pharmacy message store. This barcode will be used to pull down the prescription from the e-pharmacy store when presented in a pharmacy. Once the prescription is dispensed, the pharmacy will send an electronic message back to the e-pharmacy store to stimulate payment. Payment for this service will continue to be a dispensing fee per item dispensed.

In 2007–08 the Chronic Medication Service (CMS), the final core service in the new contract, is hoped to be rolled out – again underpinned by IT support. Seen as ‘the jewel in the pharmacy crown’, this service will enable community pharmacists to contribute to the management of long-term conditions. Over a 12-month period pharmacists will provide monitoring, medication review and, if supplementary prescribers, adjust the doses of patients’ medicines.

This will require a shared care agreement between the pharmacist, GP and the patient. Once this has been drawn up, the GP will print the master prescription with a barcode. Again an electronic prescription will be sent to the e-pharmacy store and, when the patient takes the master prescription to the pharmacy, the prescription can be pulled down from the e-pharmacy system. CMS will require patients to register with a pharmacy and payment will be on a capitation basis.

It is CMS that will present community pharmacy with the greatest opportunities in providing preventative, anticipatory care by managing long-term conditions. It will also allow pharmacists to use their supplementary prescribing skills and, ultimately, independent prescribing skills. The stage is set for 2007; delivery is key.

References

1. Delivering for Health, Scottish Executive 2005 (www.scotland.gov.uk/Publications/2005/11/02102635/26356 ).
2. Delivering for Health Implementation Plan, Scottish Executive 2006 (www.show.scot.nhs.uk/sehd/mels/hdl2006_12.pdf ).