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Appointing your pharmacist as a partner

In April 2004, Dr Chris Bowman's practice was the first to appoint a pharmacist as one of the partners. Three years on, Dr Bowman describes

the benefits and what

the future holds

We are a rural dispensing PMS practice in north Devon covering an area of 200 square miles serving a scattered population of 6,300. Dispensing accounts for a significant proportion of our income, underpins our viability, and is highly valued by our patients.

When the local chemist retired in the summer of 1998 and a replacement pharmacist was not forthcoming, the partnership formed a limited company and applied for, and was granted, the pharmacy licence in 2000.

With the granting of the licence it was

essential to find a superintendent pharmacist to run the business – a task easier said than done. By 2003 the benefits of practices opening pharmacies on their premises were being exalted with a promise of a 'golden

future'.

In this climate of optimism, and to ensure we were best able to develop the pharmacy and respond to both the new GMS and pharmacy contracts, we appointed Karen Acott, who had been our PCT prescribing adviser, as a 0.5 WTE partner (with a year to parity) on 1 April 2004.

At the time the new pharmacy contract was still being negotiated and had not been priced. As we dispensed to the whole of our practice population the benefits of switching from a dispensary to a pharmacy and its additional regulations, including the need for a pharmacist to be present when any medication was sold, were uncertain and the decision was put on hold.

However, with Karen's expertise and business management skills, she has been able to maximise the profitability of the dispensary.

Our OTC range and sales have increased, stock ordering is more efficient, discounts have been better managed and maximised, and stock levels have reduced. This was achieved while following the guidance on inappropriate prescribing and remaining in the top quartile of practices meeting the generic prescribing targets and receiving prescribing initiative payments.

Medication reviews

In preparation for the new pharmacy contract, and to support the practice in achieving the maximum QOF points, Karen took a key role in the management of patients with a chronic disease. She completed her training as a supplementary prescriber and expects to qualify as an independent prescriber any day now.

Working to individual patient clinical management plans, she provides the

medication reviews for patients with epilepsy, hypothyroidism, hypertension and chronic pain. Also she works with the practice nurses in the long-term conditions clinics managing patients with diabetes, CVD and CKD.

To further support the GP partners and to allow them to focus on patients with complex care needs, Karen has developed and provides the following services:

• Discharge medication reviews – including updating the computer medication record and organising any requested blood tests

• Managing patient medication

inquiries

• Managing PCT prescribing audit

reviews

• Reviewing NICE guidelines and advising on appropriate prescribing

• HR support to the practice manager.

Not only has this ensured a high level of care for our patients and provided them with a readily accessible extended range of expertise, but it has helped reduce the workload of the other partners. It is said a pharmacist could manage 25 per cent of GP consultations.

In the first year of Karen's appointment this was achieved, with increased profitability and increased profits for all – a very welcome outcome. There is no doubt this happy state of affairs would have continued had it not been for the introduction of category M drugs on 1 April 2005.

The will of this Government has been to remove the profit element from dispensing for both community pharmacy and dispensing doctors. Category M drugs were introduced to do just that by creating a generic tariff that reflected the true but lower purchase costs of many drugs.

For dispensing doctors, this generic tariff has resulted in a loss of income of about £6,000 a year for every 1,000 patients. Not surprisingly this has had a significant impact on our profitability in the past financial year and many community pharmacists describe 2006 as their 'annus horribilis'.

With further generics continuing to be added, the financial situation for dispensing practices can only get worse.

However, the introduction of both the new pharmacy contract and the dispensing services quality scheme do provide the means to mitigate some of these losses.

Three levels of service

The new pharmacy contract incorporates three levels of service. Two of them – 'essential' and 'advanced' – are nationally costed but locally commissioned. The third, 'enhanced services', will be commissioned locally by PCTs or potentially through practice-based commissioning.

As well as the dispensing and repeat dispensing of medicines, essential services will include a greater emphasis on clinical governance, audit and health promotion. Advanced services focus on, among other things, medicines use reviews (MURs), periodic structured reviews of compliance with patients receiving medicines for long-term conditions.

Enhanced services will be negotiated locally where a need for a particular service is determined, such as smoking cessation. This contract complements nGMS, allowing income streams to flow between the two, with enhanced services likely to be commissioned from the same funds as those for GPs.

The impact that MURs provided by pharmacists will have on nGMS income is unknown, but with a MUR currently priced at £23 and an accredited pharmacist allowed to perform 400 a year, the need to rob Peter to pay Paul exists.

The dispensing services quality scheme has a similar emphasis on clinical governance with a focus on dispenser training and standard operating procedures (SOPs). However, instead of MURs there are DRUMs – dispensary review of use of medicines – a review of concordance.

For 2007/8, DRUMs will need to be performed on 10 per cent of the dispensing list of patients. Worth £2.58 per dispensing patient per annum this is an income stream that should not be ignored.

The partnership now sits at a crossroads. If we continue as we are it is likely the steady erosion of our profits will in time threaten our viability. We have registered an interest with Devon PCT to provide the DSQS, but at the time of writing many of the rules remain unclear and so no decision has been made.

To change direction and open a pharmacy would allow us access to different funding streams. As Karen already provides many of the essential services she would be funded for many services she is currently providing. As an independent prescriber she should readily be accredited to provide additional services, including MURs.

However, with the Royal Pharmaceutical Society of Great Britain requirement that a pharmacist be present on the premises at all the times medications are sold or dispensed, this would be a significant additional cost and would undermine the benefits from the other services.

But a pharmacy would not be limited by the practice boundary and could provide pharmaceutical services to a much wider population. Also, with the amalgamation of PCTs and the associated reduction in pharmacy advisers, the opportunity exists for GPs and commissioning consortia to commission that service from Karen.

Our spreadsheet skills, and a 'what if' attitude, will with luck help us steer our way through this financial minefield over the next few years.

I trust we will all be here in a further three years for the next update.

Christopher Bowman is a GP in Chulmleigh, Devon

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