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The rising power of pharmacy: what will be the impact?

Pharmacists are to be thrust into competition with GPs under Government plans - we look at the implications

By Nigel Praities

Pharmacists are to be thrust into competition with GPs under Government plans - we look at the implications

Your friendly local pharmacist is feeling rather cheerful. While GPs scan the horizon for threats from the private sector, pharmacy is being quietly groomed for a favoured role in the future NHS. Pharmacists are likely to take on a raft of work that has previously always been the domain of general practice.

The scale of the encroachment has gone largely unnoticed, but far-reaching Government proposals published in a white paper last month could see pharmacists in England competing with GPs to provide services in primary care. Pharmacists are set to screen for cardiovascular disease, prescribe more widely and manage and refer patients with a variety of long-term conditions.

The Government insists its proposals will free up around an hour a day for GPs to concentrate on patients with more pressing concerns. But those assurances have failed to convince some GPs, with critics concerned the policy shift will fragment care and be potentially unsafe.

The roots of what amounts to little short of a revolution in the delivery of primary care came as long ago as 2005, with introduction of a new community pharmacist contract in England. Pharmacies moved from merely dispensing drugs to providing medicines use reviews and delivering additional services previously only available from GPs, such as minor illness services and blood pressure monitoring.

Minor ailments


Scotland introduced minor ailment services in July 2006, and these have now attracted registrations from 15% of all people registered with a GP. Scottish pharmacies are undertaking over 60,000 consultations a month.

The shift in service provision is set to accelerate in England. The Department of Health is proposing that half of all GPs consultations for minor ailments should be conducted by pharmacists within three years and that pharmacists should take a greater role in managing long-term conditions.

There is some evidence to support pharmacist-led interventions. A number of international studies show advice and monitoring from pharmacists improve self-management and compliance, and reduce hospitalisations and treatment-related costs, for diseases such as asthma and heart disease.

But other studies show pharmacists antagonise older patients, who prefer to take advice from trained doctors, and are less effective than specialist nurses at improving outcomes for patients with long-term conditions such as heart failure.

Professor Carmel Hughes, chair in primary care pharmacy at Queen's University Belfast, says the evidence supports a ‘complementary' role for pharmacists in long-term conditions. ‘The central role of the GP cannot be ignored. But in terms of long-term disease, pharmacists are in a unique position to monitor patients and reinforce advice on lifestyle and compliance,' she says.

But Professor Hughes acknowledges there is limit to pharmacists' abilities: ‘Diagnosis of major medical conditions should be left to the doctor and prescribing should be done as part of a team,' she adds.

But one reading of the Government's proposals would see pharmacists assess cardiovascular risk, independently prescribe a statin and then subsequently refer on, without the patient ever seeing their GP.

The plans infuriate GP Dr Bill Beeby, chair of the GPC clinical and prescribing subcommittee. He believes pharmacists are not trained to provide holistic care and questions the potential impact of the Government's proposals on continuity of care.

‘I am struggling to understand why we are trying to fix things that are not broken. Introducing another prescriber may lead to an increase in the harmful effects of treatment, because it will be very difficult for everyone to coordinate care effectively.

‘If you are asking pharmacists to suddenly take on bit of long-term care, then I'm just not sure how that is safe . I don't always have enough information from secondary care providers, so having another prescriber could potentially be very risky.'

Professor Joy Wingfield, professor of pharmacy law and ethics at the University of Nottingham, is in no doubt of the size of the potential shift in delivery of care. She believes the proposals are revolutionary, but she warns pharmacists would need their own patient lists to ensure continuity of care and the safety of their prescribing.

‘There is an argument, if patients accept it, of having something like practice lists so pharmacists can collaborate with the prescriber managing that patient,' she says.

There are also potential legal questions over who bears responsibility for patients managed by pharmacists. Professor Wingfield warns: ‘Pharmacists will have to take the same responsibility for prescribing decisions as GPs do. The more they do the more they will be responsible for.'

The Government's enthusiasm for pharmacy is driven by the belief that its use can reduce costs – fuelled by the success in Scotland with minor ailment services.

Impact assessments published by the Department of Health indicate the Government sees competition between GPs and pharmacists as key to driving down costs.

Drug bill cuts

The assessments conclude rapidly rolling out minor ailment services in England will decrease the overall primary care drug bill. ‘There is some indication following from the Scottish Experience that supply costs would fall as a result from a shift to pharmacy-led provision,' one report concludes.

Dr Beeby is unconvinced. ‘There is the assumption it costs less to do things in the pharmacy than general practice. But what if the pharmacist is risk-averse and refers the patient back to primary care, and we are no longer funded for it?'

The report also says pharmacists are ‘more conservative' in their prescribing habits than GPs, and recommends PCTs allocate them part of the general practice prescribing budget as take-up of minor ailment services increases. The implication is clear - GPs and pharmacists are to be thrust into direct competition for patients, and for the funding to treat them.

Dr Beeby says this focus on competition is risky for practices, who could face bidding for services on the basis of cost. ‘We start to fragment and compete for doing little jobs. I shudder for the future for patients – this is not going to be in their interests for the long-term.'

But for a Government apparently obsessed with competition, the 5,872 GPs in 1,365 dispensing practices appear represent a substantial blind-spot.

If the white paper is ratified new ‘control of entry' rules for practices will be introduced based on the proximity of patients to a pharmacy. This will mean dispensing practices within a certain distance from a pharmacy – a distance yet to be decided - will no longer be able to dispense.

Dr Martin Harris, a GP at a dispensing practice in Bloxham, Oxfordshire, insists these proposals are ‘anti-competitive' and could spell disaster for some rural practices.

‘About 20-30% of our income comes from dispensing. In some practices it's higher than that, as much as 50%,' he says.

‘I don't think there's any happy outcome from the white paper. I can understand what the idea is, but it will destabilise local rural services.'

While the changes worry GPs, community pharmacists across the country are relishing the prospect of expanding their reach into primary care. A boldly worded report published by the School of Pharmacy last December claimed community pharmacy represented the future of European healthcare.

One of the authors of the report was Professor David Taylor, professor of pharmaceutical and public health policy at the Institute of Pharmacy and a member of the Department of Health's Medicines Management Advisory Group. He says pharmacists will become ‘pivotal' in healthcare provision and urges GPs to be ‘grown-up' and work closely with them.

‘We've got to make sure there are constructive working relationships with GPs, although that doesn't mean being terrified of competition,' he says.

And, in a demonstration of the differing fortunes of the professions in recent years, Professor Taylor claims GPs are in need of the support of pharmacists.

‘I think one of the responsibilities for pharmacy is to really support GPs, who have really been unfairly criticised in the last decade or so, but that shouldn't stop pharmacy developing services where appropriate,' he says.

Pharmacists feeling sorry for their GP colleagues? How the times have changed.

Government plans for pharmacists

Case management - Supplementary or independent prescribing as part of a multidisciplinary team

Long-term conditions management – Medicines management, with routine patient monitoring and possibly supplementary prescribing and referral. Care planning.

Prevention and early detection – Pre-treatment diagnostics e.g. blood pressure, vascular checks, vaccinations, obesity/smoking cessation programmes

Promoting better health – Greater use of OTC medicines, counselling on medicines, information provision e.g. lifestyle advice, NHS Choices, social care information

Pharmacists may take up to 50% of minor ailment work under Department of Health proposals

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