The issue of a new community pharmacy contract, which has fallen below the radar recently, is likely to resurface in the near future as the process for setting a new dispensing fee and specifying new clinical services is brought closer to finality. In earlier scribblings, this column outlined a number of principles that could usefully be written into the new contractual framework to assure the continued vibrancy of the independent community pharmacy network, while also addressing the need to bind it more closely into a reformed primary care setting where the emphasis is on maximising the delivery of healthcare to be as near as possible to the patient.
A new pharmacy contract is an important element of a reformed health service and whatever comes forward must address the needs of patients, pharmacists and the funder and find a balance in terms of giving to each most or all of what they need.
One of the great advantages of deregulation is that it has allowed pharmacies to open in places previously off limits, which in turn has improved accessibility for patients.
The community pharmacy sector itself, which remains dominated by independent contractors who are rooted in the communities they serve, has also done well from the growing economy, the increasing health budget and the escalating cost of drugs.
But that issue has now become a serious financial headache for the Health Service Executive, which has embarked on an economy drive by cutting wholesale prices.
This move antagonised the community pharmacy sector because while the cut in wholesale prices was supposed to affect the middleman, it has in practice impacted entirely on the retailers, as it is they, and not the wholesalers, who have the reimbursement relationship with the HSE. That row, in turn, tended to deflect attention away from the issue of defining clear principles and new services in a revised pharmacy contract.
The principles are straightforward enough and the major ones could include:
- Mandating pharmacies to dispense generics to the greatest extent possible.
- Introducing gain sharing to give them a share of the savings from dispensing generics to channel into new clinical services that ease the pressure on GPs.
- Empowering pharmacists to prescribe where they have appropriate training.
- Setting fees at a level that reflects the real costs of the current and evolving dispensing models, especially ‘blistering’ which is costly and time-consuming for the pharmacy, but of great benefit in encouraging correct use of medicines.
- Ensuring patients retain the services of the pharmacy they currently use by defining the contractual terms and conditions in a way that gives the smallest operators a fair chance of survival, while also comforting the funder that accessibility to pharmacy services is maximised for all patients.
There are a great many services that could usefully be provided in a community pharmacy setting, which would strengthen the role of pharmacy in primary care and ease the pressure on GPs. This is a question of using the skilled, scarce resources we have as well as we can, and putting the focus on prevention wherever possible.
Among the new services which pharmacies could provide are minor ailment treatments for patients on the GMS, blood sugar testing, cholesterol screening, blood pressure monitoring, long-term illness management (including pharmacist prescribing and support for self-care at home), and medicine utilisation reviews (these would be especially useful in reducing medicine-related harm from the misuse of certain prescription drugs and over-the-counter preparations containing codeine).
Moreover, there is a strong evidence base for community pharmacy-based services in smoking cessation, coronary heart disease management and prevention, diabetes screening management and hypertension – all ‘big ticket’ preventative services.
Quality assurance focus
One of the issues identified by the HSE in its call for submissions on the non-fee elements of a revised community pharmacy contract was the inclusion of a quality assurance focus. It’s not clear how this would be reflected in the contract, but there is undoubtedly an opportunity for providers and the funder to work together in order to slash the escalating drugs bill through mandating the dispensing of generics to the greatest extent possible, while at the same time not compromising patient safety.
Another issue identified was the desirability of stronger governance, presumably for value- for-money purposes. It should be possible to design a system that ticks all the boxes for the HSE but, at the same time, does not impose an unacceptable cost in terms of paperwork for pharmacies.
The power and potential of information technology, which has already been used to automate reimbursement returns and payments, should be extended so that maximum information is captured with minimum effort.
Although relations between the community pharmacy sector and the HSE have taken a beating over changes in the reimbursement rates on medicines, it is clear that there are significant new services which could be developed for the benefit of patients.