The recently launched ‘NHS Long Term Plan’ proposes to make better use of community pharmacists’ skills and explore further efficiencies in community pharmacy in new primary care networks. In this blog, Ali Hindi, Ellen Schafheutle and Sally Jacobs highlight important factors for enhancing the use of community pharmacy services within primary care for patients with long-term conditions.

• Workload pressures in general practice have been aggravated by increasing patient demand, workforce shortages and financial constraints facing the NHS.
• To meet some of the patient demands and reduce GP workload pressures, policymakers have enhanced the role of community pharmacy by introducing new medicines and public health services, which go beyond the more traditional services of medicines supply.
• Our research offers a number of ideas for policymakers to consider when developing strategies to enhance the role of community pharmacy services in patients’ primary care pathway.

Increasing patient demand and GP workload pressures

The NHS is facing one of its biggest challenges in managing the needs of patients with long-term conditions. To reduce hospital visits, many healthcare activities related to the management of long-term conditions have been shifted towards primary care. However, this shift has led to considerable additional workload in general practice, which has led policymakers to seek new strategies for providing accessible high quality, patient-centred and cost-effective care.

Expanding community pharmacy services

Community pharmacies are accessible and convenient healthcare venues with long opening hours and non-appointment-based services. Policymakers have recognised this potential and made many reforms to expand the scope of community pharmacy’s role in primary care.

In 2005, a new community pharmacy contractual framework was introduced which reimburses pharmacists for medicine-related and public health services, in addition to traditional medicines supply. This contract therefore provides pharmacists with opportunities to support patients with long-term conditions. Particularly relevant are NHS funded medication review services such as the Medicines Use Review (MUR) and the New Medicine Service (NMS), which focus on improving patients’ medication understanding and adherence. Other medication and public health services (such as smoking cessation, blood pressure checks, lifestyle advice weight loss) can be commissioned depending on local need.

However, there is evidence to show that patient awareness, demand and uptake of pharmacy services are low and that community pharmacy integration within primary care remains poor.

How could community pharmacies be better used and integrated within primary care for people with long-term conditions?

Our research involved eight focus groups with community pharmacists, GPs and patients with long-term conditions (diabetes or respiratory).  Discussions were guided by a novel approach applying marketing theory, specifically the 7Ps model, which looks at – “product”, “process”, “people”, “place”, “physical evidence”, “promotion” and “price”.

Outlined below are some of the key findings summarised under the 7Ps framework, with regards to community pharmacies being used by primary care patients with long-term conditions:

• Product – community pharmacy services: Community pharmacists could provide some services for patients with long-term conditions. In our study, patients with difficulties obtaining GP appointments supported community pharmacies to regularly provide routine check-ups/procedures (e.g. blood tests, cholesterol tests) and medication reviews for well managed long-term conditions.
• Process – service delivery, use and integration into primary care: Our study revealed that some existing community pharmacy services were not well defined and commonly varied in availability and service specification. Patients, pharmacist and GPs in our study thought that services with clear specifications and focus on a single, specific intervention such as flu vaccinations and inhaler techniques were valuable. Patients, pharmacists and GPs in our study also favoured having integrated information systems which enable community pharmacists’ read-write access to patient records. Pharmacists currently only have read access to patients’ summary care record, which is limited to details on allergies, adverse reactions and medication. However there is some progress as pharmacies will be able to update GP records with flu vaccination data by winter 2019.
• People – patients and pharmacy staff: Supporting patients with long-term conditions effectively requires pharmacists to work more closely with GPs. Pharmacists and GPs in our study were aware that collaboration optimised patient benefit but mentioned that existing funding mechanisms for services meant they were in competition over funding, rather than incentivised for positive patient outcomes, such as flu vaccination rates. Pharmacists also recognised the importance of utilising skill-mix by delegating more technical activities of medicines supply to pharmacy support staff, thus freeing up their own time for services.
• Physical evidence – community pharmacy premises:  Patients, pharmacists and GPs in our study criticised the retail context of community pharmacy which offered limited space for healthcare services. Whilst consultation rooms are a prerequisite for providing medication review services, they are commonly small and not always suitable for confidential consultations with patients.
• Place – location and accessibility: Accessibility of community pharmacies, without appointments and longer opening hours were important factors for patients in our study. Patients preferred them over GP practices for non-urgent and less invasive services. Community pharmacies being located close to GP practices was seen as aiding communication and workflow.
• Promotion of services: Patient satisfaction with community pharmacy services is commonly high, yet awareness is low. Our study explored which promotional strategies could encourage patients to use pharmacy services. Patients, pharmacists and GPs felt that nationally promoting community pharmacy services was helpful. They also noted the strength of a positive patient experience on future behaviour and the trust patients and GPs would have in the value of community pharmacy services.
• Price – added value: Patients valued fast access and convenience for some services, such as regular monitoring. GPs equally appreciated some of their time being free so they could focus on patients with more complex needs. 

Take home message – the need for clarity and consistency in community pharmacy provision

There is potential for community pharmacies to provide more support for patients with long-term conditions.

Clearer and more consistent service specifications and provision will be important considerations for NHS England and Clinical Commissioning Groups.

Moreover, better integration between community pharmacy and general practice through integrated information systems and incentivised joint-working will be essential for the new primary care networks.

Update:
The Pharmaceutical Journal also published a summary piece, based upon the work of the blog authors:

Hindi AMK, Schafheutle EI, Jacobs S. Lessons for better use of community pharmacy in primary care. Clinical Pharmacist 2019; online: DOI: 10.1211/CP.2019.20206288