This article was originally published in On Primary Care, a collection of essays identifying the challenges and opportunities facing policymakers today in the UK primary care sector. Here, Dr Ali Hindi, from the Center of Pharmacy Workforce Studies and Dr Sally Jacobs, from the Institute for Health Policy and Organisation, respond to a lack of guidance from NHS England on how to best achieve integration between general practice and community pharmacy in order to improve the overall care and services provided to the public.

• As part of the NHS Long Term Plan to improve the quality of care within the primary care sector, the role of community pharmacy has expanded to meet the growing demand.
• Research suggests there are inconsistencies in the quality of care provided among different pharmacies.
• Clearer guidelines between general practice and pharmacy are needed to achieve better integration and higher levels of collaboration.

Maintaining and improving the quality of patient care is an NHS priority with the overall objective of achieving health care which is safe, effective, timely, efficient, equitable and person-centred.

The importance of quality in a growing field

The NHS has been at the forefront internationally for its quality improvement policies in primary care, notably, the implementation of a series of quality-improvement initiatives and the introduction of the largest health care ‘pay-for-performance’ scheme in the world, the Quality and Outcomes Framework (QOF) for GPs.

The QOF has been extensively researched since its implementation and there have been key developments, (most notably the role of the National Institute for Health and Care Excellence (NICE) in developing and reviewing indicators) over the years to ensure quality measures are developed in a systematic and transparent manner.

At the same time as expanding the role of primary care, the role of providers outside general practice has gained momentum. Community pharmacy is one established primary care provider with the potential to improve access for patients and relieve pressures on general practice. In 2019, the NHS Long Term Plan acknowledged that community pharmacy will have an even bigger role in urgent care and prevention, enabled by the Community Pharmacy Contractual Framework (CPCF). This introduces new pharmacy services over the next five years, which will integrate with other primary care settings through integrated referral pathways.

As the role of community pharmacy continues to expand, the need for ensuring high-quality services, meeting patient needs and integrating across patient primary care pathways has never been greater.

Primary care networks: an opportunity for quality through integration?

NHS England has made clear its intention to drive collaboration between general practice and other community-based providers, such as community pharmacy, in its Five Year Forward View (2014) and the NHS Long Term Plan (2019). Achieving better integration of general practice with other healthcare providers could improve the quality of health care by ensuring patients receive timely, effective and efficient patient-centred care though clear referral pathways.

However, our recently published systematic review exploring the views of pharmacists and GPs on community pharmacy services (2005-2017) identified that GPs’ awareness of pharmacy services was low and collaboration between pharmacists and GPs was poor, despite the introduction of new pharmacy services intended to encourage joint working.

Moreover, a recent study involving GPs, community pharmacists and patients identified a lack of alignment between community pharmacy and GP contracts. This has led to competition over funding, rather than incentivised joint working to improve the quality of care for patients, for example in the case of flu vaccinations.

The study also found that GPs were supportive of community pharmacists providing some of the services traditionally provided by GPs (such as minor ailments and medicines reviews) to increase patient access and reduce workload pressures, but mentioned difficulties in collaboration due to interprofessional tensions arising from funding conflicts. For example, some GPs had advised patients to avoid using community pharmacies for flu vaccinations.

Recent developments have addressed some of these issues.

The introduction of primary care networks (PCNs) includes an obligation for general practice to work with other non-GP providers and community-based organisations, such as community pharmacies, to provide more joined-up care for patients. In light of this, the new community pharmacy contract has introduced quality payment incentives for pharmacies to collaborate with GPs and engage effectively with PCNs. In the GP contract, there is some acknowledgement of GPs working with community pharmacy as part of primary care networks.  However, neither the community pharmacy nor GP contracts provide any specific guidance as to how community pharmacy teams will work closely with colleagues in general practice.

It therefore remains unclear how better integration between community pharmacy and general practice will be achieved in order to enhance quality of patient care.

Monitoring and ensuring quality in community pharmacy

The first big change to the reimbursement of community pharmacy occurred with the 2005 contract, which introduced a number of public health and medicines services, recognising the contribution of community pharmacy and its expanding role in primary care. Payment for these services was a ‘fee-for-service’ model, but there have been concerns over the quality of some community pharmacy services using this reimbursement model.

A major study carried out by the Centre for Pharmacy Workforce Studies (CPWS) highlighted that there was a positive culture in some pharmacies, encouraging the delivery of service quantity and quality by focusing on skill mix, team development and extended staffing models.

However, other community pharmacies were shown to prioritise quantity over quality of service delivery in order to maximise financial gain. In these pharmacies, high dispensing workloads and insufficient staffing levels led to dispensing duties being prioritised over medicine-related and public health services. In addition, management pressures to deliver a range of community pharmacy services led to increased waiting times, decreased clinical input, and increased risk of dispensing errors.

In the past decade, many approaches have been developed for measuring and assuring quality in community pharmacy, including new processes for:

• pharmacy regulatory inspections;
• contract monitoring and reporting;
• annual patient satisfaction questionnaires;
• error reporting and analysis.

However, our research suggests that quality measurement in community pharmacy is often opaque and variable, with little known about how widely implemented community pharmacy quality initiatives are, or how successful they are.

For example, there is no clear definition of quality in community pharmacy, and there is a lack of reliable and valuable methods for measuring service quality. When quality is measured, it is done using subjective informal mechanisms such as self-assessment by the pharmacy, patient feedback, GP feedback, and observed changes in a patient’s health or behaviour.

In response to increasing concerns about a lack of quality measures or indicators in community pharmacy, NHS England introduced the Quality Payments Scheme in 2017, which aligns payment with value and quality by attaching financial incentives to provider performance.

Under the 2019 CPCF, the new scheme, renamed the Pharmacy Quality Scheme (PQS) has been revised with updated and retired indicators, as well as changes to the structure and content of the quality criteria.

The PQS promises to be a step towards tackling some of the problems around prioritisation of financial gain over patient care and encouraging engagement with PCNs.

As the PQS is in its early stages, the evidence around its implementation and effectiveness is sparse. Unlike the more established QOF for GPs, with a rigorous evidence-based process for selecting, piloting and evaluating performance measures, little is known about the process involved with the development of PQS indicators, or their effect on improving quality in terms of access, patient outcomes, or integration of community pharmacy within the wider primary care system.

Another approach may be to adopt a continuous quality improvement (CQI) programme such as the SafetyNET-Rx programme trialled in pharmacies in Canada, which offers payments for pharmacies that continuously and systematically examine work processes to identify and address causes of poor quality over time.

An evidence-based, collaborative approach to quality improvement

The NHS Long Term Plan seeks to improve patient care and relieve some of the pressures facing GPs by encouraging closer working with other health care organisations such as community pharmacies, although silo working still predominates in the NHS.

To optimise the potential of community pharmacy in meeting patient needs and alleviating workload pressures in general practice, there needs to be reassurance of the quality of care in this setting.

NHS England needs to ensure processes are in place for better integration between community pharmacy and general practice, which will translate into actions that improve service quality and patient outcomes. This requires aligning GP and community pharmacy contracts and providing more specific guidance as to how better joint working could be achieved via PCNs. It will be important to evaluate whether and how the PCNs, requiring pharmacies to collaborate with GPs, support effective integration.

Quality is still not well defined in community pharmacy, and systems for monitoring and improving quality are relatively underdeveloped. The evidence base for quality improvement in community pharmacy is insufficient. Research is required to develop valid and reliable evidence-based quality indicators (similar to QOF) which clearly demonstrate if and how community pharmacies are improving the quality of care in an integrated primary care system.

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