Health and Social Care Committee
Inquiry into the implementation of the National Service Framework for diabetes in Wales and its future direction
DB 22 National Pharmacy Association
Bay Tree House
Colwinston
Cowbridge
Vale of Glamorgan
CF71 7NL
Tel: 01656 658703
25th October 2012
Dear Mr Drakeford
Subject: Health and Social Care Committee Inquiry into the delivery of the diabetes NSF and its future direction
The National Pharmacy Association (NPA) is the trade body which represents the full spectrum and vast majority of community pharmacy owners in the UK, including across Wales. We count amongst our members nationwide pharmacy multiples, regional chains and independent pharmacies. This spread of large and small member companies, our UK-wide geographical coverage, and our remit for NHS and non-NHS affairs means that we are uniquely fully representative of the community pharmacy sector. In addition to being a representative voice, we provide members with a range of commercial and professional services to help them maintain and improve the health of the communities they serve.
In my role as the Representation Manger for Wales I am the sole representative for community pharmacy on both the All Wales Diabetes Forum and the Task & Finish Group established by the Minister to look into the delivery of diabetes care and therefore feel that I have an excellent feel of the way that community pharmacy can make a significantly greater contribution to the care of the people of Wales living with diabetes.
As the NPA is not among the pharmacy organisations called to attend an oral evidence session I have included below and overview of my thoughts as I am anxious to have an opportunity to contribute to the debate.
Community Pharmacy and its potential contribution to integrated diabetes care in Wales
Introduction
There is a network of over 700 community pharmacies in Wales, located where people work, shop, travel and live. They can be found in large conurbations and also right at the heart of local communities. In areas of deprivation there are a larger number of pharmacies than in more affluent locations. The location of the network, when combined with longer opening hours, means that, for many people, community pharmacy is the most accessible part of NHS Wales. Research by Public Health Wales clearly shows that there is a higher concentration of pharmacies in areas of deprivation where diabetes care needs are greatest.
Community pharmacists are highly trained healthcare professionals and are the medicines experts on the high street. They are trusted and respected by patients and are an excellent source of advice for many. The vast majority of patients, especially those with prescribed medicines for chronic conditions, will have contact with their pharmacist on a monthly basis and therefore have significantly greater contact with their pharmacy than they do with their GP practice. It is this expertise and regular interface with diabetic patients, alongside a patient-centred service, that is currently not being effectively leveraged.
It was back in 2003 when Derek Wanless recognised the need for full engagement of all healthcare providers and recommended a movement of workload to community pharmacy: this has yet to happen. More effective utilisation of the community pharmacy network will not only bring on stream underutilised capacity; it will in addition, release capacity in GP practices. Release of capacity in GP practices is essential in facilitating the delivery of the Setting the Direction objectives.
To fully engage the community pharmacy network in integrated diabetic care is not a big ticket investment. There is no investment required in real estate and no employment costs to be borne by NHS Wales. Whereas there will be a need to fairly reimburse contractors for services provided; it will be an extremely cost effective investment. NHS Wales will only need to reimburse community pharmacy for the time that it is involved in the delivery of services i.e. there are none of the usual employment costs or overheads to be covered. In addition the majority of the risk is borne by the contractor and not the Health Service.
In addition to the above community pharmacy has one other unique advantage that sets it apart from other healthcare providers. Community pharmacies across Wales are visited on a daily basis by people who are well as well as by people who are ill. They have an extremely high footfall, particularly the larger chains and supermarket pharmacies, and therefore there is no better location to deliver educational messages and to facilitate lifestyle change.
In producing this paper I have considered how these distinct advantages can be better utilised, to support improved identification and management of diabetes in a way that fully integrates with GP practice provision. I feel that the key lies in a partnership approach to caseload management, utilising community pharmacy where it adds value, will improve patient services and will free up time for other healthcare professionals to focus on their distinct areas of expertise.
Community pharmacy’s potential contribution to diabetes care
Population awareness
As I write this report community pharmacies across Wales are gearing up to raise awareness, amongst the general population, of the risk of developing diabetes and stoke through a national public health campaign. As the cost and requirement to deliver public health campaigns is already built into the community pharmacy contract arrangements; I would recommend that we introduce an annual diabetes awareness campaign, the content of which can be varied as and when appropriate.
Community pharmacy is also able to ensure that literature or educational material produced by NHS Wales finds its way to those at high risk, those newly diagnosed with diabetes and to existing diabetic patients.
Risk assessment
In addition I would suggest that we introduce an all year round service; where any patient, concerned about their lifestyle risk, could walk into any pharmacy and receive a simple paper bases risk assessment similar to the Findrisk assessment, a pack of structured information and, in the case of patients identified as high risk, a HbA1c test. Introducing a service of this nature would allow NHS Wales to take a significant step forward in identifying undiagnosed diabetics, while at the same time ensuring only those people with high HbA1c measurements are referred through to GP practices.
If required the community pharmacy could provide the GP practice with a full range of diagnostic test results allowing the GP to move straight into diagnoses and treatment.
Community pharmacy has been recognised by the Ministerial Task & Finish Group as a convenient and appropriate location to provide vascular risk assessment. Community pharmacy is able to bring on stream some of the additional capacity required to deliver the national healthcheck service, in whatever format it materialises
Education and support
One of the realities on the ground is that, in many locations, there is a lack of trained dietetic support and little in the way of support for lifestyle intervention. One of the key initiatives in the Healthy Living Pharmacy model, which has DH backing in England, is that each of the pharmacies has appointed a member of staff as a lifestyle coach. This member of staff has undertaken public health approved training and has acquired both the confidence and change management expertise to deliver lifestyle interventions. My recommendation is that this model is used to deliver first line healthy lifestyle support to newly diagnosed diabetic patients. The length, nature and content of the lifestyle intervention would be defined by PHW. There is universal acceptance of the need for appropriate lifestyle intervention and community pharmacy could easily become the delivery model. GPs, who had patients who would benefit from structured lifestyle intervention, could then simply refer patients to community pharmacy and have the confidence to do so. There are additional benefits in pharmacy staff delivering this intervention: they would be stable members of the team, someone local who could link in with other local organisations or groups and someone who would be able to provide the support in a language and manner that is in tune with the needs of the local population.
The development of lifestyle coaches in community pharmacy, who are confident in change management, will in addition provide a vehicle to deliver stop smoking support, obesity management and alcohol advice to diabetic patients who require it. Lifestyle coaches could also oversee and support computer aided education if required.
As each pharmacy has a pharmacist who is a medicines expert and a highly trained individual; there is a real opportunity to tap into this expertise, and the regular contact between patients and their pharmacists, to deliver patient education and support. Whereas NHS Wales has some excellent structured educational programmes it appears that only a small percentage of diabetic patients benefit from this service. There is clearly an opportunity to provide elements of structured education through community pharmacists. This would allow patients to benefit from their expertise and in doing so bridge the obvious gap between initial education and involvement in structured education. For example a pharmacist is more than capable of ensuring that patients are able to use blood glucose monitoring equipment effectively, understand how and when to undertake self management of blood glucose and to check that routines are adhered to. If this simple service was combined with the transfer of responsibility for the supply of test strips to community pharmacy the NHS could remove this workload from GP practices. By ensuring that SMBG testing is undertaken according to nationally defined recommendations there would also be a potential saving in the cost of test strips.
On-going care
It is well recognised that the workload associated with the management of diabetes will continue to grow and as funding pressures increase current services may struggle to meet this demand.
Community pharmacists are in a position to use their expertise in medicines management to ensure that all patients benefit from a Medicines Use Review specifically tailored to the needs of diabetic patients. Pharmacists could be engaged to provide additional support to diabetic patients on newly prescribed medicines, both improving compliance and reducing waste. Pharmacists are able to support the transfer of patients between care settings ensuring that the receiving setting is provided with a full list of prescribed medicines and a process of medicines reconciliation occurs on discharge.
Pharmacists are also available to support GPs with prescribing effectiveness by providing feedback where prescribing for diabetic patients is out of line with prescribing guidelines.
It is a real lost opportunity to not grasp the opportunity provided through a regular interface between diabetic patients and their pharmacy. Pharmacists are ideally placed to educate patients on symptoms management and to monitor patients on a regular basis. For example pharmacists could easily perform a HbA1c test on a diabetic patient at an agreed interval and provide the results to the diabetic nurse.
There is much to be gained from recognising the ways in which community pharmacy can provide support to diabetic patients and to meet some of the current gaps in service provision. As NHS Wales looks to a model of integrated diabetic care, the future role of community pharmacy in diabetic care needs to be properly considered and over time incorporated into the community pharmacy contractual framework.
Contact:
Steve Simmonds M.R.PharmS, MBA
Representation Manager (Wales) National Pharmacy Association
