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PJ Online | News feature: A new vision for GPs: can pharmacy raise its sights for a new contract too?

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The Pharmaceutical Journal
Vol 268 No 7197 p641-642
11 May 2002

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News feature

A new vision for GPs: can pharmacy raise its sights for a new contract too?

A new contract for general practitioners was unveiled last month. Jonathan Buisson looks at what it offers for GPs, pharmacists and patients and asks if, in its quest for a new contract, community pharmacy can show a similar breadth of vision

A new contract for pharmacy?


New GP contract

Details of the proposed new contract can be found on the British Medical Association's website (www.bma.org.uk). There are two main documents: an explanatory letter from the NHS Confederation and guidance from the BMA's general practitioners committee.

The BMA can be contacted on 020 7387 4499.

Last year, general practitioners became so disillusioned with their contract with the National Health Service that they voted to submit undated resignations from the contract if the Government failed to agree significant changes to it.

Following this ballot, the Government appointed the NHS Confederation (which represents NHS managers) as its agent for negotiations. The result of these negotiations was revealed last month — a new general medical services (GMS) contract that is striking in its vision of a better funded and higher quality GP service. In return for better terms, conditions and career prospects, GPs are to be relieved of many of their out-of-hours responsibilities and administrative tasks. However, they will have to sign up for an escalating scale of quality improvements with financial rewards linked to meeting ever higher standards of care for their patients.

"In overview, the new GP contract is about managing demand and access to health care services. It is also about developing integrated health care pathways," says Hemant Patel, secretary to North East London Local Pharmaceutical Committees and a member of the Pharmaceutical Services Negotiating Committee. "There is a focus on disease management that comes through time and time again."

National contract: local choices

The new contract will contain national terms and conditions and will apply in England, Scotland, Wales and Northern Ireland. National negotiations will set prices for a range of services but there will be local flexibility in how some of these are implemented by primary care organisations (PCOs). Contracts will be between practices and PCOs, not individual GPs, and each practice will have a pooled list of patients.

"GPs will be paid from a global sum, like pharmacy, but through a formula that will look at the needs of weighted practice lists. This gives GPs a chance to manage the work they want to do and the level of income they aspire to," says Mr Patel.

Three levels of services are envisaged. At the bottom are essential services for "the management of patients who are ill or believe themselves to be ill". All practices will have to provide essential services. Next are additional services such as vaccinations, disease management and child health. Practices will be expected to provide all these services unless there is some specific reason why they cannot (eg, staff shortages). In this case, the PCO will have to arrange for alternative provision. All these services will be funded nationally through a new allocation formula administered via PCOs.

Above these comes an optional range of enhanced services, negotiated on either a national or a local basis. Some enhanced services will have to be provided in every PCO area, such as minor injury services and anticoagulant monitoring, but not by every practice. Both national and local enhanced services will be funded through a unified budget and there will be a protected local expenditure floor. PCOs will be able to increase the funding for enhanced services, if they want to, but not to divert it to other schemes.

PCOs will take on responsibility for out-of-hours care between 6.30pm and 8am on weekdays and all day at weekends and on bank holidays and will commission or provide appropriate services.

PCOs will also be responsible for funding and maintaining all information technology schemes for practices and for funding practice management.

Careers and quality

A three-module career pathway is to be established for GPs. The first module, skills development, will apply to newly qualified GPs or those returning to practice. This may include salaried work at a variety of practices. The second module covers special interest development. A third phase, clinical leadership, is for GPs who exchange some of their face-to-face clinical work for more time spent in education or management, such as serving on PCO boards. The three modules do not have to be taken in any set order.

In return for all of this, GPs will have to agree to meet new standards of care for their patients. There will be an escalating scale of reward payments for meeting ever higher levels of quality, outcomes and patient satisfaction. Money will be available up front for infrastructure costs, such as extended premises or new staff. Practices will signal in advance the levels of quality care they are aspiring to each year and will be rewarded if they reach them.

"When the NHS was formed in 1948, Health Minister Aneurin Bevan was quoted as saying of doctors that he 'stuffed their mouths with gold' to get them onboard," says Mr Patel. "There is an element of that here too. Patients will have added weight given to their views. The new contract is about involving patients and improving their outcomes within national guidelines — the price to pay is more gold."

Implementation of the new contract nationally will require primary and secondary legislation, but it is intended to phase it in over the next two years.

The negotiating teams are to agree a series of prices for the contract and this will be put to a further ballot of GPs later this year. Health Ministers in the four countries have already indicated that they agree with the principles of the new contract.

Expanded role for pharmacists

The new contract also sees an expanded role for community pharmacists in taking on work relating to medicines management and supplying medicines for minor illnesses.

"The introduction of supplementary prescribing by nurses and pharmacists will make it easier for patients to obtain the regular medicines they need and to make more use of the skills of both nurses and pharmacists," explanatory notes for the contract prepared by the NHS Confederation say.

"In particular, voucher schemes in which patients can have access to treatments for minor, self-limiting illnesses via pharmacists rather than GPs need to be piloted and evaluated further. Where there is positive evidence, we will seek to push for national rollout of such schemes."

A pilot of one such scheme, "Care at the Chemists", undertaken in Bootle, Merseyside, enabled the transfer of over one-third of the workload for 12 minor conditions from GPs to community pharmacists (PJ, 31 March 2001, p425). The scheme was subsequently extended to cover the whole of the Bootle and Litherland Primary Care Trust area. Similar work has been undertaken in North Tyneside.

Negotiating pharmacy's contract

Negotiations on a new contract for community pharmacy are just getting under way. Mr Patel says that the new GP contract means that it is imperative to develop a new pharmacy contract in parallel.

"The GP contract is the spine around which the other health care professions will have to work. There are key issues on allocating work to appropriate people. Pharmacy can play its part in managing demand, improving access and developing integrated care pathways."

Frank Owens, chairman of the Scottish Pharmaceutical General Council, agrees: "Pharmacy negotiators should follow carefully the progress of this work." He believes that both sides have learnt significant lessons while developing the new GP contract to its present state.

He points out that for GPs a global sum, to include practice infrastructure costs, will deliver practice income. This will be based on a complex national formula that will take into account weighted practice populations.

"Pharmacy negotiators should examine this concept carefully. We are aware that the Scottish Executive has commissioned research into the establishment of a similar formula as a means of allocating the pharmacy budget in Scotland."

Speaking at the Institute of Pharmacy Management International's conference on 28 May, Godfrey Horridge, financial executive of the PSNC, said that discussions in England will cover six main areas, over and above the core dispensing service. These are: the clinical quality of the pharmaceutical services offered, including areas such measuring and recording levels of owings and near-miss dispensing errors; standards of premises; provision of private consultation areas; record keeping and information for patients; CPD for pharmacists and their staff; and clinical governance.

There is a possibility that all of these could be combined into an accreditation scheme. Such schemes have worked successfully in Australia on a national basis and in some individual health authority areas in England, Mr Horridge said.

Frank Owens says that one of the hallmarks of the new GP contract is the right it gives to practices to opt in to providing enhanced clinical services. The emergence of new pharmaceutical services, where many pharmacists have chosen to opt in to provide locally funded additional services, means "it is not difficult to see the attraction Health Departments might see in this contract model being implemented in pharmacy".

What might a new pharmacy contract look like if, if it was to be based on the new GP model? The panel below breaks down some of the services currently offered through either the existing contract or locally negotiated schemes under the headings used in the GP contract.

Although it offers a superficially more attractive picture for community pharmacy contractors, the main problem would be in moving from the current volume-based dispensing model to a service-led model with a greater emphasis on fees for service and capitation payments.

Contractors have invested heavily in infrastructure and staff to support the status quo. A new vision of how community pharmacy might work is needed but so is a plan for getting there.

A new contract for pharmacy?

The new contract for GPs has been the result of a lot of hard bargaining. What might a new contract for community pharmacy look like if it were to follow a similar model?

Services

 Essential services Dispensing prescriptions for most widely available medicines. Counselling patients. Mandatory for all pharmacies.

• Additional services Extemporaneous dispensing, dispensing expensive or difficult to obtain medicines (such as refrigerated lines), filling monitored dosage systems, collecting and delivering prescriptions, running voucher schemes for minor illnesses. Expected of all pharmacies, subject to demand and capacity.

• Enhanced services Medicines management, diagnostic testing and monitoring. For local and national negotiation.

Infrastructure

• IT Primary care organisations to be responsible for connecting all pharmacies to the NHSnet to allow electronic transfer of prescriptions.

• Pricing Electronic pricing and reimbursement for dispensed prescriptions.

• Premises PCOs to fund upgrades to premises to allow counselling and medicines management services.

Quality

• Organisational Pharmacies to meet basic standards for premises, hours of opening and record keeping.

• Clinical Phases and tiered steps of improved pharmaceutical care for patients. Greater reporting of prescribing and dispensing errors and of adverse events.

• Clinical governance Protected time for clinical governance and CPD.

Funding

• Global sum Global sum for pharmacy services based on capitation not dispensing volume. Extra payments for additional and enhanced services.

• Local services PCOs to add to protected floor of funding for agreed local services.

Many changes to the way in which pharmacy services are currently offered would be necessary in order to make such a contract workable. These might include the placing of the contract with groups of pharmacies in an area rather than a single contractor; patient registration with pharmacies; relocation or rationalisation of the number of dispensing pharmacies; implementation of supplementary pharmacist prescribing; greater use of automated or mail order dispensing; and changes to skill mix or staffing in pharmacies.

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Jonathan Buisson is on the staff of The Journal


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