Building PBC capacity through pharmacy event

1
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

2
Introduction and welcome

• James Kingsland, NAPC
• Sean Fenelon, PCC

3
Aims of today's event

• To bring together pharmacy, PBC and PCT
  commissioners/PC managers
• To share examples of existing services which
  include pharmacy within the service specification
• To stimulate local plans and action to promote
  the inclusion of pharmacy in PBC
• To understand the role of the commissioner vs.
  the provider

4
Desired outcomes

• Identify reasons why PBC hasnt engaged with
  pharmacy and identify solutions
• Highlight barriers and ways of overcoming these
• Champion the best practice examples of pharmacy
  engagement and share these widely with PBCs /
  PCTs
• Understand the role of the commissioner and
  provider and where CP in particular fits with
  this
• Challenge PBC consortia representatives and PCT
  commissioners to look at how pharmacy adds value
• Build the information from today into further
  resources to support further development
• Ensure these models fit with wider strategic
  commissioning (LDPs / LAAs / SSDPs etc)

5
Housekeeping

• Fire alarm
• Seating plan
• Refreshments
• Lunch
• Mobile phones
• Toilets
• Delegate packs
• Attendance certificate
• Morning workshops
• Questions
• Dietary requirements

6
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

7
NHS REFORMandCOMMUNITY PHARMACY

• Dr James Kingsland
• Chairman
• National Association of Primary care
• General Practitioner
• Wallasey, Merseyside

8
Getting the message right
9
Future of Commissioning in the NHS

• Devolution of decisions about securing services
  to the front line
• Demand and Divi is over no more local
  monopolies
• Referrer defines service requirement through
  referral activity and deploys resources
• Traditional model is unsustainable
  uncontrolled/unchallenged activity must cease
• Release resource tied up in existing providers
• Engagement/collaboration is key

10
PBC What it is

• A drive to improve efficiency in the deployment
  of NHS resources....by
• Shifting the focus to extending Primary Care
  delivery....by
• Extending the skills and mix of the PHCT....who
• Have the opportunity to redesign NHS care.by
• Commissioning services for their patients.with
• A devolved indicative budget

11
PBC- How its done

• In Partnership.but
• Practices are free to choose if they work with
  other practices or not.and
• Its not a one-size-fits-all approach
• Other clinical groups can hold a budget.but
• Seek to obtain good value for money but most of
  all we need.
• Skilled leadership, cultural change and the tools
  to make it work

12
The Current Situation

• Improvements to care are not being delivered
  systematically through PBC
• A number of significant barriers have been
  identified
• Lack of priority given by PCTs and SHAs
• Insufficient Mx and analytical support from PCTs
• Immature contracting skills within some PCTs
• Insufficient collaboration between PC and SC in
  some areas
• Relatively weak financial incentives
  (particularly where PCTs are facing financial
  challenges)

13
OPPORTUNITYNOWHERE
14

• The pharmacists perspective
• did someone
• mention pbc?

15
The issues

• National message is PBC is important should be
  doing something not sure what!
• Very little (local) information reaching pharmacy
  - what there is, is focused on secondary care
  (not our forte)
• Fear risk to local commissioning by PCTs from
  pharmacy
• GPs holding all the cards (and money!)
• Is PBC a better fit with the role of practice
  pharmacists?

16
The opportunities

• Knowledge of patients and medicines not just
  what is prescribed but how it is used
• Premises and infrastructure modern, open longer
  hours, no appointment, more time
• New contract
• Repeat dispensing / Electronic prescription
  service
• Medicines Use Review
• Business background competition welcome to our
  world

17
Challenges

• Mapping pharmacies to PBCs/GPs
• Overlapping and competing providers
• Being accepted by GP stakeholders sharing the
  risk/accountability
• Putting up a good argument for pharmacys
  involvement
• Making links between contribution and priorities
  for PBCers
• Should we work for or with GPs?

18
Building pharmacy into PBC Priorities
Focus Appropriate referral Primary care
pathways Avoidable admissions Follow ups
Embedding the new contract Essential
services Advanced Services Local
commissioning Enhanced Services PBC
commissioning New Services
Diabetes
AE Attendance
What is the potential Contribution of CP?
Dermatology
Community Services
Rheumatology
Prescribing
19
Asthma management service

• A focused medicines use review delivered by
  community pharmacists through a structured
  consultation with the patient, in the pharmacy
• Aim - to opportunistically identify patients who
  are experiencing difficulties with controlling
  their asthma.
• Evaluation of the service found that
• 63 not controlled during the past 4 weeks
• 52 required further patient education
• 38 poor control due to therapeutic inefficiency
• 26 referred to GP

20
COPD Needs assessment (Devon LPC)

• Nationally Up to 75 of all cases may be
  misdiagnosed /undiagnosed 1 in 8 acute medical
  admissions over 1 million hospital bed days
• Devon LPC worked with practices to identify unmet
  need
• Practice based and admissions data used to
  identify patients being admitted to hospital and
  not in moderate/severe categories covered by case
  management and/or respiratory nurse

21
Evidence Research
Patients
Admissions
Cost
List Size
10,415
COPD register
112
High Risk Case
7
2
4,000
managed
1/3
Medium Risk
Respiratory Nurse
6
1
2,000
managed
No previous
99
6
12,000
2/3
admission Group
Source Dr W Bird Met Office
22

• Now that we have led the horse to the water how
  do we make it drink?

23
Encouraging engagement
PCTs
PBCs
LPCs
Review local engagement between PBC and pharmacy,
develop enabling environment
Share priorities, plans and data with local
pharmacy stakeholders
Prepare and equip pharmacy champions to engage
with local PBCs. Work with PCT MM teams.
Develop clear communications channels
Review how essential and advanced pharmacy
services can support PBC
Understand how PCT/PBC processes will work and
communicate this to all contractors
Facilitate strong local engagement between PCT
medicines management teams, community pharmacists
and PBC and PCT commissioners
Engage with pharmacy leaders
Ensure that PBC information i.e. priorities,
plans, data, etc. can be accessed by all
contractors
24
Encouraging engagement
Pharmacists
GPs
Organise into groups to mirror PBCs structures
Share priorities, plans and data with local
pharmacy stakeholders
Engage with local GPs, to discuss progress with
essential and advanced service
Review how essential and advanced pharmacy
services can support PBC
Use LPC websites and communications to understand
local progress and/or talk to LPC members
Engage with local pharmacists
25
PROVIDER OPTIONS

• Extending GP contract provision
• Creating new clinics in General Practice
• Developing expanded community provision

26
And for pharmacists?

• The story so far -

27
Creating new strategic partnerships

• Working together for patients with joint codes of
  conduct and governance
• Establish longer and more accountable
  associations
• Refocus away from any previous poor practice
• Networking in different ways

28
From Partnership- to Integration

• Providing a service through APMS or sPMS
• New care pathway design supporting PBC. New
  health economic models
• Managing Rx reviews of LTCs in the community
• Providing NPT/diagnostics
• Supporting new community hospital development

29
Doing the same thing the same way and expecting a
different result

• INSANITY
• Albert Einstein

30
Thank you

• Questions?

31
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

32

• Q A Session
• 10.45 10.55

33
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

34
Practice Based Commissioning (PBC)
Michelle Webster Assistant Director
35
Who is IF

• Established 1st April 2006
• Incorporates National Primary Care Development
  Team (NPDT - established 2000)
• Core business is supporting public services in
  improvement work.
• NHS
• Other public services
• International improvement work
• Co-ordinator of all national PBC activity for
  Department of Health

36
Whos Involved

• Nationally
• 120 PCTs LITs consisting of GPs, Managers,
  Nurses, Patients
• Over 20 million patients covered

37
Challenges in Implementation of PBC

• Ensuring Patient Focus
• PCT Finances
• 18 Week Target
• Clinical Engagement Inclusivity
• Continued Development / Partnership with all
  Stakeholders

38
(No Transcript)
39
Lessons learnt

• Need to break from Provider Led NHS Commissioning
  Culture
• Advent of PbR
• Importance of Effective Commissioning as a
  separate function within a cycle
• Commissioning / Contracting / Procurement
• Who is best placed to commission for services?

40
Why Should Pharmacists Get Involved?

• Patient Public Opinion
• Readers Digest Most Trusted Professions Survey
  2007
• Pharmacists trusted by 95 of the surveyed public
• GPs came out at 91

41
Fire Fighters came top with 97 I wonder
why??
42
Monopoly of Provision

• Pharmacists bring an added dimension to the
  provision of services
• More diverse provision leads to greater patient
  choice
• Commissioning needs to get away from the Provider
  Led commissioning of the past
• Pharmacy occupies a unique position in the
  community

43
Increased Access

• Pharmacists operate longer opening hours than GP
  practices
• No appointment necessary!
• Can add value and added benefit to existing
  urgent care models
• Develop new and innovate urgent care models
• Shift F/U and many hospital based diagnostics to
  the community

44
Patient Education

• Pharmacy has increased flow of patients through
  their service than GP practices
• Over 5 million patients visit their local
  pharmacy every day
• Approx 1.5 million patients visit their GP
• Targeted patient education

45
Pharmacists as Public Health Educators

• Excellent Communication Skills
• Trustworthy
• People Oriented
• Easily Accessible
• Experts in giving health care information
• Well connected with other healthcare providers

46
Lessons Learnt

• Engagement of GPs / Clinicians and Practice Teams
• PCT Support for All Parts of the Health Economy /
  Development of Primary Care
• Clear / Inclusive Planning (Context of the Whole
  Systems Needs e.g.18 week target)
• High Quality Information / Information Systems
  (not just data)

47
The Successes

• Improved Working Relationships
• Shared Understanding and Vision between Practices
  and PCTs
• Shared Responsibility
• Good Systems in place to Collect Data and Monitor
  Budgets and Outcomes
• Practices have Welcomed the Opportunity to Lead
  Change

48
Case Study

• Control practice
• Reduction of 14
• Increase of 2
• 12 rise

• Pilot practice
• 58 reduction in overall number of nights
  patients stay in hospital
• 97 reduction in excess bed days, (over trim
  point and therefore costing lots)
• 97 reduction in cost due to reduced bed days

Saving of over 0.25m for practice .. and
increasing Potential of 3 million for cluster
and more!!
49
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

50
Refreshments 11.10 11.30

• Interactive workshop sessions
• 11.30 12.30

51
Workshop ACost effective prescribing and
medicines management what can community
pharmacy deliver?

• Richard Seal, NPC

52
The Dragons Apprentice
53
(No Transcript)
54
The Scenario

• Cost effective management of dyspepsia- what can
  community pharmacy deliver?
• Read the instructions sheet
• 30 minutes to prepare proposal
• 3 minutes to make presentation
• Executives decision is final

55
Lunch12.30 13.20

• Park Suite Mezzanine Foyer

56
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

57
PBC priorities in medicines management

• Richard Seal, NPC

58
Practice based-commissioning

• Involving community pharmacy through prescribing
  and medicines management

59
Poor Prescribing Medicines Management
60
.leads to

• Harm not help
• Inappropriate interventions
• Failure of treatment
• Avoidable ill health
• drug interactions
• unwanted effects
• Unnecessary medicines - wastage
• Demands on scarce resources
• Time
• Money

61
National Priorities for prescribing and medicines
management
Patient Safety
Long term conditions
Effectiveness
Choice access
Value-for-money
Support for self care
62
Local priorities

• I E balance
• Holistic budgets
• Prescribing budgets incl BCBV indicators
• 18-week wait
• Reducing admissions and re-admissions
• Length of stay
• Early discharge

• Effective prescribing
• Clinician engagement
• Practice-based commissioning
• Specialist commissioning
• Management of long terms conditions
• Self-care
• Case and disease management

63

• What can pharmacy offer ?

64
Competitive advantages

• Acceptable to patients
• No waits
• Closer relationship to patient
• Well-located
• Disadvantaged communities
• Increased coverage
• Vulnerable hard-to-reach groups
• Out-of-hours
• Skilled and willing
• Cost-effective
• Huge potential
• Currently on 1 of community pharmacies are
  commissioned to provide disease specific
  medicines management services

65
The LTC marketplace
Source Long term conditions Integrating
community pharmacy RPSGB (2007)
66
Effective Medicines Management

• Right drug
• Right dose
• Right patient
• Right time
• Everytime !

67
Common problems

• Untreated conditions
• Wrong drug, dose or strength
• Medicines prescribed without an indication
• Improper medicine selection
• Side effects
• Drug interactions
• Errors in prescribing or transcribing
• Lack of information
• Unwanted medicines

68
So what could you contribute?
69
GORD Effective prescribing

• Generic prescribing
• Therapeutic switching
• Advice on self-management(step-down and PRN
  medication cf NICE guidance)
• Reduction in quantities of acute prn medication
  supplied
• Encouraging patients to purchase simple remedies
  for self-care

70
GORD 18-week wait

• Medicines use review and compliance
• Avoidable AE attendances
• Disposal of unwanted medicines
• Support for self-care
• Repeat dispensing
• Signposting

71
GORD Redesigning care pathways

• Near patient testing
• H. pylori screening testing
• Prescribing
• PGD for eradication
• Supplementary/independent for treatment or
  maintenance
• Disease management
• Management of step-down
• Clinical medication reviews
• Co-morbidities NSAIDs, Ca blockers

72
Further opportunities

• Essential services
• Dispensing/repeat dispensing
• Disposal of medicines
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced services
• Clinical medication review
• Medication monitoring
• Supplementary prescribing
• (Independent prescribing)
• Palliative care
• Out of hours provision
• Interface services

• Essential services
• Dispensing/repeat dispensing
• Disposal of medicines
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced services
• Minor ailment schemes
• Medication review
• Medication monitoring
• Supplementary prescribing
• (Independent prescribing)
• Palliative care
• Out of hours provision

• Essential services
• Repeat dispensing
• Advanced services
• Medicines use review
• Prescription intervention
• Enhanced Services
• Minor ailment schemes

• Essential services
• Disposal of medicines
• Promotion of healthy lifestyles
• Signposting healthcare services
• Advanced services
• Enhanced services
• Smoking cessation
• Minor ailment schemes

73
Enabling environment

• Multidisciplinary involvement
• Quality assurance of services
• Acceptance by local healthcare staff
• Effective marketing to commissioners, doctors and
  patients
• Reimbursement

74
Next steps

• Consider local needs very carefully
• Review existing services to assess development
  opportunities
• Identify synergy with GMS
• Identify local leaders
• Develop business case
• Independantly
• Collaboration
• Make the case

75
Building PBC capacity through pharmacy event

• Thursday 12th July 2007
• Hilton London Metropole Hotel

76
Table top sessions

• 21st Century Runaround for the NHS
• Intended to maximise delegate exposure
• Important to stay in allotted seats

77
Interactive table top sessions14.00 15.20

• 3 separate sessions
• Session lasts for 20 minutes a bell will ring
  at the end of each session
• Please be considerate and listen actively
• Try not to hide table facilitators / leads will
  ensure all contribute
• Nominate a scribe (different one for each
  session)
• Stay at your allocated table presenters will
  come to you

78
Next steps

• Sean Fenelon, PCC

79
And finally..

• Innovation and enthusiasm IS out there
• Barriers exist but not insurmountable
• Future PCC products
• Planning group invitation sean.fenelon_at_pcc.nhs.
  uk
• Thanks

80
Building PBC capacity through pharmacy event

• Thank you for attending