afresh

start_anew-LRG

Two tweets have finally spurred me into writing a blog; every week I think about a subject I want to talk about, and every week something gets in my way of doing it (usually work/beer).  The tweets in question came first from @TheMMP1, the second from @EPSPharmacist (both of whom I found to be thoroughly nice blokes at the RPS & GPhC’s Which? event): the first got me thinking about the future of retail then the second had me daydreaming whilst parked up on the M3 that if I were the one true God of Pharmacy and felt it was time to start it all afresh – which I get the impression it probably is – what would I want it to look like at the finish…

And aptaim smelled the sweet savour; and aptaim said in His heart: ‘I will not again curse the ground any more for pharmacy’s sake; for the imagination of pharmacy’s heart is evil from its youth; neither will I again smite any more every thing living, as I have done. While pharmacy remaineth, prescriptions and dispensing, and counselling and services, and medicines and appliances, and 100-hour premises shall not cease…

On the first day I will create a retail pharmacy from which patients will mostly get public health advice and a fully running minor ailment scheme from.  They’ll also get regular ongoing management of long term conditions heavily based around adherence to therapy, including support with newly prescribed medicines either from GP or hospital, made easier with access to the patient’s SCR.  Funding will be about half from joint health and social care budgets directed by the health and wellbeing boards, the rest from prescription volume. The pharmacists won’t be prescribers, but the medicines on sale will all be strictly evidence based and either GSL or a new pharmacist-only category of medicines that require an initial consultation and regular checks for ongoing supply: think oral contraceptives.

On the second day I will create GP practices that’ll have pharmacists and technicians in the background managing the governance, safety and clinical effectiveness of the prescribing.  Advising, supporting the prescribers, both doctor and nurse, and giving specific training as needed.  They’d mostly be employees of the CCG, paid for from running costs not budget top-slices, and they’d be deployed to practices as determined by risk and need.  That said, some practice will think to employ their own from LES monies to get the service they want.

On the third day, hospitals will be built where patients will see specialist clinical pharmacists, all prescribers, able to support their medicines taking from admission to discharge.  They’d be specifically responsible for ensuring accurate medicines information is passed on to the patient’s GP practice, and the retail pharmacy nominated by the patient for their EPS.  They’ll work alongside clinical leads, ensuring evidence based practice is applied in a way that suits the patient so that they can self-administer at all times possible on the wards, and be able to take their medicines without problem when they get home.  If they think there will be a problem, they’ll know who to call in the community to make sure the patient is well looked after post-discharge.

On the fourth day, I will command that community service providers will all have their own pharmacists and technicians, working between the primary and secondary care interfaces to ensure safe and appropriate use of medicines.  They will provide direct patient care on discharge, ensuring medicines are reconciled and appropriate, and manage issues directly with their GP practice, hospital and retail colleagues as necessary. Some may be prescribers, but it’s unlikely – and only where there’s a clear need, such as in mental health trusts or services.  They will also be responsible for the ongoing safe and secure use of medicines in those services without direct pharmacist contact – urgent treatment centres, and children’s or community nursing for example.

And on the fifth day I will see to it that supporting all of these areas will be academic pharmacists, continuing to ensure a sound evidence base to future developments, and support the decommissioning of services that are not delivering the expected patient outcomes.

Leaving two days, which isn’t too bad I think.  So what have I forgotten?

CSUs (for as long as they survive)? Sure we’ll find one pharmacist, maybe with a technician, here working on behalf of multiple CCGs spanning various geographies to ensure consistent commissioning of specialist medicines and management of new medicines as needed.

Area teams? Here I’m less convinced, certainly from a ‘pharmacy’ perspective, but this is more because of the shifting remits and structures. I was initially demanding that the structures have a pharmacist, but now I’m not convinced: what can they deliver that those listed above couldn’t?

Social care? There’s a definite need, but the sector is so closely matched to community services they’d be daft not to host a joint post where geography allows.

You may have also noticed I’ve not once used the word optimisation. That’s because all of these scenarios should deliver this without us needing to use the term: if it’s not delivering good patient outcomes from medicines then it needs to be decommissioned, period.  I’m fed up of getting hung up on terminology.

And aptaim said, “Let there be pharmacy,” and there was pharmacy. And aptaim saw that the pharmacy was good.

Of course, it’ll be when I hand it over to you mere mortals that it’ll fall apart again, won’t it?

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