Vishal Mashru discusses the role of clinical pharmacists in a restructured NHS, with reference to successes within Cross Counties Healthcare PCN

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MASHRU Vishal

Vishal Mashru

  • changes to the structure and operation of the NHS to improve patient care
  • the increased focus on medicines optimisation in the new GP contract
  • the role of clinical pharmacists in achieving the objectives of the reforms.

Implementation actions for clinical pharmacists in general practice

Read this article online at: GinP.co.uk/456578.article

In 2015, NHS England introduced sustainability and transformation plans, which set out a 5-year vision for all aspects of NHS funding within 44 geographical footprints covering the whole of England.1 The aim was to develop long-term, place-based plans based on local priorities and challenges to improve the quality, efficiency, and integration of health and care services—and, in turn, the health and wellbeing of the patient population—in each geographical area.1

Building on these plans, NHS England published the NHS long term plan in 2019,2 a transformational programme of improvements to structures and ways of operating designed to ensure that the NHS is‘fit for the future, and to get the most value for patients out of every pound of taxpayers’ investment’.3 The three key building blocks on which the plan is based are:3

  • making sure everyone gets the best start in life
  • delivering world-class care for major health problems
  • supporting people to age well.

Box 1 shows how the NHS intends to achieve this ambitious 10-year plan.

Box 1: Delivery of the objectives of the NHS long term plan3

To ensure that the NHS can achieve the ambitious improvements we want to see for patients over the next 10 years, the NHS long term plan also sets out how we think we can overcome the challenges that the NHS faces, such as staff shortages and growing demand for services, by:

  1. Doing things differently: we will give people more control over their own health and the care they receive, encourage more collaboration between GPs, their teams, and community services as primary care networks, to increase the services they can provide jointly, and increase the focus on NHS organisations working with their local partners as integrated care systems to plan and deliver services which meet the needs of their communities
  2. Preventing illness and tackling health inequalities: the NHS will increase its contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems, and avoid type 2 diabetes, with a particular focus on the communities and groups of people most affected by these problems
  3. Backing our workforce: we will continue to increase the NHS workforce by training and recruiting more professionals—including thousands more clinical placements for undergraduate nurses, hundreds more medical school places, and more routes into the NHS, such as through apprenticeships. We will also make the NHS a better place to work, so that more staff stay in the NHS and feel able to make better use of their skills and experience for patients
  4. Making better use of data and digital technology: we will provide more convenient access to services and health information for patients, with the new NHS App as a digital ‘front door’, better access to digital tools and patient records for staff, and improvements to the planning and delivery of services based on the analysis of patient and population data
  5. Getting the most out of taxpayers’ investment in the NHS: we will continue working with doctors and other healthcare professionals to identify ways to reduce duplication in how clinical services are delivered, make better use of the NHS’ combined buying power to get commonly used products at a cheaper price, and reduce spend on administration.

Contains public sector information licensed under the Open Government Licence v3.0.

The key areas I will focus on in this article are what these changes mean for current structures within the NHS, and how these structures are likely to change in the future.

Medicines optimisation: past and present

The new GP contract, Investment and evolution: a five-year framework for GP contract reform to implement the NHS Long Term Plan, was issued by NHS England in early 2019.4 This was one of the most significant reforms of the GP contract in years, and is fundamental to the direction of healthcare in England. The new contract translates the following objectives of the NHS long term plan into core components of the GP services contract:4

  • addressing workload issues resulting from workforce shortfall
  • bringing a permanent solution to indemnity costs and coverage
  • improving the Quality and Outcomes Framework
  • introducing automatic entitlement to a new Primary Care Network (PCN) Contract
  • joining up urgent care services
  • enabling practices and patients to benefit from digital technologies
  • commitments in the NHS long term plan
  • giving practices clarity and certainty on 5-year funding
  • testing future contract changes before introduction.

These changes at primary care level were accompanied by changes at the level of commissioning and strategy. Plans for all parts of England to be served by an integrated care system (ICS)—a partnership between the organisations that meet health and care needs across an area—from April 20215 generated some uncertainty about the future of CCGs. Although many areas had already been working collaboratively in the preceding 5 years, this formal change was intended to integrate them into single strategic organisations. What this would mean for functions currently carried out at commissioner level, and which of these would be affected, were just some of the questions being asked, particularly in the field of medicines optimisation.

In 2016, regional medicines optimisation committees (RMOCs) were developed with the aim of optimising ‘the use of medicines for the benefit of patients and the NHS’.6,7 RMOCs were put in place to support, but not replace, area prescribing committees (local formulary committees). There was to be no change at the level of area prescribing committees,8 and this structure is to remain in place for the foreseeable future—but will work in more strategic ways to improve the use of medicines. This was reinforced by the RMOC Operating Model, which was revised for 2021.7

The role of medicines optimisation teams (also termed medicines management teams) has varied over the years since the need for pharmaceutical advisers was first recognised by health authorities in the 1990s.8 Some have supported the strategic function of the role, whereas others have focused on the provider function. Since the introduction of clinical pharmacists through the NHS England Clinical Pharmacists in General Practice programme, which has led to more than 1000 full-time-equivalent clinical pharmacists working across England since the scheme began in 2015,9 many CCG medicines optimisation teams have focused on the strategic function of the role.

The place of medicines optimisation in primary care networks

In April 2019, GP practices began to establish PCNs—collaborations with other practices and organisations providing integrated care to local populations.10 The development of the PCN Directed Enhanced Service (DES) Contract outlined the core requirements of PCNs,11 which are summarised in Box 2. The Network Contract DES formed part of the larger package of contract reform to implement the goals of the NHS long term plan set out in Investment and evolution.4,11

Box 2: Summary of the organisational requirements for PCNs11

  • The criteria for a PCN are:
    • an identified network area that
      • is sustainable for the future
      • aligns with a footprint that best supports delivery of services
      • has a boundary that makes sense to the core network practice(s), other providers, and the local community
      • covers a geographically contiguous area
      • does not cross CCG, STP, or ICS boundaries, except in exceptional circumstances
    • a list size on 1 January 2020 of 30,000–50,000 people, except in exceptional circumstances
    • a nominated payee, who must hold a primary medical services contract
    • a network agreement signed by all PCN members—this must
      • incorporate the mandatory provisions set out in the national template network agreement[A]
      • reflect the requirements of the Network Contract DES Specification
    • an accountable clinical director
    • appropriate arrangements for patient record sharing in line with data protection legislation—this will support the delivery of
      • extended hours access service requirement from 1 April 2020
      • all other service requirements set out in the Network Contract DES
  • A PCN must ensure that it remains compliant with these criteria at all times
  • A previously approved PCN must ensure that there is no interruption in the provision of services in the transition from the previous year’s Network Contract DES to the current Network Contract DES
  • Commissioners and PCNs must not vary the Network Contract DES, particularly the financial entitlements
  • Supplementary network services must not be included in a varied version of this Network Contract DES, but should instead be contained in a separate local incentive scheme.

[A] NHS England. Network Contract Directed Enhanced Service Network Agreement. www.england.nhs.uk/publication/network-contract-directed-enhanced-service-network-agreement/

PCN=primary care network; DES=Directed Enhanced Service; STP=sustainability and transformation partnership; ICS=integrated care system

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The Network Contract DES committed to an investment of £2.4 billion by 2023–2024 for the development of approximately 1250 newly formed PCNs (or £1.47 million per typical PCN).11,12 This funding was intended to assist PCNs to:

  • deliver eight new service specifications over 5 years4,10
  • recruit additional healthcare professionals to support the provision of care4
  • tackle inequalities and improve care across multiple domains through the Investment and Impact Fund (IIF).13

The introduction of PCNs is key to the future of medicines optimisation within the NHS. Although the introduction of some PCN service specifications has been delayed by the COVID-19 pandemic, medicines optimisation was among those introduced in 2020 as part of the new GP contract. These are:4,10

  • enhanced health in care homes
  • structured medication review and medicines optimisation
  • extended hours access
  • early cancer diagnosis.

The vision of the PCN in which I am currently Head of Medicines and Research is to develop a strong, collaborative approach to enable the delivery of high-quality care to the patient population. To facilitate delivery of this vision, the PCN board supported the development of a management team, consisting of a Clinical Director, Head of Operations, and Head of Medicines and Research. Together, our role was to develop the strategic plan, and implement delivery of the expectations of the Network Contract DES by the PCN.

The role of clinical pharmacists

The Additional Roles Reimbursement Scheme (ARRS)—a scheme to support the recruitment of up to 20,000 additional staff to work in primary care teams implemented as part of the Network Contract DES9,11 —was critical to the delivery of the PCN service specifications, in particular through the appointment of clinical pharmacists. The PCN board agreed to invest a significant proportion of our ARRS funding to increase clinical capacity through the recruitment of clinical pharmacists during 2020–2021; some would argue that this was ambitious. This investment in pharmacists for our PCN has since increased by a further 30% in 2021–2022. The investment has facilitated an increase in clinical capacity, and allowed us to enhance our focus on how medicines are managed at PCN level. Medicines management at PCN level includes:

  • budgetary achievement
  • managing safety alerts (for both the Medicines and Healthcare products Regulatory Agency and the Central Alerting System)
  • determining the most cost-effective medicines in line with local policy
  • safe management of medicines through policies and processes.

Over the past 5 years, the role of the clinical pharmacist has become more clearly defined. The attributes of these practitioners were first defined in Annex B of the Network Contract DES, and are detailed in Box 3.11

Box 3: Key responsibilities of clinical pharmacists11

Where a PCN employs or engages one or more clinical pharmacists under the Additional Roles Reimbursement Scheme, the PCN must ensure that each clinical pharmacist has the following key responsibilities in relation to delivering health services:

  • work as part of a multidisciplinary team in a patient-facing role to clinically assess and treat patients using their expert knowledge of medicines for specific disease areas
  • be a prescriber, or completing training to become prescribers, and work with and alongside the general practice team
  • be responsible for the care management of patients with chronic diseases, and undertake clinical medication reviews to proactively manage people with complex polypharmacy, especially elderly people, people in care homes, those with multiple comorbidities (in particular, frailty, COPD, and asthma) and people with learning disabilities or autism (through STOMP)
  • provide specialist expertise in the use of medicines while helping to address both the public health and social care needs of patients at the PCN’s practice(s) and helping with tackling inequalities
  • provide leadership on person-centred medicines optimisation (including ensuring that prescribers in the practice conserve antibiotics in line with local antimicrobial stewardship guidance) and quality improvement, while contributing to the Quality and Outcomes Framework and enhanced services
  • through structured medication reviews, support patients to take their medications to get the best from them, reduce waste, and promote self-care
  • have a leadership role in supporting further integration of general practice with the wider healthcare teams (including community and hospital pharmacy) to help improve patient outcomes, ensure better access to healthcare, and help manage general practice workload
  • develop relationships and work closely with other pharmacy professionals across PCNs and the wider health and social care system
  • take a central role in the clinical aspects of shared care protocols, clinical research with medicines, liaison with specialist pharmacists (including in mental health and reduction of inappropriate antipsychotic use in people with learning difficulties), liaison with community pharmacists, and anticoagulation
  • be part of a professional clinical network, and have access to appropriate clinical supervision. Appropriate clinical supervision means:
    • each clinical pharmacist must receive a minimum of one supervision session per month by a senior clinical pharmacist
    • the senior clinical pharmacist must receive a minimum of one supervision session every 3 months by a GP clinical supervisor
    • each clinical pharmacist will have access to an assigned GP clinical supervisor for support and development
    • a ratio of one senior clinical pharmacist to no more than five junior clinical pharmacists, with appropriate peer support and supervision in place.

PCN=primary care network; COPD=chronic obstructive pulmonary disease; STOMP=Stop Over Medication Programme

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Since the publication of the PCN DES, pharmacists within general practice have begun to support clinical capacity by completing a variety of activities, including:

  • medication reviews (including structured medication reviews)
  • medication-related queries (for example, to suggest alternative medication)
  • audit and review of prescribing
  • medicines safety
  • drug monitoring and shared care.

The benefits of the clinical pharmacists working at Cross Counties Healthcare PCN have been remarkable, and they are now a core part of the PCN and practice offering. Tables 1 and 2 show the tasks undertaken by the clinical pharmacists during 2020–2021 and continuing into 2021–2022, and demonstrate the invaluable support they have provided to the PCN, its practices, and the members of the primary care team.

Table 1: Clinical pharmacists’ activities at Cross Counties Healthcare PCN, 1 April 2020–31 March 2021[A]
ActivityPCN total

SMRs

1978

Medicines-related tasks

33,826

Medicines reconciliation and discharge letters

6382

Patient safety alerts

794

Prescribing audits

11

[A] Internal data from Cross Counties Healthcare PCN

PCN=primary care network; SMR=structured medication review

Table 2: Clinical pharmacists’ activities at Cross Counties Healthcare PCN, 1 April 2021–31 August 2021[A]
ActivityPCN total

SMRs

1484

Medicines-related tasks

13,912

Medicines reconciliation and discharge letters

2972

Patient safety alerts

831

Community pharmacy consultation service referrals

20

[A] Internal data from Cross Counties Healthcare PCN

PCN=primary care network; SMR=structured medication review

In addition, PCNs were set the goal of improving medicines safety as part of the IIF incentive scheme.14 The medicine safety domain of the IIF aims to:14

  • support local reviews of prescribing, alongside other risk factors for potential harm
  • minimise the use of medicines that are unnecessary and when harm may outweigh benefits
  • identify when the risk of harm can be reduced or mitigated, including through prescribing of alternative medicines or medicines that mitigate risk
  • reduce the number of hospital admissions that may be associated with medicines.

The specific indicators that PCNs were tasked with improving are shown in Table 3.14

Table 3: Achievement across all three indicators of medicines safety at Cross Counties Healthcare PCN in March 202114,[A]
IndicatorUpper threshold (%)Lower threshold (%)Proportion of patients (%)[A]Achieved

MS01: Percentage of patients aged ≥65 years currently prescribed an NSAID without a gastroprotective medicine

30

43

9.26

Yes

MS02: Percentage of patients aged ≥18 years currently prescribed an oral anticoagulant (warfarin or a DOAC) and an antiplatelet without a gastroprotective medicine

25

40

38.57

Yes

MS03: Percentage of patients aged ≥18 years currently prescribed aspirin and another antiplatelet without a gastroprotective medicine

25

42

37.50

Yes

Rationale for inclusion: patients prescribed the specific medicines described in MS01, MS02, and MS03 without a gastroprotective medicine are at a heightened risk of hospitalisation for a gastrointestinal bleed. These indicators, which are also reported on the NHS Business Services Authority medicines safety dashboard, aim to encourage general practice to prescribe gastroprotective medicines alongside these medicines to reduce related hospital admissions.

 

[A] Internal data from Cross Counties Healthcare PCN

PCN=primary care network; NSAID=nonsteroidal anti-inflammatory drug; DOAC=direct oral anticoagulant
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Clinical pharmacist-led activities at our PCN ensured that patients included in the IIF indicators were reviewed, the resulting reviews supported achievement across all three indicators in the medicines safety domain, earning the PCN £4612.92 for reinvestment into PCN services (internal data from Cross Counties Healthcare PCN).

Planning for the future

The vision for medicines optimisation services at our PCN is to continue to develop the team through a 12-month internal education programme covering long-term conditions that will run alongside the Centre for Pharmacy Postgraduate Education’s primary care pharmacy education pathway.15 In addition to this, we aim to expand the PCN clinical research arm, and further expand the team to provide a complete pharmacy service across the PCN. In the meantime, the team will continue to support workload capacity and implementation of the PCN DES across primary care for the remainder of 2021–2022.

This vision is shared by many PCNs across England. As the PCN DES specifications are updated and the domains covered by the IIF increase in number, there will inevitably be more onus on the clinical pharmacy team at PCN level to lead the medicines agenda. This may be the new future for how medicines are managed across the ICS.

Summary

Those of you who have been transitioning and implementing the changes to the NHS over the past 2 years will know that this has been a challenging period. The light at the end of the tunnel is the development of additional roles to support you in developing new ways of working—particularly pharmacists, who have positively demonstrated the impact that can be made at practice and PCN level.

Key points

  • Successive changes to the structure and operation of the NHS have aimed to develop long-term, place-based plans to improve the quality, efficiency, and integration of health and care services
  • The new GP contract translates the objectives of the NHS long term plan into core components of a GP’s role, and accompanies the establishment of PCNs and ICSs as part of the NHS restructure
  • Structured medication review and medicines optimisation were given greater focus in the changing NHS when they were included in the PCN service specifications introduced in 2020 as part of the new GP contract
  • Clinical pharmacists appointed under the ARRS have proven critical to delivering the PCN service specifications and meeting the medicines safety indicators of the IIF
  • Clinical pharmacists working in general practice have now begun to support clinical capacity, with benefits for PCNs, practices, and patients.

PCN=primary care network; ICS=integrated care system; ARRS=Additional Roles Reimbursement Scheme; IIF=Investment and Impact Fund

Vishal Mashru

Head of PCN Medicines & Research, Cross Counties Healthcare PCN and North Blaby PCN

Implementation actions for clinical pharmacists in general practice

written by Shivangee Maurya, Clinical Pharmacist, Soar Beyond Ltd

As highlighted in this article, clinical pharmacists are instrumental for successful delivery of the PCN DES and IIF. There are several practical ways to achieve this:

  • Consider which indicators are easiest to achieve and generate maximum benefit for the practice and for patients
  • Ensure you know the requirements for the indicators and be strategic about your focus according to which ones a pharmacist has the greatest capacity to influence
  • Utilise existing or bespoke clinical systems searches and templates to monitor and report on performance
    • there is no need to reinvent the wheel unnecessarily; network and see what others are doing before deciding to start from scratch
  • Stratify and prioritise key population cohorts and those that help on numerous parameters
    • for example, in the SMR segment, some of the most relevant areas to target include care homes, polypharmacy, and severe frailty
  • Create a plan of action on how to allocate resources to ensure all requirements are met—make use of the wider MDT and seek their input on your proposed delivery plan
  • Track progress regularly to ascertain whether the thresholds will be achieved
  • Have a contingency plan in place if things go off track; for example, consider:
    • who is available to accommodate the workload?
    • are there some tasks for which pharmacy technicians could provide support to free up pharmacist time?

PCN=Primary Care Network; DES=Direct Enhanced Services; IIF=Investment Impact Fund; SMR=structured medication review; MDT=multidisciplinary team

References

  1. The King’s Fund website. Sustainability and transformation plans (STPs) explained. www.kingsfund.org.uk/topics/integrated-care/sustainability-transformation-plans-explained (accessed 1 December 2021).
  2. NHS England. The NHS long term plan. www.longtermplan.nhs.uk (accessed 1 December 2021).
  3. NHS England. The NHS long term plan—a summary. London: NHS England, 2019. Available at: www.longtermplan.nhs.uk/wp-content/uploads/2019/01/the-nhs-long-term-plan-summary.pdf
  4. NHS England. Investment and evolution: a five-year framework for GP contract reform to implement the NHS Long Term Plan. London: NHS England, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf
  5. NHS England website. What are integrated care systems? www.england.nhs.uk/integratedcare/what-is-integrated-care/ (accessed 1 December 2021).
  6. NHS England website. Regional medicines optimisation committees. www.england.nhs.uk/medicines-2/regional-medicines-optimisation-committees/ (accessed 1 December 2021).
  7. NHS England. Regional medicines optimisation committees—operating model. London: NHS England, 2021. Available at: www.england.nhs.uk/wp-content/uploads/2017/04/B0998_Regional-Medicines-Optimisation-Committees-RMOC-operating-model_04112021.pdf
  8. Angus L; NHS Clinical Commissioners, NHS Confederation. The role and functions of CCG medicines optimisation teams. London: NHS Confederation, 2021. Available at: www.nhsconfed.org/sites/default/files/2021-07/Role-and-functions-of-the-CCG-medicines-optimisation-team.pdf
  9. NHS England website. Clinical pharmacistswww.england.nhs.uk/gp/expanding-our-workforce/cp-gp/ (accessed 1 December 2021).
  10. British Medical Association website. Primary care networks (PCNs). www.bma.org.uk/advice-and-support/gp-practices/primary-care-networks/primary-care-networks-pcns (accessed 1 December 2021).
  11. Primary Care Strategy and NHS Contracts Group. Network Contract Directed Enhanced Service contract specification 2020/21—PCN requirements and entitlements. London: NHS England and NHS Improvement, 2020. Available at: www.england.nhs.uk/wp-content/uploads/2020/03/Network-Contract-DES-Specification-PCN-Requirements-and-Entitlements-2020-21-October-FINAL.pdf
  12. NHS England website. Network contract DESwww.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/ (accessed 1 December 2021).
  13. NHS England website. Investment and Impact Fund. www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/iif/ (accessed 1 December 2021).
  14. NHS England. Network Contract Directed Enhanced Service—investment and impact fund 2020/21: guidance. London: NHS England, 2020. Available at: www.england.nhs.uk/wp-content/uploads/2020/09/IIF-Implementation-Guidance-2020-21-Final.pdf
  15. Centre for Pharmacy Postgraduate Education website. Primary care pharmacy education pathwaywww.cppe.ac.uk/career/pcpep/pcpep-training-pathway (accessed 1 December 2021).

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