EXECUTIVE SUMMARY

1.  Lloydspharmacy welcomes the opportunity to submit evidence to the Health Select Committee's inquiry into the contriution of the NHS to reducing health inequalities.

2.  We believe that, by providing easily accessible healthcare, the community pharmacy network holds an unrivalled position and a real opportunity to impact on public health and the reduction of health inequalities.

3.  The entire community pharmacy network has the potential to support the NHS in this way and is a solution that can be accessed today to ensure healthcare is delivered to under-doctored areas and Spearhead PCTs.

4.  Lloydspharmacy believes that without reforming access to health services, the Government will fail to meet the public health challenge.

5.  Incentivising primary care providers to work more closely with one another is paramount to encouraging a vibrant primary care market that addresses the health needs of the local community.

6.  We believe that through alignment of the Quality and Outcomes Framework (QOF), GPs should be incentivised to work more closely with pharmacy and vice versa.

7.  Lloydspharmacy is not only able to deliver services targeted at health prevention and promotion but is also able to ensure they are easily accessible within the heart of communities they are most required.

8.  There needs to be an acceptance of the community pharmacy role, demonstrated by greater integration of NHS primary care workforce and formalised through a new primary care contract for service provision.

9.  Providing public health from a non-traditional pharmacy setting is achievable through innovative partnerships with Local Authorities and County Councils. The new Local Area Agreements could be the mechanism for delivering services by joined up working of multiple agencies (public, private and voluntary).

INTRODUCTION

  Lloydspharmacy is the largest community based healthcare company in the UK. Our pharmacists manage 1,659 pharmacies where 15,000 health trained staff deliver innovative and quality pharmacy services to our 2 million weekly customers.

  Located where people live, Lloydspharmacy enables easy access to healthcare. Our network of pharmacies extends to both remote rural locations and some of the most deprived areas of the UK. Lloydspharmacy believes in allowing patients and the public to take control of their own healthcare by the provision of a range of pharmacy services, including the dispensing and advice of medicines, screening services, and ongoing public health information.

Credentials

—  Over 1 million free blood pressure tests

—  Over 1 million free diabetes tests

—  Over 163,000 people referred to GPs

—  Over 1,650 pharmacies providing public health information on obesity, smoking cessation and sexual health

—  20% of pharmacies providing smoking cessation services

—  47% of our pharmacies provide assistance with substance misuse

—  13% of pharmacies provide needle exchange services

—  24% of pharmacies provide EHC services

—  Over 1,400 pharmacies have private consultation areas

—  Over 390,000 Medicines Use Reviews completed

—  Over 300 pharmacies integrated into health centres with GPs and others

COMMUNITY PHARMACY—HELPING TO TACKLE HEALTH INEQUALITIES

  Lloydspharmacy believe that community pharmacy should be an integral part of the NHS, with effective pharmacy provision today not only taking the strain off GPs, but also meeting the demands of a society that is constantly mobile and seeks access to healthcare at any time and in any place.

  With rising expectations being placed on the NHS, the role of the pharmacist has increasingly been tied in with prevention and diagnosis through the implementation of the Pharmacy contract in April 2005.

  Pharmacy not only has the potential to make a far greater contribution to the NHS, but there is a strong economic, as well as practical case for directing more services into pharmacy.

—  The pharmacy network is a phenomenally under utilised resource which is expert at delivering local health needs. It should be used to its maximum to help deliver key government objectives, such as the move towards more a more preventative model of care which focuses on "lifestyle diseases" and the management of long term conditions and as announced recently by the Prime Minister[88].

—  Pharmacy premises that are located in under-doctored areas should be extended and adapted in order to increase access to walk-in facilities and the provision of clinical services.

—  Better integration and recognition of pharmacists within the broader NHS network would enable more collaborative models of working to tackle the public health challenge and health inequalities.

—  Local contracts focused on preventative health measures such as testing should be established that are in line with PCT health priorities.

—  Access to healthcare could be increased through providing pharmacy-led services in non-traditional settings.

  Improving the nation's health and specifically tackling health inequalities have been defined as key priorities by the Government[89]. While these challenges are well known, and although some progress has been made to tackle them, effectively addressing disparities in health and public health concerns has proven to be difficult.[90]

UNRIVALLED ACCESS TO HEALTHCARE FOR COMMUNITIES

  Located where people live, community pharmacy is well-placed to play a greater role in the delivery of health services. Pharmacist's exposure to the general public is unique and should be maximised to help deliver key government objectives in the areas of public health and health inequalities. As a profession, we are ready and willing to help deliver the necessary services in the areas of greatest need and while there is recognition amongst government and other healthcare professionals that community pharmacy is capable of delivering such services, there needs to be an acceptance of our role demonstrated by greater integration of NHS primary care workforce and formalised through a new primary care contract for service provision.

LEVERAGING THE PHARMACY NETWORK TO TACKLE HEALTH INEQUALITIES

  Health inequalities pose a large threat to the health of our nation. It is widely agreed that areas of social deprivation have a higher prevalence of cancer, coronary heart disease and obesity and the Government has acknowledged that it is many of these areas that are in fact under-serviced by healthcare professionals[91].

  In its assessments of how best to stem the gaps in health provision, Government and PCTs need to consider how they best utilise the existing pharmacy network.

  Lloydspharmacy's network alone has over 600 pharmacies located within under-doctored areas[92]. Our continued presence in such areas provides much needed access to services which help to deliver a range of targeted care to communities. One example of this is in Birmingham, where Lloydspharmacy has 34 pharmacies in Birmingham East and North PCT, which has been recognised as both a Spearhead PCT and under-doctored. Working with the PCT's recognised key public health priorities; smoking, coronary heart disease and health awareness, Lloydspharmacy has focussed on the delivery of core services to tackle these challenges.

Case Study

  Working with the Birmingham PCTs, the Heart MOT is targeted towards the male over 40's population and aims to identify individuals with an increased cardiovascular risk.

  Early results show that:

—  30.4% of all people accessing the service were identified as having a CVD risk of > 20%

—  43.6% of all males accessing the service were identified as having a CVD risk of > 20%

—  Over 600 patients screened

—  49% referred to GP

—  32% referred due to high CVD risk

—  2% of patients previously not registered with NHS/GP

  Lloydspharmacy is not only able to deliver such services targeted at health prevention and promotion but is also able to ensure they are easily accessible within the heart of communities they are most required.

  The entire community pharmacy network has the potential to support the NHS in this way and is a solution that can be accessed today to ensure healthcare is delivered to under-doctored areas and Spearhead PCTs. In particular, thought should be given to extending and adapting pharmacy premises that are located in under-doctored areas in order to increase facilities for the provision of clinical services.

  Building on the role that community pharmacy already plays in providing testing services, Lloydspharmacy believes that this should be further extended to create better access to services. Many people have very little contact with healthcare professionals; it is generally the "worried well" that proactively seek advice, while those that require care often avoid any form of consultation. Making services such as blood pressure monitoring or cholesterol testing available to public where they naturally gather would help increase people's exposure to healthcare services and advice.

  Working in partnership with Kent County Council, we are exploring how best to develop a number of public health pilots in addition to the current services available across Kent. The intention is to demonstrate that by increasing people's access to services and by delivering them outside of traditional locations, cost effective ways of providing health and social care services which ensure maximum public engagement can be achieved. This provision therefore not only helps to improve the health of local communities across Kent but also informs the development of integrated funding models within new Local Area Agreements[93].

  The following sets out the initial opportunities that have been discussed between Kent County Council and Lloydspharmacy and describes a number of options.

  The initial opportunities are centred on:

1.  The need to engage school communities to raise awareness of the health issues related to smoking, the introduction of smoke free school grounds, and the need to provide younger people with the opportunity to engage in smoking cessation services.

2.  The utilisation of the Kent Gateway strategy. These are "one stop" centres in which the public can access County Council services. The first location is in Ashford and there are plans to open more centres across Kent. Lloydspharmacy in partnership with Kent Gateway will provide targeted public health services in these non tradtional settings.

  Implementing services such as these, that not only focus on providing public health messaging, but also work to create personalised care has enabled Lloydspharmacy to promote public health and raise health awareness amongst individuals though pharmacy, while also supporting the NHS and other local services.

  In Norfolk, we are also working locally to deliver an activity programme, "Fit Together". The initiative, which was developed in partnership with Sport England, promotes small increases in activity levels to improve overall health and well-being. "Fit Together" particularly focuses on walking and cycling and is promoted in pharmacy in conjunction with existing pharmacy services including diabetes testing, blood pressure checks and Medicines Use Reviews (MURs).

  Better integration and recognition of pharmacists within the broader NHS family would enable collaborative models of working which help deliver public health services, to not only the broader population, but also to areas of greatest need.

  Whilst work in Kent and Norfolk is still in its very early stages, the projects help demonstrate how pharmacy expertise can be innovatively utilised to increase access to services.

EFFECTIVE DELIVERY OF SERVICES

  Lloydspharmacy believe that service provision will form an increasing part of pharmacy's future role. We have invested in consultation areas, which are now equipped with PCs, promoted MURs and enhanced services, as well as the provision of services such as diabetes monitoring, blood pressure testing and healthy heart checks.

  However, there are differing levels of engagement within the overall pharmacy network. While many pharmacies are proactively driving services and are keen to develop this further, others remain focused solely on dispensing.

  The over-riding majority of current remuneration is focused towards dispensing and fixed fees—for many, the most profitable action is to focus on dispensing alone. The ongoing volume increase of prescriptions (which has outstripped funding growth), and the ongoing rising cost base and inflation, has meant many pharmacies are predominantly focused on dispensing at the minimum cost achievable.

  Although efficiency is desirable, shifting new or existing funding towards quality based payments and developing service capability will ensure that these areas are also given proper focus (by the whole network).

  In our submission to the Galbraith review; "Review of contractual arrangements for NHS pharmaceutical services in England", we proposed reallocating some of the variable dispensing fee (the Practice Payment). Over time, a proportion of pharmacy income for pure dispensing activity could be reallocated to allow an increased proportion to be used to drive behaviour towards the service plus dispensing agenda.

  It also suggested a two tier variable dispensing payment—a lower rate for pharmacies providing only essential services, and a higher rate for pharmacies capable of providing a given range of advanced (or enhanced) services.

  Our proposed Framework is a value for money mechanism designed to provide patients and the public with high quality services, enhance PCT autonomy, link primary care providers, deliver NHS public health goals and provide business certainty for pharmacy contractors.

  The Framework combines three elements, underpinned by a new financial model for community pharmacy:

1.  An objective, transparent methodology to determine where and whether a pharmaceutical contractor can provide NHS pharmaceutical services—"Pharmaceutical Needs Planning" (PNP) assessment.

2.  A standard contractual framework to enable PCTs to more effectively commission pharmacy, GP, dentist and ophthalmology services.

3.  Incentives to create new models of dispensing which would enable greater pharmacist interaction with patients and the public.

EQUITABLE ACCESS TO HEALTH SERVICES

  Lloydspharmacy believes that in the pharmaceutical market, regulation is a prerequisite for the protection of public health and the public interest. The rules that control the balance between cost containment and competition must not put at risk access to public health service provision. Without these controls, we believe that there would be an under provision of health services to the public, as the concentration and clustering of pharmacies around GP surgeries and health centres would increase as each contactor competes for prescription business. We do not believe that further deregulation of the pharmacy services market would bring additional value to the general public or the Treasury.

  We believe that Government has a duty of care to ensure equitable access to healthcare for the population and that there is a strong continuing need for some regulation in order to achieve geographical spread of pharmacy provision.

  The current arrangements enables pharmacies to remain in communities, neighbourhoods and rural locations as well as improve access and choice in metropolitan areas— addressing inequalities in healthcare provision, particularly in under doctored areas as already highlighted.

INCENTIVISING GREATER COLLABORATION

  Incentivising primary care providers to work more closely with one another is paramount to encouraging a vibrant primary care market that addresses the health needs of the local community. In particular, Lloydspharmacy believes that through alignment of the Quality and Outcomes Framework (QOF), GPs should be incentivised to work more closely with pharmacy and vice versa.

  Whilst we propose that the QOFs of various health care professionals should be aligned, the pace of this alignment must be thought through carefully so as not to overburden primary care health professionals and their patients with unreasonable activities and targets. Future enhancement of our proposed community pharmacy QOF should be an iterative process where the "bar" is raised so that over time, as the range of indicators is raised there will be convergence of the GP and community pharmacy QOF to ensure that continued improvements in service, quality and patient outcomes are maintained through the collaborative activities of community pharmacy and GPs.

  Although the opportunities to expand the existing contractual framework for community pharmacy and the potential value of adding a QOF element are clear, there are a number of requirements to enable pharmacy to effectively participate.

  Pharmacists must be enabled to access the NHS Care Records System in order to ensure cohesive service provision across professions. In addition to this, it will also be important to agree a standardised reporting system to ensure consistent patient tracking and follow-up.

ENSURING THE APPROPRIATE DIRECTION OF SERVICES

  Community pharmacy has a tremendous role in assisting with the management of Long-Term-Conditions. As the second phase of Lord Darzi's NHS Reviews explores various clinical pathways, it is important for the Government to recognise where community pharmacy can contribute to the patient journey, from prevention, detection and the long-term management of illness.

USING PHARMACY TO FACILITATE CHOICE

  Improving awareness of choice in primary care services can also improve access to healthcare as well as ensure the appropriate use of services. Utilising the level of exposure community pharmacy already has with the public and the expertise the profession has in delivering customer choice, Lloydspharmacy believes that community pharmacy should be leveraged to highlight patient choice. Through sign-posting local health services and raising awareness of the appropriate use of services, community pharmacy could do much to alleviate the strain on GP practices and refer patients and the public to the most appropriate health service provider.

CONCLUSION

  The answer to the question "Can the NHS make an impact on reducing health inequalities" is yes, and how this is achieved in a timely manner because of the urgency in need requires leadership from all stakeholders.

  Success in reducing health inequalities and improving public health would be demonstrated by the NHS, Local Authorities, Voluntary sector and the Private sector agreeing how to work differently together.

  Community pharmacy can make a significant contribution by:

1.  utilising their access to people living in under-doctored areas by developing facilities to provide "walk-in" pharmacy led services

2.  delivering services targeted at prevention, such as reduce smoking, lowering blood pressure, cholesterol and weight would make positive impact in reducing health inequalities

3.  realising the cost effectiveness of public health services being offered in pharmacy and the long term benefits to local people and the health economy

  The levers that would enable change to take place are:

—  Community pharmacy being recognised by all stakeholders as integral to the solution to reduce the impact of health inequalities as part of an

—  integrated local plan.

—  Incentivising primary care providers to work jointly and alignment of professional contracts.

January 2008

89   Secretary of State for Health keynote address to the New Health Network on Health inequalities, 12 September 2007. Back

90   Our Health Future Secured: A Review of NHS Funding and Performance, Sir Derek Wanless, commissioned by King's Fund, 11 September 2007. Back

91   New Practices for Under Doctored Areas, Department of Health Press Release, 23 November 2007. Back

92   As defined by the Department as an area or PCT with fewer WTE GPs/100k weighted population than the national average. Back

93   The LAA is designed to allow services to be delivered in a more joined-up way by bringing together partners from the public, private and voluntary sectors and pooling funding streams of each partner into a single pot, designed to avoid duplicating effort and wasting money. Back