After news that Scottish contractors are set to benefit from significant funding boosts, it’s clear to see why pharmacy is looking rosy in the land of neeps and tatties. But as NIPinF Editor Laure James discovered, success isn’t just down to money.

And it’s done them no harm. The Scottish pharmacy contract is widely lauded elsewhere in the UK as a leading light in terms of delivering pharmaceutical care and professional support from all levels, and when NIPinF’s editor Laure James visited Edinburgh in June, it soon became clear why. As Dr Elspeth Weir and Alex MacKinnon from Community Pharmacy Scotland - formerly the Scottish Pharmaceutical General Council – explain, it is from taking some necessary risks that so much success has been enjoyed.

The Scottish contract, a two tiered model based around national and additional local pharmacy services, ensures that patient need is at the core of its structure. Alex, head of corporate affairs at CPS, believes that if you look after patients first, then everything else will tessellate. “Our four national services, some of which are yet to be fully rolled out, provide the foundations to the contract,” he explains. “The patient driven approach was always what we wanted, along with ensuring that IT underpinned service implementation and delivery.”

The national services, which include the exemplary e-Minor Ailment Service (eMAS), Public Health Service and the Acute and Chronic Medications Services, have drawn praise from other healthcare professionals, sectors and organisations from across the UK, but what makes them so effective? “AMS and CMS are still to be rolled out but pilots have indicated good levels of compliance and understanding from stakeholders early on,” Elspeth added. “An installation pack for the Electronic Transfer of Prescriptions to support AMS was recently launched and we hope to have all contractors involved by March 2009.”

eMAS, launched back in July 2006, has been extremely well received by pharmacists, patients and GPs. “Since Scotland will have abolished prescription charges by 2011, the future face of eMAS is uncertain although we hope to develop a scheme available to all, with the likelihood of a restricted formulary,” Elspeth explained. “The second in our portfolio of national services, Public Health, is also something that can be built upon for the future.”

The Public Health Service is an initiative that promotes opportunistic interventions by pharmacists, such as identifying patients with COPD who also smoke, and then suggesting a smoking cessation programme. Surely however, this is something that pharmacists have long been practising? “This is true, but it is about engcouraging more of what happens already and getting recognition for community pharmacy’s public health role,” admits Alex, “And, CPS is looking at widening the number of opportunities for cross-promotion of services, particularly sexual health and smoking cessation. Public Health was established as a core part of the contract and is a long term commitment to care provision. We have an aging population and a rising number of people with chronic conditions, so it is about creating a strategy fit for the future and identifying what can be done.”

Of course, a strong and well respected negotiating committee is not the only component required for a sustainable, successful pharmacy contract and profession. CPS has long been engaged in political lobbying and, with the key assistance of Chief Pharmaceutical Officer Bill Scott, has benefitted from the support of Members of the Scottish Parliament (MSPs), the Scottish Government and the officials in the Department of Health and Wellbeing. “Ensuring you have political support is half the battle,” Alex continued. “Our core aims as pharmacists are to improve patient care and improve public health and while no Department can dispute the benefits of community care such as reducing the number of hospital readmissions and increasing patient compliance with medication, you need to be able to demonstrate this.”

CPS and other pharmacy organisations have worked hard to highlight the value of pharmacy and in turn, this has helped to secure funding for important pilots and services. Alex said; “The ethos of the Scottish Government is for a mutual NHS where people collaborate to deliver services rather than compete with each other.
“Significant funding was also provided whenever new IT equipment was required for the new services, and this went some way in helping contractors embrace change. Developing community pharmacists as supplementary and independent prescribers is also something we have sought investment for and were successful.”

CPS also won favour with their shrewdly negotiated remuneration package. “CPS was seen as quite radical in this area,” said Elspeth. “Elsewhere in the UK, money from purchase profit clawbacks was being suspended at local level and seldom seen again within pharmacy. However in Scotland, the initial margin from Category M was used in part to fund eMAS and PHS making sure that by mapping this into services, it was not lost to community pharmacy. Pharmacists here have also moved away from direct payment per prescription to shift the primary focus onto the pharmaceutical care of patients.”

Elspeth also spoke about favouring an independent regulatory body for Scotland, and with it gave a vote of confidence for the Pharmaceutical Society of Northern Ireland. “Community Pharmacy Scotland has been monitoring closely the splitting of the RPSGB’s regulatory and professional functions,” she said. “Community Pharmacy Scotland did put forward a view that there should be a separate professional body for Scotland because of the impact of devolution on Health Service provision. How the process develops should be a matter for members to consider and decide.”

The Scottish profession is so thoroughly strengthened that even supermarket owned contracts, perceived to be one of the greatest threats within Northern Ireland, is not a problem for independents. Although there are still just a handful of supermarkets with dispensaries, this number is set to increase with continued out of town development throughout Scotland. However, thanks to cross party support for the community pharmacy network, 100 hour contracts will not be found. “While the retail division of supermarkets will welcome customers throughout the day and night, the pharmacies will be closing at the same time as the others,” explains Jill Chiwara, area manager for Rowlands Pharmacy. “Our Dalgety Bay branch is based within premises owned by Tesco but not within the supermarket itself. Its location is more concerned with the nearby health centre.”
Edinburgh contractor Alan Berrie has had countless years of experience within pharmacy although claims to have never seen a more exciting and rewarding time than the present. “Before it was a struggle to gain the recognition for the work we carried out, whether that was at government or practice level,” he explained. “However the contract has given us a much more detailed, defined and challenging role and although I’m not sure the remuneration package accurately reflects the more service based work we’re doing now, it couldn’t be described as a raw deal.”

NHS Lothian, as with all Health Boards, issue pharmacists with guidelines about services but Alan has the freedom to shape them for his patients’ requirements. His pioneering Wellbeing Clinic, designed to give customers a full range of health services from Reiki and pregnancy massage to warfarin programmes has generated significant interest from the local community, with an average of seven appointments each day. Alan also has several consultation rooms which are available to experts such as podiatrists, physiotherapists and osteopaths under lease. Alan has even managed to negotiate with the locality’s GP surgeries to contribute towards the cost of running the wellbeing clinic.
“They can see the wider benefits of community care and preventative therapies,” said Alan, who is a supplementary prescriber. “I am half way through training to become an independent prescriber and have a sound idea of how I will best use this qualification. A number of pharmacists quite rightly take such courses but are unsure of what to do with it when they pass. My advice to Northern Ireland contractors is to pre-empt the contract as much as possible. Consider what services you’d like to introduce and make those preparations. You need a strong, extremely well trained team of support staff behind you to shoulder some of the increased workload. Finally, negotiations may take time but it is best to get it done properly. Our contract’s services are still being rolled out, it is not something that happens overnight or even over less than five years.”
Jill Rennie, a young Rowlands pharmacist who qualified just three years ago, is a strong advocate for the contract’s opportunities. “The contract has really shaped service provision to benefit patients, not to meet quotas or tick boxes,” she explains. “The focus on care has enabled us to offer additional local pharmacy services such as a free EHC programme and Chlamydia testing which have gained a great response from our customers. Shortly, I hope to start a flu or travel vaccination clinic.” Jill, who is training to become an independent prescriber, is also based close to a health centre and works closely with GPs. “There’s no question that the majority of practitioners here appreciate and value the services provided by pharmacists and I have had a tremendous amount of support during my prescribing training,” she added. “There’s no confusion over our common goals of improving public health and consequently little apathy or resistance from other healthcare professionals.”

Catherine Sullivan, another young Rowlands pharmacist based in Rosyth, has relished the opportunity to work with other professionals and spend less time in the dispensary. “Smoking cessation and methadone substitution are currently our two biggest services,” explained Catherine. “We have a really busy dispensary which does put demands on my time but I am fortunate enough to have a really strong support team, including a checking technician. Prior to the contract’s introduction, I found my role was limited to dispensing but now I am in a much more engaged role with greater opportunity for multidisciplinary working as well as getting involved with services. The contract has been a hugely pivotal point for pharmacists in Scotland and has really changed the profession for the better.”

Not everything is Utopian in Scottish healthcare however, with new services yet to be implemented and time pressures upon pharmacists mounting. Back at the CPS, this is certainly acknowledged. “We are still within what is called our ‘transitional period’,” Elspeth explained. “Each month contractors receive a transitional payment which will continue until we can accurately quantify how much each will be entitled to when all services are implemented. For the meantime, it helps to ease the uncertainty as although we have seen some very positive outcomes from the contract, we cannot predict the future.”

Alex’s advice to contractors in Northern Ireland is to continue to be patient. “We made no excuses for how long it took to get this far and how long it could take before we have completed the next phase of the contract,” he said. “The huge benefit of the contract was that it was correctly, sensitively and thoughtfully negotiated and applied. It has helped to position community pharmacists as clinicians and prescribers, with the ambition that they will be judged in the future on how they improve clinical outcomes for patients, and not just on how cost effective they can be for the Health Service and this is something Northern Ireland can also look forward to.”