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Leading the pharmaceutical care revolution in Scotland

Rose Marie Parr succeeded Bill Scott as the Scottish Government’s chief pharmaceutical officer last June. In doing so, she took on the key leadership role in driving forward the much greater clinical role for community pharmacists set in train by the ground-breaking Prescription for Excellence policy document, which was the brain-child of her predecessor. Douglas Simpson called on Professor Parr at her St Andrew’s House office in Edinburgh to find out how things have been going

Professor Parr says that it is an honour to have her new job and to have the chance to make pharmacy services better in Scotland. She adds that she applied for the post because of her passion for pharmaceutical care, for which she feels there is a great need. She exemplifies this with a story about a 91-year-old housebound widow whose children had predeceased her. Her social support was really good, with carers visiting throughout the day. But her pharmaceutical care amounted to MDS packs that confused her. And she was probably taking unnecessary drugs. No one was trying to do anything about it. She was, thus, a prime candidate for the kind of pharmacy service now envisaged for Scotland.

Since taking up her new post, Professor Parr has been visiting pharmacists in different settings – community, hospital and primary care – seeing how they work. She has visited every health board in Scotland, too.

She has inherited the Prescription for Excellence programme for Scottish pharmacy. What does she think of it?

“I think it is the right way forward,” she says. But she acknowledges there have been problems: “It came out in 2013 as a Scottish Government action plan for the next eight to 10 years. It faced difficulty initially as people were not clear about what it meant. In my travels, I found hospital pharmacists who thought it was not for them and community pharmacists who did not feel engaged in it.”

So she decided, she says, that the best thing to do was to start a process for refreshing Prescription for Excellence. But this is only in operational terms because she feels that “the vision is right and that it must remain”.

Professor Parr: it’s an honour to have
the job

 

GP focus

Currently, a key focus is on primary care and pharmacists working with GP practices.
Professor Parr says: “Prescription for Excellence is about pharmaceutical care, no matter what setting. We know that GP practices are overwhelmed with some of their workload and that community pharmacists can help in this. So, one of our PforE models will be one that allows pharmacists to support GP practices.

“We have been lucky enough to get some primary care funding. Over the next three years we have got £16.2m to get up to 140 pharmacists working with GP practices. They will be doing things like polypharmacy clinics, taking sessions with patients and helping in any way that they can.”

Will these pharmacists be part of the GP practice?

“We don’t see them as just that. It is important that we have community pharmacists in community pharmacies running clinics for GPs as well. They do not always have to be in GP premises.”

Will some of that £16.2m go to supporting those kinds of pharmacists?

“It will and we want it to do that.”

It is a matter, though, for health boards. “We have given the money to health boards and they will engage the pharmacists in their areas.”

ICP knows of a community pharmacist in Fife who is running two clinics for GPs, one in her pharmacy and the other in a local surgery. This is being paid for though Scottish Government money. Professor Parr indicates that there should be funding for this pharmacist under the new arrangements. Community pharmacists like the one in Fife are the green shoots of the pharmaceutical care revolution in Scotland. She believes that they should be supported and encouraged.

She declares: “We want a sustainable community pharmacy network that can be more clinical. The golden nugget is how we pay community pharmacists in a way that makes them clinical and sustainable. The contractor network is very important.”

Where will the pharmacists be coming from to work in GP surgeries? Will they all be from Scotland?

“We would want to see them coming from as many different places as possible. It wouldn’t be right if they all came from hospital because that would denude that service. We want a mixture of practice, primary care, hospital and community pharmacists. And we might see some portfolio-type working. There would be no barriers preventing pharmacists from across the United Kingdom participating.”

The vision
The following vision statement appears within the Prescription for Excellence document:“All patients, regardless of their age and setting of care, receive high quality pharmaceutical care from clinical pharmacist independent prescribers. This will be delivered through collaborative partnerships with the patient, carer, GP and other relevant health, social care, third and independent sector professionals so that every patient gets the best possible outcomes from their medicines, and avoiding waste and harm.”

Some of the pharmacists working in GP practices might be supplementary and independent prescribers. At the moment, pharmacists who prescribe can only handwrite prescriptions and can’t prescribe electronically. Should something be done about that?

“It is a huge frustration. It is a big problem stopping pharmacists working well. It is a patient safety issue, too. We need to solve that.”

How soon will students coming out of the schools of pharmacy be able to fulfill the prescribing clinical role envisaged in PforE?

“I have been talking to final year students in the two Scottish schools and they are keen to do this work now. Asked if they want to be prescribers, they all put their hands up. They have the potential to start now.”

Automation

Another key work stream under PforE concerns automation. An examination is taking place of working practices, aimed at allowing more time for pharmaceutical care.
“What we are doing is seeking to create space in the service for clinical engagement,” Professor Parr says.

“Our focus,” she adds, “is on trying to move away from pharmacists’ work on sales, supply and dispensing and replacing it with work about pharmaceutical care.”

What is envisaged in relation to automation?

“A programme of work is about to begin to look at what we are calling ‘spoke and hub’. The really important bit is the spoke, ie, the community pharmacy network. We are looking at the feasibility of community pharmacists being primarily engaged in the clinical work and not so much in work that could be undertaken by robots or though skill mix. And we are working things out with contractors. It is about feasibility. It is not about forcing a particular model.”

There has been negativity in the past, with contractors’ representatives feeling that they were being excluded from bodies implementing PforE. But that is now
changing.

Professor Parr says: “The positive thing about the refresh is that we have brought in Community Pharmacy Scotland, representing contractors, and the directors of pharmacy all across Scotland. They are involved in the implementation group on automation as well as groups dealing with such issues as governance. And they have been really helpful in moving the agenda on.”

The health boards have been given funds for implementing PforE. Is there any mechanism for reporting what they are doing and for this information to be shared?
“The refresh is designed to create the kind of framework that allows boards to report on what they have been able to deliver. Disseminating information is high up on my list of things to do.”

In England the government is calling for more clinical engagement by community pharmacists while at the same time cutting the global sum by 6 per cent. Will we be seeing the same sort of thing in Scotland?

“Negotiations on the 2016-17 remuneration package are going on and have yet to reach a conclusion.”

Role
The CPO’s primary role, as set out in the announcement of Professor Parr’s appointment, is “to provide leadership to NHS pharmaceutical care in Scotland” and be “policy lead for NHS pharmaceutical practice in the community, primary care, secondary care and public health”.

Other key responsibilities include: chief professional adviser to ministers and the Scottish Government; policy on prescribing matters; and administration of the Medicines Act in Scotland

CMS

The current contract in Scotland provides for the Chronic Medication Service, where treatment for long-term medical conditions can be managed by community pharmacies. Implementation has been slow because many GPs have been reluctant to set up the serial prescriptions that are essential for its operation. Does Professor Parr have any plans to speed things up?

“I have that high on my agenda as a result of my travels. We need to move CMS on. There are IT issues but there is also a cultural issue round serial prescribing.”

Does she agree that it is the individual pharmacists’ relations with GPs that is key?

“Absolutely. It is a relationship issue.”

CMS, she adds, is more than just managed repeats but “an added-value system of pharmacists taking over management of stable patients. That needs to be brought out to GPs.”

Out-of-hours services

Does she envisage a wider role for pharmacists in out-of-hours services through extending the minor ailments service, maybe with wider use of PGDs?

“The Scottish report on OOH services urged greater use of pharmacies on things like minor ailments. There has been a positive response to that and we now have to bring it into reality.”

CV
Professor Parr graduated in pharmacy in 1981 from Strathclyde school of pharmacy. Her preregistration year was completed in Monklands Hospital, Airdrie. She registered in 1982 and completed a Masters in clinical pharmacy in 1984 and a doctorate in education at the university of Glasgow in 2005.

She worked in hospital pharmacy in various posts in the Lanarkshire and Forth Valley health board areas. In 1993 she became the director of the Scottish Centre for Pharmacy Postgraduate Education. When SCCPE was combined with professional education groups for other professions as NHS Education for Scotland, Professor Parr became its director for pharmacy. She relinquished this role when she became CPO.

Professor Parr is a past chair of the Scottish Pharmacy Board of the Royal Pharmaceutical Society of Great Britain and a fellow of its Faculty. She is an honorary professor at Strathclyde school of pharmacy in Glasgow and of Robert Gordon University, Aberdeen.

Five things

The role of the CPO is not just confined to implementing Prescription for Excellence.
Professor Parr has, she says, four other things on her to-do list.

“My second aim,” she says, “is to try to do something about safer use of medicines.” She is to establish a strategic group on the matter.

The issue also falls within the remit of the Scottish Patient Safety Programme, which is looking at such matters as polypharmacy and adverse drug reaction reporting. There is also a collaboration designed to share best practice across Scotland on therapeutic use of drugs.

Third on Professor Parr’s list is explaining what pharmacy is and what it does. “I want to tell people what they can expect from pharmacists – what their skills and competencies are.” Alongside that could be a career framework for pharmacists, worked out with the regulator and the professional body.

Her fourth item is evidence-based outcomes: how can better use be made of information on the effectiveness of medicines.

“We are looking at aspects of clinical effectiveness with the Farr institute in Edinburgh and others. This is a long-term project and could involve measuring whether pharmaceutical care makes a difference. Recording of community pharmacy interventions could be part of that process”

Last on her list is “strategic engagement”. She wants, she says, to operate in a more collaborative way. “To that end, we have restarted meetings of the UK chief pharmaceutical officers.” She also wants to work collaboratively with the professional and representative bodies.

Professor Parr does not intend to let the grass grow under her feet: “Bill Scott was here for 25 years, 22 years as CPO. I don’t have that long. So I’m in more of a hurry.”




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