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Advocate of the Year Dilip Joshi encounters territorial battles as LPCs seek to expand pharmacy's role in immunisation

Saturday August 2

I work alternate Saturdays at the pharmacy but today I am attending a 'safe administration of vaccines' course at King's College €“ one element of the training requirements for this year's immunisation programme commissioned by NHS England. Based on the success of last year's campaign, during which some 75,000 flu vaccines were provided through community pharmacy across London, this year's programme is more ambitious.

NHS England is to commission an enhanced programme to include inactivated influenza, live attenuated influenza, shingles, pertussis and pneumococcal vaccines. Again, this year, there are timing issues affecting service level agreements, PGDs and training. The first two are largely NHS England's responsibility, but Pharmacy London has agreed training appropriate to the new service. This includes intramuscular, subcutaneous and intranasal routes of administration and anaphylaxis management, which are being covered today.

Additionally, there are two Centre for Pharmacy Postgraduate Education modules to pass and a declaration of competency to be made. All in all, it's a lot of work but I am delighted to see the number of pharmacists that have expressed interest and turned up for today's training.

Monday August 11

Bad news! NHS England has had a meeting with Pharmacy London and London-wide local medical committees, following which it was announced that shingles and pertussis vaccines would not be commissioned through community pharmacy after all. It is fair to say the GPs have not been entirely supportive of immunisations being provided by us. I feel it is more than a coincidence that the backtracking took place following this meeting, when NHS England was previously so positive. This means some aspects of our training have become unnecessary.

On a positive note, children and pneumococcal vaccinations are welcome additions, and as shingles and pertussis are not seasonal (unlike flu) they could be introduced at any time. We have put a message out to this effect to our contractors but we feel somewhat deflated. Once again, it seems territorial issues have taken precedence over improving patient services.

Thursday August 14

I meet with the LPC chief executive today to consider the support we need to provide for contractors in delivering services. The office has produced a step-by-step guide for the immunisation service, starting from expression of interest (EOI) to training needs, form-filling and declarations. However, there are some who attend the training without making the prerequisite EOI and others who, for various reasons, haven't read the notifications. I hear the CEO's frustrations and complaint about the level of hand-holding required. I reflect that, for all the promises of delivery we make to commissioners, if we fail to deliver there will be a major loss of credibility and confidence that could affect us all, even if there is a minority of poor performers.

Policy on the scope of London pharmacies' role in immunisation changed after LMCs had their say

Tuesday August 19

I have a meeting with the Vitamin D distribution coordinator at the pharmacy today. Vitamin D deficiency has been a major news item recently, resulting in a political imperative to improve levels in pregnant women, young children, and mothers of young children. In Lewisham, before pharmacy was involved, only a 5 per cent distribution rate was achieved. This increased to 35 per cent within a year and the Lewisham community pharmacy Vitamin D scheme was shortlisted for a national award. Based on this success, a coordinator was appointed for Lambeth.

She is a qualified nutritionist with a previous client-facing role. Funding (as always) is limited and payments to pharmacists are nominal; she is only employed to the end of the financial year. We discuss the possible expansion of nutritional advice through pharmacy and, although having few dealings with us in the past, she could see the potential for access, disease prevention and health promotion to fit well within a pharmacy setting.

We agree to work up an outline project to put before local authority commissioners. Evaluation is key and we have perhaps failed to quantify benefits of various initiatives adequately in the past. The success of the Vitamin D project in Lewisham has been measured and I am optimistic that a similar performance in Lambeth will result in a better-rewarded nutrition project in the future.

Thursday August 21

My CEO and I attend a Lambeth primary care development meeting on how community pharmacy can be better integrated into primary care. Attendees include the director and assistant director of commissioning, a secondary care pharmacist, the GP chair of medicines management and pharmaceutical advisors. The assistant director and GP, in particular, have been great supporters of pharmacy and it was with the former's sponsorship that we had the only successful healthy living pharmacy national pilot bid in London.

Discussions focused on effective information exchange, avoiding duplication and ensuring consistent messages from all healthcare providers. We ask the hospital pharmacist and GP to help us develop a discharge policy that communicates any medicine changes to both GP and pharmacist. It is also agreed to use a test disease area (cardiovascular) to develop a care pathway that encompasses pharmacist input, including prevention, health promotion, screening, targeted MURs and disease management.

Communication is key and referral mechanisms to both GPs and directly to secondary care will be considered. We leave satisfied with the genuine goodwill expressed by all and even a promise to provide 'some' funding!