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20/56 HS&DR Community pharmacies commissioning brief

 

Contents

Commissioning brief 20/56 – Community pharmacies

(two stage – Stage 1 to Stage 2)

Identified research need

NICE identified a research need to understand how the expanding role of community pharmacies are integrated with other health and social care services. Community Pharmacies (i.e. local chemists that are accessible to all and not based in a hospital, clinic or solely online) are currently undergoing rapid change and expansion in the services they offer to support the health and social care of people in their local area. Community pharmacies operate as commercial businesses, of which the majority (60%) are part of multiple chains, with the remaining 40% of pharmacies being independents or small chains of less than six outlets [1]. The NHS Long term plan [2] sets out ambitions to make greater use of the skills of community pharmacy teams and their opportunities to engage patients. In support of these goals, the Community Pharmacy Contractual Framework (CPCF) 2019/20 – 2023/24 [3] outlines key changes to the role of community pharmacies (CP) with a greater emphasis on the provision of services that go above and beyond the dispensing of medicines. These extended community pharmacy services are sometimes referred to as cognitive, non-dispensing or non-supply services.

A 2018 systematic review [4] of patient and public perspectives of CP suggests that opinions towards CP services (including extended community pharmacy services) are positive but awareness of services beyond the supply of medicines remains low. In England, 89% of the population, and over 99% of people in the most deprived communities, live within a 20-minute walk of a community pharmacy [5] making them well placed to support the health needs of their community, and to help address health inequalities by engaging with populations who may not be accessing other reliable sources of health information. An insight into how access to and uptake of extended community pharmacy services can be increased, particularly amongst more at risk and disadvantaged groups will help to understand the role of CP services within the wider healthcare system and their potential to help address health inequalities.

Types of extended community pharmacy services include, but are not limited to, health checks, new medicines services, treatment for minor illnesses and injuries, and quit smoking services. These may be provided by a pharmacist, pharmacy technician or other health workers employed by a community pharmacy. A recently published Cochrane review (2018) [6] found that some extended services provided by CP can have positive effects for patients but results from trials vary with limited understanding of which components of these services deliver positive outcomes.

Expanding the role of CP has the potential to relieve pressure on and support other parts of the health and social care system such as emergency departments, primary care and social care. NICE guidance on CP [7] recommends establishing formal pathways for inward and outward referrals between CP and other services. However, limited evidence exists to inform best practice on how extended community pharmacy services should be integrated into existing care pathways, this is especially important for primary health care. Additional considerations include governance issues covering safety, confidentiality and integrated communications between CP and other care providers e.g. general practice and social care, to support these new extended roles.

In the CPCF 2019/20- 2023/24 extended community pharmacy services are initially focusing on those related to urgent care, medicines optimisation, public health and prevention, but there may be other extended services already being delivered or that have the potential to be delivered by CP. In October 2019, the Community Pharmacist Consultation Service (CPCS) was launched following successful pilots, enabling NHS111 services to refer patients directly to CP for a face to face consultation to treat minor illnesses and injuries. Pilot sites are currently underway expanding this service to also include referral from general practices. This will involve referrals following an initial assessment by trained GP reception staff [8].
The benefits of referrals to CP has been demonstrated from secondary care, in managing transitions of care of people moving out of acute care and into community settings, with CP undertaking medicines optimisation to ensure changes to medicines are managed, polypharmacy reduced and that people are able to take their medication at home [9].

Referrals into CP from other services such as social care also has potential to reduce unnecessary admissions to hospital and other acute healthcare settings due to medication issues. For example, Bridgend Community Resource Team [10] include pharmacy technicians from local CP as part of a multidisciplinary team who deliver medicines optimisation to ensure that people can manage their medication in their own home. Evaluating the impact of such services on reducing avoidable hospital admissions would help understand the role and potential role of CP in supporting the delivery of social care and providing care closer to home which could extend beyond the pharmacy setting itself e.g. in people’s homes and in care homes.

There is limited evidence of the role and impact of outward referrals from CP. The ability for CPs to make direct referrals to other health services could help alleviate pressure on general practice (which is typically the first point of referral) whilst also affecting patient factors such as reducing time to treatment and improving health outcomes and service user experience. A review of evidence (2018) conducted by NICE [7], identified only four studies which explored the use of outward referrals and signposting by CP, of which only one study had explored direct referral to non-GP services i.e. sexual health [11].

From April 2020, CP were required to become Level 1 Healthy Living Pharmacies (HLP), creating teams that are aware of local health issues and consistently demonstrate they are promoting public health [3]. These changes are expected to lead to a greater need for CP to be able to make direct referrals and at the appropriate level to other services e.g. GP services, social care, sexual health, weight management, smoking cessation, vaccination services, mental health services, alcohol and drug misuse, and sleep disorders. Evaluating the barriers and facilitators to implementing the referral processes will help to understand how best to organise and deliver these services and deliver integrated care. Furthermore, understanding how the changing role of CPs is perceived and the acceptability amongst other health and social care services mentioned above is also needed to facilitate more effective partnerships and integration between services. Changing roles will also need to be reflected in workforce and professional development going forward.

Scope

The focus of this call is on extended community pharmacy services i.e. services delivered by a community pharmacy that go above and beyond just the dispensing of medicines. 

The setting is not limited to services that take place within the community pharmacy itself. For example, evaluating services delivered by a community pharmacy which take place in a person’s own home, care home or other community setting would be within remit for the call and are encouraged.

Research proposals should be co-produced with health and social care service commissioners, providers and service users to ensure that the proposed research asks the right questions, and is conducted in a way as to provide actionable findings to improve health and social care services, which is of immediate use to decision-makers. Links with health and social care planners and professional bodies are also encouraged to facilitate the impact and scaling up of research findings to benefit the wider health and social care system.

The COVID-19 outbreak is having a significant impact both directly and indirectly across our Health and Social Care Systems. As this research will be conducted during the COVID-19 response and recovery stage, the following research questions will benefit from being framed within a real-life perspective, including a recognition of the impacts of the COVID-19 outbreak. Please build in flexibilities and consider how the COVID-19 response and recovery may affect your ability to conduct your research and also the indirect impacts upon your research area if relevant. Applications that are directly related to COVID-19 are encouraged to consider applying to the COVID-19: Recovery and Learning funding opportunity.

The NIHR is committed to actively and openly supporting and promoting equality, diversity and inclusion (EDI). All NIHR applications need to demonstrate they have met the requirements of the Equality Act (2010) by embedding EDI throughout the research proposal, ensuring there is no discrimination across the following domains; age; disability; race, including colour, nationality, ethnic or national origin; religion or belief; sex; sexual orientation; gender reassignment; being married or in a civil partnership; being pregnant or on maternity leave. Applicants are expected to pay attention to populations in locations with greatest need, socioeconomic disadvantage, which have disproportionately less access to health and social care services and are of an under researched area.

Any, or all of the following issues are of particular interest, though other issues may be proposed. All applications should provide a clear justification of their importance and the potential impact it will have on health and social care services:

I. Equity, Acceptability and Accessibility: What is the acceptability and accessibility of extended community pharmacy services to patients and public - with a focus on underserved members of the community? From the perspective of and engagement of public and patients.

II. Organisational: What organisational models of extended community pharmacy services exist? How are they integrated with other services and what is required to improve integration between services? Potential outcomes of interest include: what is their impact on reducing inequalities and improving health and social care outcomes; reducing time to treatment; ensuring safety, and quality of care? How do costs compare between the different models?

III. Integrated care pathways: Which approaches work best to ensure integrated care pathways and effective communication and referral between extended community pharmacy services and other health and social care services, especially ensuring strong links with primary health care?

IV. Wider System Engagement: Which approaches, and communication activities have been most successful in engaging health and social care services to support and enhance delivery of extended community pharmacy services?

V. Quality & Safety: What models exists for enhancing the quality of extended community pharmacy services including ensuring patient safety and how these are managed, recorded and reported on.

VI. Workforce: Which workforce approaches are most effective to develop new staff roles and enable professional development to support staff in delivering extended community pharmacy services?

The NIHR Health Services and Delivery Research (HSDR) Programme supports applied research with the aim of improving health and social care services across the nation. In order to enhance the success of a proposal a clear theory of change and pathway to impact with links into the NHS and social care delivery process is suggested. It is useful to consider in your study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care– the focus is on applied research with tangible impacts on systems that improve the quality, accessibility and organisation of health and social care services. This also includes stakeholder engagement and the development of processes, tools and guidelines to strengthen workforce capacity. Further general information about the Health Services and Delivery Research Programme can be found here.

The programme is open to any methodology which is appropriate to answer the proposed research question. This has to be fully explained and justified. Further information on the background to this call, including evidence gaps and relevant research is given in the call supporting information document.

References

1.   Anderson C, Sharma R. Primary health care policy and vision for community pharmacy and pharmacists in England. Pharm Practice, 18. 2020. Available Online. Accessed May 2020
2.   NHS England. NHS Long Term Plan. 2019. Available Online. Accessed March 2020.
3.   The Community Pharmacy Contractual Framework for 2019/20-2023/24: supporting delivery for the NHS long term plan. 2019. Available Online. Accessed March 2020
4.   Hindi AMK, Schafheutle EI, Jacobs S. Patient and public perspectives of community pharmacies in the UK: A systematic review. Health Expectations, 21. 2018.
5.   Todd, A., Copeland, A., Husband, A., Kasim., A and Bambra, C. The positive pharmacy care law: an area level analysis of the relationship between community pharmacy distribution, urbanity and social deprivation in England. BMJ Open, 2014.
6.   de Barra M, Scott CL, Scott NW, et al. Pharmacist services for non-hospitalised patients. Cochrane Database of Systematic Reviews 2018, Issue 9. Art. No.: CD013102.
7.   NICE. NICE Guidance: Community Pharmacies; NG102. 2018. Available Online. Accessed March 2020.
8.   NHS England. NHS Community Pharmacist Consultation Service (CPCS) – integrating pharmacy into urgent care. 2020. Available Online. Accessed March 2020.
9.   Nazar, H., et al. A systematic review of the role of community pharmacies in improving the transition from secondary to primary care. Br J Clin Pharmacol 80(5): 936-948. 2015.
10. Welsh Pharmaceutical Committee. Pharmacy: Delivering a Healthier Wales. 2019.
11. Michie L, Cameron S, Glasier A et al. Pharmacy based interventions for initiating effective contraception following the use of emergency contraception: a pilot study. Contraception, vol 90 (4), p447-453. 2014.