A Study of Pharmore+: Pharmacy Walk-in Service Pilots

6 Lessons Learned

Opportunities

6.1 Although the approaches varied across the pilots, there were a number of opportunities common across all pilots;

• Improved patient choice and appropriate access to health care: The pilots aimed to bring services within easier access of the wider population. This was particularly important where services may not have been accessible to deprived communities or where people felt unable to access these services via other routes. Pilots were also keen to ensure their services were tailored to meet specific needs and that, in the case of the minor injuries and illness clinics, patients received the appropriate care and treatment (for example, the NHS Lothian pilot was clear that they offered their service for people who could not access their GP).
• Reducing attendance at A&E and out-of-hours services: Those pilots which provided unscheduled clinics noted there was significant potential to decrease attendance at A&E and out-of-hours services where patients could more easily and appropriately access minor injuries/illness services through the pharmacy. NHS Grampian noted most of the minor injuries which presented to A&E could easily be managed within a pharmacy environment.
• Expansion of the role of the community pharmacist and wider team: Pilots present benefits to professionals providing the service and the wider pharmacy staff though utilising existing skills and enhancing these through training and support. Pilots who introduced clinics noted that wider pharmacy staff benefited though increased awareness and knowledge of the clinic where they were triaging patients to the clinics or signposting to other services offered by the pharmacy. These benefits are not necessarily limited to pilot sites and there is potential for other pharmacy staff such as pharmacist independent prescribers and pharmacy technicians to expand their role and/or offer a wider range of services should they also receive the same training and support provided within pilots.
• Engagement and joint working with other services: Engagement of other services and professionals was essential for the pilots to deliver an extended range of services. NHS Greater Glasgow and Clyde noted success with working collaboratively with the Community Addictions Team both provided extended services out of the pharmacy and supported the pharmacy staff to deliver complementary services. NHS Lothian felt their pilot benefited greatly from multidisciplinary working and sharing good practice through peer review and clinical mentorship, establishing a 'learning in practice' model which greatly enhanced wider services and enabled joint working with the Lothian Unscheduled Care Service.
• Engagement with independent community pharmacy contractors: To enable implementation, health board pilot project teams needed to work closely with community pharmacy contractors to identify the pilot sites from which the pilot work would be tested and delivered. Community pharmacy contractors were supportive of the pilot programme and to deliver on its aims to widen access to a wider range of services and accommodate the practical requirements for implementation, such as the use and adaptation of premises to accommodate the new services. However, there were challenges, especially where pilot sites needed to undertake existing commitments, such as core contract services, and where there were infrastructure requirements, in particular developing compatible IT systems between pharmacy contractors or NHS and contractor requirements such as building and occupancy agreement.

Challenges

6.2 The opportunities presented by implementing the pilots also presented the following challenges;

• Long lead-in time: Where pilots were introducing new services, in particular new models of care, they required a long lead-in time to plan and implement the service. Particular challenges were evident in; engaging with NHS local priorities and ensuring the pilots reflected local priorities and linked into existing services; ensuring the right equipment and facilities were available within the pilots to implement the service; establishing workable information system for data sharing; and the recruitment, training and support for staff delivering the service.
• Balancing new with existing commitments: When delivering the services, pilots needed to balance existing commitments with the additional services they were providing. This was particularly evident where pilots included pharmacy technicians to take on non-clinical health improvement roles. Pilots in general were aware that in order to provide additional services they still needed to deliver their core contract services commitments as well, which would then enable funding to be available to expand the range of service they could provide. A key tension experienced by the pilots was managing the existing service in particular delivering on the volume of prescriptions required to be dispensed, with the development and implementation of new services for patients.
• Engaging other services and professionals: Where pilots sought to engage with out-of-hours services, this proved challenging for some. In some cases other out-of-hours services were unsure about the potential quality of care and whether pilots would duplicate existing service. Furthermore some pilots reported suspicion from other professionals about the potential of the pilots to provide safe and effective care. However where pilots were able to sufficiently demonstrate the role of the community pharmacy in providing complementary out-of-hour service, there was broad support for the service. There was a recognition by other services that the pilots were small scale and localised with limited possibility for expanding the service or recognising the skills and expertise of the processionals' delivery of the service beyond the pilot. Therefore the possibility of expansion of services was felt to sometimes be limited as service planners were reluctant to offer a service that they couldn't deliver.

Future development

6.3 Capacity to undertake the pilots was an issue. In order to plan and implement the pilot, staff had to invest much more time and commitment than initially thought. The success of the pilots reflects the dedication and commitment of the staff who implemented them, however the ability to sustain the involvement was a challenge, particularly if the pilots were to move beyond testing new models or introduction of new services. As the pilots were time limited, pilot sites were unable to commit further resources where future service development is uncertain. Of the two remaining pilots still in operation. NHS Grampian felt, due to the time taken to become established, they had only recently just got going and as a result were keen to continue despite challenges with securing future resources. NHS Lothian's service has been delivered for more than 2 years now. It is still getting established as a routine access point to out of hours care by the public but that is a long term education exercise which they haven't pursued too strongly because it is not a service that will necessarily be there in the long term.

Scottish Government Role

6.4 The pilots were funded nationally through the Scottish Government. National funding and the freedom to interpret the aims of the pilot were seen as helpful by the pilots as this allowed them to respond to local NHS priorities, enabling greater potential for buy-in from decision makers about service priorities and the potential role of pharmacies to contribute. National funding also meant that the piloting was possible. It was suggested that the pilots may not have been implemented if they had been considered within the priorities at local level.

6.5 While national funding was seen as helpful, some pilots suggested that it brought challenges locally. For example some suggested that engagement with NHS service leads including CHPs at local level was challenging as the pilot was seen as national initiative. Finance also proved difficult where pilots were funded for two years, then a further year which meant that pilots found it challenging to plan their services (which was further complicated by delays in start up and the swine flu crisis).

6.6 As this was a Scottish Government initiative, to some extent the pilots tended to select services which reflected the aims of the pilot (expending opening hours, access to wider range of services) and practical considerations about which pharmacies may be best placed to deliver on these. However, there was a suggestion that local engagement and ownership might be improved if consideration of local health priorities was carried out first then how the community pharmacy could contribute to the delivery of these priorities.