Community Pharmacy Services

Question 1

Where do pharmacies get their income from?

Answer 1

1) NHS Contract 2005 onwards including other NHS services: Essential services, Advanced services,
Locally commissioned services
2) Private prescription services
3) Private pharmacy services
4) Specialist services, e.g. private prescriptions and/or stock supplies to prisons/ hospices/ drug treatment units/MOD
5) Pharmacy sales

Question 2

Why are the services offered by a pharmacy so Important?

Answer 2

1) Prior to 2005, dispensing was a well paid for service funded by the NHS.
2) 2005 NHS contract laid out a services framework which has been further expanded.
3) Funding is continually being taken away from dispensing within the contract and put into further service provision.
4) 2015 There is little profit to be made from dispensing alone.
4) Services are an increasingly important part of pharmacy business

Question 3

Pharmacies in England who have contracts with the NHS provide three tiers of services. what are these 3 tiers of service

Answer 3

1) Essential services- mandatory-paid for offering the whole NHS service and for each patient interaction for dispensing
2) Advanced services- optional- paid for each patient interaction
3) Enhanced/ locally commissioned services- optional-paid for each patient interaction

Question 4

list some Essential services which are part of the NHS pharmacy contract

Answer 4

1) Dispensing
2) Repeat Dispensing
3) Disposal of unwanted medicines
4) Promotion of healthy lifestyles (public health)
5) Sign-posting patients to other healthcare providers
6) Support for self-care
7) (Clinical governance)

Question 5

The most important part of the NHS contract is Dispensing which is an essential service. what is dispensing?

Answer 5

1) The supply of a medicine, appliance, chemical reagent or other allowable substance against an NHS prescription written by an authorised prescriber.
2) Supply must be made within a reasonable time providing it is clinically safe to do so. Supply, clinical interventions, owings and referrals must be recorded on a patient medication record (PMR).
3) Standard Operating Procedures (SOPs) must be in place
4) Collection of correct dispensing fee/check exemption (DRUG TARIFF!)

Question 6

As part of the dispensing process Pharmacies provide extra services to supplement the requirements of the NHS contract (with no NHS payment and not part of the contract). list some of these services

Answer 6

1) Prescription collection service
2) Delivery Service- Usually medication is driven to patient’s homes by couriers or employed staff (SOPs & training for drivers)
3) Compliance Aids
4) (monitored dosage systems- MDS)
5) Care Home Services

Question 7

how would you reorder a repeat medication?

Answer 7

1) For regular prescriptions, no need to see the GP each month.
2) patients can use the repeat request form to reorder medication. the white slip will contain the mecations the patient is on. just tick the ones they would like for nextime and ask them when they will next need it. check the review date on the white slip as well
3) Also surgery websites/emails/fax to reorder

Question 8

what is the Prescription collection service?

- what are the 4 different types

Answer 8

1) Pharmacy collects script only – patient orders from GP surgery.
2) Order medication and collect – patient brings repeat form to the pharmacy, who order medication from GP surgery and collect Rx
3) Keep Repeat Service – pharmacy keeps the repeat form and patients phone, email or call in to order medication. Pharmacy orders meds from GP surgery and collects Rx
4) Managed Repeat Service – pharmacy orders items and collects Rx for the patient

Question 9

what compliance aids are provided in the pharmacy?

Answer 9

1) 7 day packs, each day has time sections- usually morning and night, or morning, lunch, evening, bedtime and tabs/caps are put in appropriate blister
- eg. Dossette boxes, Manrex , NOMAD, Medisure , MTS plus packs
- Pharmacist must be satisfied patient can use device safely

Question 10

what are Care Home Services and why do pharmacies provide them?

Answer 10

1) Medicines for residents of care homes packed into individual blisters, colour co-ordinated for different times of day
2) Easier and safer for care home staff
3) Medicines Administration Record (MAR) chart: Generated by pharmacy at time of dispensing prescription.
- Used by care home staff to record administration to patient
- Responsibility for MAR chart accuracy lies with care home staff/ their procedures

Question 11

what is Services-Repeat Dispensing, and which patients are normally provided with this service?

Answer 11

1) Although an essential service and is nationally commissioned, uptake depends on GPs in the locality
2) Up to 12 months of prescriptions are issued at once usually in 28 day ( batch of 12 prescriptions) or 56 day (batch of 6 prescriptions) without the need to return to GP
3) Only for patients on stable medication, pharmacists responsibility to ensure suitability of repeat supply
4) RA and RD prescription forms
5) Formatted for EPS2 (electronic prescribing)

Question 12

what is an RA and a RD?

Answer 12

1) RA- repeat authorisation- only one signed copy and contains the number of repeats available. you cannot dispense from this form
2) RD- repeat dispensing batch prescription. there are many copies, unsigned and each one specifies which repeat ( RD 1 of 12, 2 of 12) . let the patient know how many repeats are left after each pick up. you can dispense these prescriptions
3) The RA is required every time an RD is dispensed as it contains the authorisation information.

Question 13

an Essential Services is the Disposal of Waste Medication. what medication is normally returned to the pharmacy? does the NHS pay for this service? what items cannot be taken by the pharmacy?

Answer 13

1) Unwanted or out of date patient’s medication can be returned to the pharmacy
2) NHS England makes arranges and pays for a specialist waste contractor
3) Pharmacy must ensure SOPs and safety equipment are in place to handle patient returns
4) Can accept waste from care homes (depends on type) -pharmacy may have to pay for it.
5) Special requirements for recording and denaturing returned CD
6) No sharps/ chemicals

Question 14

an Essential Service is the Promotion of a Healthy Lifestyle. how do pharmacists spot patients who might benefit from this service?

Answer 14

1) Provision of opportunistic advice to patients with prescriptions indicating need, e.g.: diabetes, smokers
hypertensive/ high cardiovascular risk
2) Promotion of healthy lifestyle to all
3) Take part in local and national health campaigns
4) Document actions

Question 15

another Essential Service is the Support for Self Care. which conditions is this normally relevant too?

Answer 15

Provision of advice for:

1) Self limiting illness (responding to symptoms)
2) Long term conditions
3) Document interventions

Question 16

Signposting is an essential service. what is signposting and where can pharmacists signpost patients too?

Answer 16

1) Recognises that pharmacists may not be able to fully support a patient’s needs and that they can refer to further sources of help: information service, local support groups, other healthcare professionals, may be a local NHS or other service
2) Also take part in local and national health campaigns
3) Document actions

Question 17

list the 5 Advanced NHS Services and state if they are optional of if the pharmacist is required to provide them

Answer 17

1) Optional
2) Medicines Use Review (MUR) and Prescription Intervention Service
3) New Medicines Service (NMS)
4) Flu vaccination service (from Sept 2015)
5) Appliance Use Review (AUR) Service
6) Stoma Appliance Customisation (SAC) Service

Question 18

The first nationally commissioned advanced service for pharmacists was an MUR. The aims of the service was to improve patient knowledge, adherence and use of their medicines. how is this goal achieved?

Answer 18

1) establishing the patient’s actual use, understanding and experience of taking their medicines
2) identifying, discussing and resolving poor or ineffective use of their medicines
3) identifying side effects and drug interactions that may affect adherence
4) improving the clinical and cost effectiveness of prescribed medicines and reducing medicine wastage

Question 19

what must pharmacists wishing to conduct an MUR have?

Answer 19

1) be accredited through completion of a recognised course
2) be satisfactorily complying with the essential services
3) have an acceptable system for clinical governance
4) have appropriate SOPs in place
5) have a suitable consultation area in pharmacy

Question 20

what are MUR’s They are designed to review:

Answer 20

1) if a patient takes a medication
2) how they take their medication
3) if they have any problems with their medication
4) assesses if medication is appropriate for the patient and is cost effective and follow guidelines

Question 21

Only certain patients can have an MUR. who is eligible?

Answer 21

1) Must take at least two medicines for chronic conditions (one if high risk medicine)
2) Must have been using the pharmacy for the previous 3 months
3) Must not have had an NMS in the last 6 months
Must not have had an MUR in the previous 12 months
4) Intervention MUR?
5) Must be able to provide signed consent

Question 22

70% of MURs are Targeted. list the types of medications and conditions that are targets for MUR’s

Answer 22

1) Patients taking high risk medicines:
Anticoagulants/ antiplatelets, Diuretics, NSAIDs
2) Patients recently discharged from hospital
3) Patients with respiratory disease (asthma or COPD)
4) Patients at risk of/ diagnosed with cardiovascular disease and regularly prescribed at least four medicines.
5) Coronary heart disease, Diabetes Atrial fibrillation, Thyroid disorders, Heart failure, Stroke/TIA, Hypertension

Question 23

what % of medications are not taken as recommended?

Answer 23

1) 30-50% of prescribed medicines are not taken as recommended
2) 10 days after starting a new medicine:
- 7% of patients completely stopped taking medicine
- 45% of non-adherence was intentional
- 66% of those still taking the medicine reported a problem

Question 24

Who is eligible for a NMS and why are these patients targeted?

Answer 24

1) Patients eligible for the service are those starting a new medication which is being used to treat:
- Asthma or COPD
- Diabetes (Type 2)
- Antiplatelet/ Anticoagulation therapy
- Hypertension
2) These groups have been selected because they:
- have greatest degree of non-adherence
- will benefit the most from the service
- Must be a new drug molecule, not a different formulation.

Question 25

what is the aim of NMS and what are the 3 stages to the process?

Answer 25

1) Provides support to people newly prescribed a medicine to manage a long term condition through helping them to appropriately improve their medication adherence.
2) Three stage process:
- Patient Engagement (Day 0)
- Intervention (Day 7-14)
- Follow Up (Day 21-28)
3) Opportunity to provide healthy living advice at each stage

Question 26

discuss the benefits of the NMS

Answer 26

1) improves patient adherence
2) increases patient engagement with their conditions and medicines
3) reduces medicines wastage
4) reduces hospital admissions due to medication related adverse events
5) leads to increased yellow card reporting
6) receives positive assessment from patients
7) supports the development of outcome and/or quality measures for community pharmacy

Question 27

Seasonal Flu Vaccination is an NHS Advanced Service. why is this service provided?

Answer 27

1) Provision of seasonal flu vaccines (IM/SC) free of charge to eligible patients
2) Improve patient choice
3) GP service: High level of uptake by over 65s but low uptake of flu vaccine to ‘at risk’ groups
4) Provide more consistent coverage and less local variation in flu vaccine uptake

Question 28

who is eligible for the Flu Vaccination service?

Answer 28

1) over 65s
2) NHS ‘at risk’ patients-6 months-2yrs and over 18s plus 2-17 yrs that cannot have ‘Fluenz’
3) At risk groups-pregnant women, care home residents, people with long term conditions e.g. severe respiratory illness, cardiac, hepatic, renal, neurological, immunodeficiency disorders
4) carers

Question 29

what are Patient Group Directions (PGD)?

Answer 29

1) Administration or Supply of POMs without a prescription
2) Written instructions for the supply or administration of medicines to a group of patients who may not be individually identified before presentation for treatment
3) Provides a legal framework to allow the supply and/or administration of a specified medicine(s) by named, authorised registered health professionals to a pre-defined group of patients needing prophylaxis or treatment for a condition described in the PGD
4) No prescription is needed but labelling requirements for POMs still apply/PIL provided/ records kept as stated in PGD documentation.

Question 30

what are the requirements for a PGD?

Answer 30

1) Patient Group Direction (PGD) OR Patient Specific Direction (PSD)
2) Verification of online and/ or face to face training
3) Standard Operating Procedures (SOPs)
4) Regular renewal and review of training/contract

Question 31

list the content found within a PGD document

Answer 31

1) Written and signed off by doctor (or dentist) pharmacist and an authorising body
2) Introduction
3) Clinical condition or situation to which this direction applies- Inclusions and exclusions
4) Designated staff authorised to supply medicines prescribed under the PGD
5) Description of treatment available under the PGD
Documentation
6) Facilities and Supplies to be Available at Sites supplying PGD
7) Management and Monitoring of Patient Group Direction

Question 32

what is a PSD and how does it differ from a PGD?

Answer 32

1) Patient Specific Direction- same as a PGD except instead of a group of patients identified by the inclusions and exclusions, it is specific for named patients (patient list)
- E.g. Dr s having a specific list of named patients for a vaccine or warfarin supply as part of a warfarin clinic service (Havering CCG 2015)

Question 33

what training does the Pharmacy Advanced NHS Flu Service require?

Answer 33

1) Face to face training :
- anaphylaxis,
- basic life support (CPR)
- injection technique IM/SC
- E-learning and e-assessment, Declaration of Competence
2) NHS PGD, pharmacy SOP, patient assessment and consent forms
3) Additional locally commissioned services in some areas, e.g:Pneumovax vaccine to over 65s (London), Local authority workers flu jab (Dorset)

Question 34

who should pharmacists inform after a flu jab and how much do they get paid by the NHS?

Answer 34

1) Inform patient’s GP after flu jab to: collate national flu vaccination data, add to medical records, ensure that patient is not vaccinated twice
2) Each patient has to complete a questionnaire
3) Payment
- Claim from NHS BSA on FP34C form with prescription data at month end (£9.14 plus flu vaccine costs)
- Locally enhanced additional services via SONAR/ Pharmoutcomes

Question 35

what are Locally Enhanced (LES) or Locally Commissioned Services? who funds them?

Answer 35

1) now paid for by:
- Clinical Commissioning Groups (CCGs)
- Public Health England via local authorities (Councils)
- NHS England
2) Formal tendering process for NHS standard contracts
3) Services local, often for a small area (Town, City, County Councils)
4) Local Pharmaceutical Committees (LPCs) instrumental in keeping local pharmacies involved and informed.

Question 36

list some Clinical Commissioning Groups (CCGs) funded Locally commissioned services services.

Answer 36

1) INR clinics and warfarin supply
2) Tailored dispensing service
3) Latent TB service
4) Palliative care service

Question 37

list some PHE funded (via local councils) Locally commissioned Services.

Answer 37

1) EHC to young people
2) Chlamydia testing kits and condoms
3) Chlamydia treatment (azithromycin)
4) Stop smoking services
5) Supervised consumption of methadone/ buprenorphine
6) Needle exchange
7) NHS Health Checks

Question 38

list some NHS funded Locally Commissioned Services.

Answer 38

1) Minor ailments scheme

2) Emergency supply

Question 39

list some Locally Commissioned Sexual Health Services

Answer 39

1) Chlamydia testing kits supply to young people
2) Azithromycin provision for positive test results
3) Condom supply

Question 40

list some private services offered by pharmacies

Answer 40

1) Erectile dysfunction (Viagra, Cialis, Levitra)
2) Antimalarials (Malarone, doxycycline, Lariam)
3) Influenza and hepatitis B vaccine (all brands)
4) Meningitis ACWY Vaccine (all brands)
5) Stop smoking (Champix)
6) Hair loss (Propecia)
7) Emergency contraception (Levonelle and ellaOne)
8) Salbutamol inhalers (for repeat supply)
9) Oral contraception (all brands)
10) Cystitis treatment (trimethoprim)
11) Travellers’ diarrhoea (Xifaxanta)
12) Female facial hair (Vaniqa cream)
13) Weight loss (orlistat 120mg)
14) Period delay (norethisterone 5mg)
15) Travel vaccines (MASTA)-include yellow fever

Question 41

PGD authorising the supply of finasteride 1mg tablets

(Propecia) to treat male pattern baldness. what might different PGD’s require for a person to be eligible?

Answer 41

Different PGDs may require a particular degree of male pattern baldness for the patient to be eligible

Question 42

apart from the private services discussed earlier list some other private services offered by a pharmacy.

Answer 42

1) Online Dr/ pharmacy links
2) P/ GSL medicines online sales
3) Supplies of medication to hospices/ prisons/
4) FMed296 prescriptions
5) Independent prescribers
6) GP surgery: medicines reviews