Services eBook

Question 1

List 8 Essential Services available under the CPCF.

Answer 1

Dispensing of medicines
• Dispensing of appliances
• Repeat dispensing
• Public health
• Disposal of unwanted medicines
• Signposting
• Support for self-care
• Clinical governance

Question 2

List 6 Advanced Services available under the CPCF

Answer 2

• Medicines Use Review (MUR)
• Appliance Use Review (AUR)
• New Medicines Service (NMS)
• Flu vaccination
• Stoma Appliance Customisation (SAC)
• NHS Urgent Medicine Supply Advanced Service (NUMSAS)

Question 3

Examples of locally commissioned services include:

Answer 3

• Substance misuse services – needle exchange and supervised consumption
• Smoking cessation
• Minor ailments schemes
• Palliative care services
• Head lice management
• Out of hours services
• Pandemic and seasonal flu services

Question 4

Compare Essential, Advanced and Enhanced Services

Answer 4

Service Type

• Commissioned Locally or Nationally
• Pharmacist Accreditation Required
• Pharmacy Must Offer (Yes / No)

Essential

• Nationally
• No
• Yes

Advanced

• Nationally
• Generally yes but see individual service specifications
• No

Enhanced

• Locally
• Generally yes but see individual service specifications
• No

Question 5

Market Entry and Pharmaceutical Needs Assessment

Answer 5

Since the Health Act 2009, Clinical Commissioning Groups (CCGs – formerly Primary Care Trusts (PCTs)) have been required to publish Pharmaceutical Needs Assessments to determine where pharmacies are needed in their area. This information then forms part of
the decision to award a contract to a company applying to open a pharmacy in the area.
Historically market entry was assessed by a ‘necessary or desirable’ test based on the adequacy of pharmaceutical services in the local area. Four exemptions from this test were introduced in 2005:
• Pharmacies in large out of town retail developments
• Pharmacies open for a minimum of 100 hours per week
• Pharmacies in ‘new’ one stop primary care centres
• Mail order or internet pharmacies
In December 2016 the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 were amended to prevent another pharmacy from stepping in straight away when two pharmacies merge together on one site provided this merger does not create a gap in
provision.

Question 6

Review the PSNC guidance on NMS and MUR patient consent requirements. Use
this box to record any notes you’d like to make about this factsheet.

Answer 6

From 1st October 2011, where a patient agrees to participate in the New Medicine Service (NMS) or the Medicines Use Review (MUR) service they must sign a consent form which uses the following wording:

Consent to participate in the NHS New Medicine Service/NHS Medicines Use Review Service
I agree that the information obtained during the service can be shared with:
 my doctor (GP) to help them provide care to me
 the Primary Care Trust (PCT – the local health authority) or successor organisation to allow them to make sure the service is being provided properly by the pharmacy
 the Primary Care Trust (PCT) or successor organisation, the NHS Business Services Authority (NHSBSA) and the Secretary of State for Health to make sure the pharmacy is being correctly paid by the NHS for the service they give me.

Following the changes to the contracting arrangements for the Community Pharmacy Contractual Framework in April 2013, the following revised wording must be used by pharmacy contractors as soon as practicable.
NHS England, NHS Employers and PSNC recognise that pharmacy contractors will wish to use up stock of consent forms using the original wording, but any reprints of consent forms should use the new wording set out below.

Consent to participate in the NHS New Medicine Service/NHS Medicines Use Review Service
(delete as applicable)
I agree that the information obtained during the service can be shared with:
 my doctor (GP) to help them provide care to me
 NHS England (the national NHS body that manages pharmacy and other health services) to allow them to make sure the service is being provided properly
by the pharmacy
 NHS England, the NHS Business Services Authority (NHSBSA) and the Secretary of State for Health to make sure the pharmacy is being correctly paid by the NHS for the service they give me.

Question 7

Confidentiality

Answer 7

The law surrounding confidentiality includes the Human Rights Act 1998, Data Protection Act 1998 and the common law duty of confidentiality. The GPhC has published guidance on patient confidentiality, which aligns with the Standards for Pharmacy Professionals.

Question 8

Confidential information includes:

Answer 8

• Electronic and hard copy data
• Personal details
• Information about a person’s medication – this includes non-prescribed medicines
• Other information about a person’s medical history, treatment or care that could identify them
• Information that patients or the public share that is not strictly medical in nature

Question 9

Information is not considered ‘confidential’ if..

Answer 9

it is anonymous, coded so that it is not possible to identify the person from it, or if the information is already legitimately in the public domain

Question 10

Safe Custody of Patient Information
You must take appropriate steps to ensure that all confidential information you hold is
protected. This includes

Answer 10

• Taking reasonable steps to protect the confidentiality of information received, stored, sent or destroyed
• Securely storing hard copy and electronic documents, including records, registers, prescriptions and other sources of confidential information
• Taking steps to prevent accidental disclosure of info
• Not discussing confidential information in an area where others can overhear
• Not disclosing information on websites, internet forums or social media
• Ensuring all members of the pharmacy team understand their duty of confidentiality
• Raise concerns about data control with the appropriate person where you suspect the security of personal information is not appropriate
• Continue to protect a person’s confidentiality after they have died

Question 11

Disclosure Required by Law. There are circumstances where

Answer 11

There are circumstances where you may be legally required to disclose confidential information about a patient. Bodies with legal authority to request disclosure include:
• The police or other enforcement, prosecuting or regulatory authority
• A healthcare regulator e.g. GPhC or GMC
• An NHS counter-fraud investigation officer
• A coroner or procurator fiscal, judge or relevant court which order that the information should be disclosed
None of these individuals or organisations have an automatic right to access all confidential patient information, therefore you must be satisfied there is a legitimate reason for the request.
In the case of any disclosure without consent, you should be satisfied that the law requires you to disclose the information, ask for clarification from the person making the request if you are unsure about the reasons for the request, and ask for the request in writing.

Question 12

Disclosing the Information

If you decide to disclose confidential information, the GPhC recommend that you:

Answer 12

• Code the information or make it anonymous unless necessary to identify the patient
• Obtain consent unless disclosure is required by law or in the public interest
• Disclose only the information needed for the particular purpose
• Ensure the person receiving the information knows that it is confidential
• Make records to show who the request came from, whether you obtained patient consent, whether consent was given or refused and what you disclosed
• Release the information promptly

Question 13

Medicines Use Review and Prescription Intervention Service

Answer 13

Medicines Use Reviews (MUR) are an advanced service provided by community pharmacists under the Community Pharmacy Contractual Framework. MURs differ from full clinical medication reviews as MURs do not require a full medical history to be obtained. MURs
focus on a patient’s medicines use, their understanding and experience of taking these medicines, as well as any side effects, drug interactions or other factors that may be affecting adherence.

Accreditation
Pharmacists and the pharmacy both need to be accredited for an MUR to be performed; the
NHS England Local Area Team accredits the pharmacy, whereas pharmacists are required to
complete an approved training course to become accredited to provide the service.
Providers of MUR courses include the Centre for Pharmacy Postgraduate Education (CPPE),
Welsh School of Pharmacy (WCPPE), Keele University and Medway School of Pharmacy.

Location
MURs must be provided from an ‘acceptable location’. The latest service specification
(PSNC, 2013) identifies an acceptable location as an area for confidential consultations at
the pharmacy premises, which is:
(i) Clearly designated as an area for confidential consultations,
(ii) Distinct from the general public areas of the pharmacy premises, and
(iii) An area where both the person receiving MUR services and the registered pharmacist providing those services are able to sit down together and talk at normal
speaking volumes without being overheard by any other person (including pharmacy staff)
Paragraphs (i) and (ii) shall not apply in circumstances where the pharmacy premises are closed to other members of the public.
MURs can be performed outside of the pharmacy, but only with prior approval from the local authority – applications to perform an MUR outside of the pharmacy or over the phone need to be made to the local NHS England team using the PREM2 form.

Question 14

MUR Eligibility

Answer 14

Patients are eligible for one annual MUR and as many intervention MURs as needed in any 12 month period. For an annual MUR a patient must be a regular patient with 3 months history with the pharmacy however intervention MURs can be performed on patients without any history with the pharmacy if necessary.
At least 70% of MUR consultations should be carried out on patients who are in one or more of the national target groups, which are:
• Patient taking high risk medicines – NSAIDs, antiplatelets, diuretics or anticoagulants
• Patients with cardiovascular disease – must be on at least one medicine to manage
cardiovascular risk and on a total of 4 or more medicines
• Patients with respiratory disease
• Patient recently discharged from hospital who had changes made to their medicines whilst they were in hospital – ‘recently discharged’ is usually within 4 weeks from discharge but can be up to 8 weeks after

Any patient who has participated in NMS would not be eligible for an annual MUR for 6 months, however an intervention MUR could be performed if necessary. For any intervention MUR it is appropriate to conduct a full review of all of the patient’s medication, not just the medication you have made an intervention for.

Question 15

TASK 6: For each of the patients below state whether the patient is eligible for MUR or the
Prescription Intervention Service, and whether this would be a targeted or non-targeted
MUR.

Mr Darvill participated in NMS 3 months ago for Aspirin 75mg Dispersible Tablets and has not reported any issues with his medication. He is also taking Simvastatin Tablets 40mg.

Mrs Tate, a regular patient of the pharmacy for the past 10 years who is taking Amlodipine
Tablets 10mg, Atorvastatin Tablets 20mg and using a Salbutamol Inhaler for asthma.

Miss Agyeman, who presents in the pharmacy saying she is having ‘problems’ using her Seretide 250 Evohaler. She has never visited your pharmacy previously.

Mr Capaldi who is taking Metformin 500mg Tablets for diabetes, Atenolol Tablets 50mg for hypertension and Sildenafil Tablets 50mg for erectile dysfunction. He has been regularly
visiting the pharmacy for the last 6 months and has not had an MUR previously

Answer 15

• No to MUR as patient has had NMS within last 6 months.
• Yes. It would be a targeted MUR as patient is on a respiratory medication for one of the target groups
• Yes if provided under Prescription Intervention Service as an intervention MUR
• Yes. It would be a generic MUR as although the patient is on one medicine for cardiovascular risk, he is only on a total of 3 medicines so doesn’t meet the requirement of 4 drugs for the cardiovascular disease target group.

Question 16

MUR Payment

Answer 16

Pharmacies can claim payment for each MUR performed using the FP34C form at the end of each month. The 2017 rate is set at £28 per MUR, with a maximum of 400 MURs per financial year (1st April to 31st March). Pharmacies can exceed this number but will only be paid for 400.

Question 17

New Medicines Service

Answer 17

The New Medicines Service (NMS) is an advanced service provided under the Community Pharmacy Contractual Framework which was designed to provide support to patients newly prescribed medicines for the treatment of selected long term conditions to help improve adherence. The service is expected to:
• Improve patient adherence
• Increase patient engagement with their condition and medicines
• Reduce hospital admissions due to adverse events from medicines
• Lead to increased Yellow Card reporting of adverse reactions to medicines, and consequently support improved pharmacovigilance

Question 18

List the 4 conditions and therapies covered by NMS. Give one example of a drug
for each.

Answer 18

• Asthma and COPD
The patient’s newly prescribed medicine is listed in one of the following BNF chapters/sub-sections:
3.1.1 Adrenoceptor agonists
3.1.2 Antimuscarinic bronchodilators
3.1.3 Theophylline
3.1.4 Compound bronchodilator preparations
3.2 Corticosteroids
3.3 Cromoglicate and related therapy, leukotriene receptor antagonists and phosphodiesterase type-4 inhibitors

• Type II diabetes
The patient’s newly prescribed medicine is listed in one of the following BNF chapters/sub-sections:
6.1.1.1 Short acting insulins
6.1.1.2 Intermediate and long acting insulins
6.1.2 Antidiabetic drugs

• Antiplatelet or anticoagulant therapy
The patient’s newly prescribed medicine is listed in one of the following BNF chapters/sub-sections:
2.8.2 Oral anticoagulants
2.9 Antiplatelet drugs

• Hypertension
The patient’s newly prescribed medicine is listed in one of the following BNF chapters/sub-sections:
2.2.1 Thiazides and related diuretics
2.4 Beta-adrenoceptor blocking drugs
2.5.1 Vasodilator antihypertensive drugs
2.5.2 Centrally acting antihypertensive drugs
2.5.4 Alpha-adrenoceptor blocking drugs
2.5.5 Drugs affecting the renin-angiotensin system
2.6.2 Calcium-channel blockers

Any change of formulation is not classed as being appropriate for NMS e.g. a patient changing from Ramipril capsules to Ramipril tablets would not be eligible for NMS, whereas a change from one drug to another in the same class would be e.g. changing from Ramipril Tablets to Lisinopril Tablets.

Question 19

NMS is split into three stages:

Answer 19

• Patient engagement
• Intervention
• Follow up

Patient Engagement
Patients are recruited into the service either by prescriber referral or by the pharmacy team when dispensing the prescription. Unlike MUR, a patient is not required to have visited the pharmacy previously. Once written consent has been obtained the patient should be given
initial advice about the medicine and how the NMS service works. Pharmacists are encouraged to use this discussion to provide opportunistic advice about healthy living and public health topics appropriate to the patient.
During this stage the pharmacist and patient should agree a method (face-to-face or via telephone) and a time for the intervention discussion; the intervention should occur between 7 and 14 days after patient engagement.

Intervention
As identified above, the intervention discussion occurs 7 to 14 days after patient engagement. During this discussion the pharmacist should confirm that the patient
understands the information they were given in the engagement stage and that the patient is still willing for their information to be shared with the GP if necessary. If consent is withdrawn then the intervention should not be performed.
If the patient has attended the pharmacy for a face-to-face discussion, the intervention should take place in the consultation room. If a phone call is preferred then this should take place in an area where the conversation cannot be heard by other people in the pharmacy.
During the intervention the pharmacist assesses the patient’s adherence to the medication and identifies any problems the patient may be having. Where issues are identified the pharmacist can either provide advice to help the patient manage their medication or refer
to the GP – an example where the pharmacist could advise rather than referring to the GP would be where changing the timing of the dose might benefit the patient. As with engagement, the intervention can be used to provide healthy lifestyle advice to the patient.
Depending on the outcome of the intervention, the pharmacist will either:
• Agree time and location for the follow up – this is usually between 14 and 21 days after the initial intervention. This would be appropriate where the patient is adherent and no problems have been identified
• Agree time and location for the follow up and any remedial steps to be taken by the patient. This would be appropriate where the patient is experiencing an issue that could be resolved with advice from the pharmacist
• Refer the patient back to their GP. If this course of action is followed the pharmacist should complete the NMS feedback form and send this to the GP. If a patient is referred back to their GP at this stage the NMS is deemed complete.

Follow Up
The patient discussion for follow up is the same as for intervention, with the service deemed ‘complete’ where:
• The patient is adherent
• A problem has been identified and the pharmacist and patient agree a solution
• A problem has been identified and the patient referred to their GP
• The pharmacist has made two separate attempts to contact the patient but been unsuccessful on both occasions

Data Collection
As with MUR, a written consent form and data collection tool meeting the data collection requirements for the service should be completed and retained for 2 years following completion of the service. The data collection requirements are listed in the service specification detailed in the further reading section. As with MUR, pharmacies are required to submit their NMS data to their local NHS England team at the end of each quarter.

Question 20

Payment NMS

Answer 20

The current remuneration for each completed NMS is £20 per new medicine

Question 21

TASK 8: For each patient below, state whether the NMS is ‘complete’

Mr Smith was recruited to NMS 7 days ago but cannot be contacted on two occasions.

Miss Jones was recruited to NMS 12 days ago. You have contacted her and she is having no
issues with her new medicine.

Mrs Davies was recruited to NMS 23 days ago. You have spoken to her face-to-face at the
intervention stage however you have been unable to contact her on two occasions for
follow up.

You had advised Mr Green to take his Ramipril Capsules at night during the intervention stage as he was experiencing “light headedness” during the day when taking the medication. During follow up the patient explains that taking the capsules has “worked wonders” but he now has an occasional dry cough, which you decide to refer Mr Gall to his GP for.

Answer 21

• No
• No – 12 days is within intervention stage so need to progress to follow up first
• Yes – intervention stage completed and two attempts made to follow up
• Yes – intervention and follow up stages both completed. GP referral in follow up stage counts as completion

Question 22

NHS Urgent Medicine Supply Advanced Service

Answer 22

The pilot of the NHS Urgent Medicine Supply Advanced Service (NUMSAS) was introduced in December 2016 as part of the 2016 review of the CPCF and runs until 21st March 2018.
Funding for NUMSAS comes from the Pharmacy Integration Fund (PhIF), which was created to provide funding to allow community pharmacy to develop the clinical services, working practices and digital platforms provided by the sector. It is important to note that NUMSAS is a separate service from standard emergency supplies and requires NHS 111 referral for this service to apply.

Question 23

The four objectives of NUMSAS are:

Answer 23

• Manage appropriately NHS 111 requests for urgent medicine supply
• Reduce demand on the rest of the urgent care system
• Resolve problems leading to patients running out of their medicines
• Increase patients’ awareness of electronic repeat dispensing

Question 24

Fees

Pharmacies receive a set of fees for provision of NUMSAS; these are:

Answer 24

Pharmacies receive a set of fees for provision of NUMSAS; these are:
• Consultation fee
• Administration fee
• Medicine supply fee – only if a medication or appliance has been supplied
• Additional medication supply fee – if additional medicines are supplied. This is at a lower rate than the medicine supply fee

Question 25

RD/RA

Answer 25

• Each RD form should be sent to the PPD at the end of the month in which it was dispensed
• The RA form is only sent to the PPD at the end of the month in which the final RD from the batch has been dispensed, or the month in which the batch issue was
stopped by the GP

Question 26

eRD has become the most common type of repeat dispensing and has slight differences to the paper system. These include:

Answer 26

• No RA form is issued – each prescription loaded to the Spine is an RD as the initial issue by the GP counts as the authorisation for repeat dispensing however a Repeatable Prescription Authorising Token can be issued by the prescriber to reassure the patient that they have a prescription
• Pharmacies need to issue and claim each RD form to be able to download the next prescription from the batch
• It is possible to issue more than one prescription from the batch if a patient is going on holiday provided the batch issues are not post-dated

Question 27

Compare paper FP10 prescriptions to EPS Release 1 and Release 2

Answer 27

Paper FP10
EPS Release 1
EPS Release 2

Prescription Colour Green
Green
White but not the
legal prescription

Prescriptions are
barcoded
No 
Yes 
Yes

Prescriptions must
be signed in ink
Yes 
Yes 
No

Nomination
required
No 
No 
Yes

Claims submitted
electronically
No 
No 
Yes

Forms sent to PPD
at end of each
month
Yes 
Yes 
Yes but only for
exemption / charge
status checks

Controlled drugs
can be prescribed
on these forms
Yes 
Yes 
Yes – legislation in
place to allow

An ‘RA’ form is
issued if Repeat
Dispensing is issued
this way
Yes 
Yes 
No

Question 28

Reimbursement
The Drug Tariff lists the price that the Government is prepared to pay when a medicine has been dispensed. The calculation for reimbursement is:

Answer 28

BASIC PRICE OF DRUG (drug tariff part VIII) - DISCOUNT DEDUCTION + CONSUMABLE ALLOWANCE = REIMBURSEMENT

Question 29

Basic Cost of Medicines (Part VIII)
This part of the DT lists the price the Government is willing to pay for each drug. Drugs are divided into three categories:

Answer 29

• Category A – Popular generics which are widely available. Based on list price of 2 wholesalers and 2 generics manufacturers.
• Category C: Items based on a particular brand or manufacturer
• Category M: Drug which are readily available. Price based on information submitted by many manufacturers.

Question 30

Use the PSNC NHS Urgent Medicine Supply Advanced Service Specification to summarise each of the steps in provision of NUMSAS. You should cover the following steps

Answer 30

Referral

• Patients contact NHS 111 to request access to urgently needed medicines or appliances
• Referral to a pharmacy, chosen by the patient, that is providing the service - referral via NHSmail or other electronic solution
• NHS 111 provide the phone number of the selected pharmacy to the patient, advising them to call the pharmacy in the following 30 minutes
• The pharmacist will assess the need of the patient for an emergency supply
• If a referral is received and no contact is made by the patient, the pharmacy should attempt to make contact; referrals can be closed if no contact is made before the next working day

Telephone call between patient and pharmacist
An initial telephone consultation will normally take place to:
-determine further information about the patient
-assess the need for an emergency supply (suitability and legality)
-decide whether or not to invite the patient to the pharmacy for a face-to-face consultation and/or supply
If the patient indicates that they cannot visit the pharmacy, the pharmacist should use their professional judgement as to whether it is appropriate for a representative to collect the medication or appliance

Pharmacy Consultation

• Can take place face to face or over the phone
• If appropriate, the pharmacist can invite the patient or their representative to come into the pharmacy
• The pharmacist will then conduct a face-to-face consultation, to collect any additional information that was not obtained during the telephone conversation with the patient

Supply
-If appropriate the patient’s SCR should be checked to confirm the previous prescription history and whether a prescription has recently been issued by the patient’s general practice
-Where the requested item has recently been issued by the patient’s general practice, the prescription may still be available on the NHS Spine
-The pharmacist can use the EPS tracker to see if a prescription is available; if so, this can be used to fulfil the patient’s need for urgent medicines
- If an emergency supply is not possible at any stage pharmacists should refer the patient:
to their own general practice; or
contact the local GP Out of Hours (OOH) provider to discuss a solution
Do not refer the patient back to NHS 111
Advice and Information

-If the required medicine or appliance is not in stock, with the agreement of the patient, identify another convenient pharmacy (Pharmacy 2) that provides the service, call them to see if they have stock and if so, forward the electronic referral received from NHS 111 to them

Records and Documentation

• A blank FP10DT EPS dispensing token will be used to document ALL referrals received from NHS 111, irrespective of whether or not a supply has been made
• Information will need to be printed or recorded in legible handwriting on the token – IT support may be available
• An NHS prescription charge per item should be collected, unless the patient is exempt from prescription charges
• The patient (or representative) must complete the relevant sections of the reverse of the token to claim any exemptions from NHS prescription charge payment and confirm supply when they receive the medicine or appliance at the pharmacy
• Make your usual records of the emergency supply in accordance with the HMR
• A Post Event Message notification to the patient’s general practice must be sent either electronically, via hardcopy or fax on the same day or the next working day

Question 31

Which quality payment can you only claim once?

Answer 31

CPPQ
HLP

• Patient Safety
• Patient experience
• Public health (HLP)

Total 100 points