Pharmacy Disposition Findings Recommendations Final by np6KJuHl


									                       NHS 111 and the Directory of Services:

     Community Pharmacy Disposition findings and recommendations

The skills and roles of Community Pharmacists are changing in order to deliver a range of enhanced
services over and above the handling of prescriptions. This can include the management of minor
ailments, advanced prescribing, provision of emergency hormonal contraception and smoking

The new NHS 111 service has been piloted in several locations in the East Midlands, including
Lincolnshire and Nottingham City. The service is underpinned by a clinical triage system called NHS
Pathways, linked to an electronic skills based Directory of Services (DoS) which should dependent
on the skills a particular service has to offer, enable callers to the service access to appropriate
community based services such as community pharmacy. Community Pharmacists may in many
circumstances have longer opening hours and could be more easily accessible to patients, especially
for the treatment of minor ailments or to access to over the counter medication for self-care etc.

When reviewing the services utilised by callers to the NHS 111 services in the East Midlands, it could
be expected that a fair proportion of calls would result in a referral to a community pharmacist

However a recent audit of dispositions ending in a community pharmacy disposition demonstrated
that only 1% of all dispositions were in fact ending at a community pharmacy. As a result it was
agreed with the national bodies that represent community pharmacists that a short time limited project
should be undertaken, to understand why such a small percentage of calls resulted in a community
pharmacy disposition. Once understood could this percentage be increased and if so how?


The data provided below comes from NHS Direct who provide the call handling element of the NHS
111 pilots in Nottingham City and Lincolnshire.

Recently the number of referrals through NHS 111 to a community pharmacist within the East
Midlands pilot areas has noticeably increased. This is due to the introduction of the updated version of
the NHS Pathways system, which required the DoS to be re-profiled to a newer 6.4 template. This
increase is largely attributed to more accurate profiling of services and what they can offer.

The percentage of relevant community pharmacy services returning from searches on the DoS seems
to have dramatically increased since Pathways 6.4 went live in October 2011.

Since the introduction of the newer version of NHS Pathways the data shows that NULL returns (a
NULL return is a call that ended in a community pharmacy referral that did not return a specific
pharmacy) are either outside of the 9-5 normal time frame or fall on weekends when there is a larger
chance that pharmacy services may not be open.

The two tables overleaf show data from two time periods, table one with the previous DoS, and table
two containing data collected since the new DoS has been live (the time ranges for this data were
selected randomly). The tables show the total number of community pharmacy dispositions reached
in the time period, and the details on whether or not those dispositions ended up with a suitable
community pharmacy referral made to a caller (a NULL return is where no pharmacy was selected
from the DoS)
            st              th
Table 1 - 1 June 2011 to 6 August 2011 (old DoS)
  Total calls     Suitable            Out of 9-5   Referral is on a   Referral is on    Unexpected
   ending in      Pharmacy             hours         Saturday          a Sunday         NULL returns
  pharmacy          Returned
      177           41 (23.2%)        68 (38.4%)     39 (22.0%)        12 (6.7%)          17 (9.6%)

            st                   th
Table 2 - 1 October 2011 to 6 December 2011 (New DoS)
  Total calls     Suitable            Out of 9-5   Referral is on a   Referral is on    Unexpected
   ending in      Pharmacy             hours         Saturday          a Sunday         NULL returns
  pharmacy          Returned
      208           131 (63%)         41 (19.7%)     13 (6.3%)         19 (9.1%)          4 (1.9%)

Comparing the two sets of results it can be seen that with the newer 6.4 DoS, 63% of calls into the
NHS 111 service were returning an appropriate pharmacy disposition from the DoS, whereas under
the previous DoS only 23.2% of calls were returning an appropriate community pharmacy, a jump of
nearly 40%. Whilst some of this increase can be attributed to a lower percentage of 'out of hours'
calls, it is still apparent that the newer DoS system appears to be returning services more consistently
and with fewer unexplained NULL returns (1.9% versus 9.6% previously).

There are however a small number of unexplained / unexpected NULL results. In order to try to
understand the reason for this, random spot checks on individual pharmacies (again chosen at
random) were carried out to see if there were any obvious inconsistencies between the data that
could be obtained as a patient (via websites) and information available in the DoS. It soon became
apparent that opening times were not always consistent for a number of community pharmacies.
Whilst this was the exception rather than the rule, this could be the reason for a pharmacy not being
returned even though it is actually open, or conversely being selected even though it is closed and the
patient being sent to an inappropriate location.

Other issues that can 'affect' the selection of a community pharmacy from the DoS, include the lack of
ability of the pharmacist to prescribe. A large number of DoS returns for primary care fall under a
disposition that requires prescribing rights. As NHS Pathways is a triage tool to determine which
service would be best for the caller, based on the most prominent symptoms described, it is unable to
distinguish between a condition that does and does not require a prescription. So to stop the patient
having to potentially visit two healthcare providers it will only select services that can prescribe.

Recommendations Moving Forward

Headline points
  DoS info needs to be kept up to date
  GAP analysis needs to be reviewed to see where pharmacies have 'lost out'
  All unexpected NULL returns need to be analysed to see why no services returned
  We need to know the national pharmacy disposition rate across all pilots to see if EM
     data matches up
  It would be good to have a national/local understanding of the pharmacy rate expected /
     what does good look like?
  Community Pharmacists that can provide enhanced services need to be more accurately

Whilst it appears that community pharmacy DoS returns are now more accurate with the new release
of NHS Pathways, there are still occasional results that cannot be explained from the data received.
Further work therefore needs to be carried out in these isolated incidents to determine the reasons for
this so that they can be addressed.
GAP analysis data will be able to inform commissioners of examples where pharmacies narrowly
missed out on maybe only a single criteria from being returned, this will enable commissioning of
these extra services from pharmacies to ensure a higher return rate in the future

Commissioners need to ensure that services in the DoS themselves are tightly monitored / regulated
to ensure that any changes in situation, services being offered, opening hours or age ranges served
need are immediately updated in the DoS ensuring referrals can reflect these. Not only will this give a
better utilisation of these services but also removes the potential issue of a patient turning up to a
pharmacy that has either shut or is no longer offering the service they require.

There is also work currently being undertaken with a view to gaining more consistent and accurate
returns from the DoS, not explicitly, but in relation to ranking systems, structure and local setup which
may well have an impact on the number and percentage of future results, this will need to be
monitored by local and regional leads to asses any impact.

A similar investigative piece of work could be carried out for other dispositions that are having a lower
than anticipated return from the DoS, however for this to happen there would need to be an
understand of what percentage of returns each area would expect from each disposition. This will be
easier to determine with both more time and more sites coming live as there will be a bigger pool of
data to draw upon.

Simon Frampton
NHS Pathways/CMS/DoS Programme Manager, NHS Midlands and East
January 2012

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