Hubs and collaboration. Hub-based working and collaborating across boundaries to improve access and care. Including examples from Sheffield, Devon and Cornwall. Greg Kalita and Dave Bearman, Northern, Eastern & Western Devon and South Devon & Torbay CCGs.

1. Pharmacy First:
Our journey
David Bearman
Greg Kalita

2. December 2013: How it all began
• In Western Locality of NEW Devon CCG commissioned:
– Winter ailments: NHS-funded supply of a limited range of
over the counter medicines for people exempt from
prescription charges to support self-care.
– Minor ailments via Patient Group Directions (PGDs):
Supply of a limited range of Prescription Only Medicines
(POMs) to treat urinary tract infections, impetigo, nappy
rash, oral thrush and bacterial conjunctivitis.
– Emergency Supply Service: Provision of emergency
supplies of repeat prescriptions and medicines at NHS
expense.
• Available to local patients out-of-hours (when their
practice is closed) and to visitors at any time

3. Minor ailments - development
2013
How it all began: Devon Western Locality commissioned: Winter ailments (supply
of over the counter medicines) – Minor ailments vis PGDs for limited range of
infections (5)- Emergency supply (local patients out of hours and visitors at all
times)– Initially winter pressures funded then commissioned by CCG - Audit
2014
Prime Ministers Challenge fund: Expanded service to North and East Devon and
South Devon and Torbay CCG – Provided consistent service across Devon with 2
different funding streams
2015
CCG / LPC Evaluation: High patient satisfaction 100% happy and would recommend
Winter ailments 40% of service but unclear benefit with half patients would have
purchased if scheme not available – 56% of PGD activity conjunctivitis showed clear
impact on urgent care system – Emergency supply was popular particularly
weekend but there was no corresponding decrease in 111 activity

4. Audit
• Added audit questions to ensure we had data to
inform future commissioning decisions
– How did you hear about the service?
– What would you have done without the service?
– For emergency supply we also asked:
oThe reason for requesting the emergency
supply
oWho usually orders your prescription?

5. Community Pharmacy Supporting
Urgent and Acute Care
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
Total
Healthcare
Provider Time
Cost Saved
GP Practice
Time Cost
Saved
Out of Hours GP
Service Time
Cost Saved
NHS Walk-in
Centres Time
Cost Saved
Hospital
Accident and
Emergency
Time Cost
Saved
17,723
8,336 7,972
1,081 743
Front Line Doctor Appointments Saved
(Nov 2014 to Feb 2016)

6. Minor ailments - development
2013
How it all began: Devon Western Locality commissioned: Winter ailments (supply
of over the counter medicines) – Minor ailments vis PGDs for limited range of
infections (5)- Emergency supply (local patients out of hours and visitors at all
times)– Initially winter pressures funded then commissioned by CCG - Audit
2014
Prime Ministers Challenge fund: Expanded service to North and East Devon and
South Devon and Torbay CCG – Provided consistent service across Devon with 2
different funding streams
2015
CCG / LPC Evaluation: High patient satisfaction 100% happy and would recommend
Winter ailments 40% of service but unclear benefit with half patients would have
purchased if scheme not available – 56% of PGD activity conjunctivitis showed clear
impact on urgent care system – Emergency supply was popular particularly
weekend but there was no corresponding decrease in 111 activity
2016
Commissioning change: After review process winter ailments no longer
commissioned, PGDs and emergency supply services continued
2017
Further review: Review required as CCG moved to a self care strategy need to align
service to this and remove items that can be purchased and National emergency
supply scheme has been commissioned. Questions on how we manage patients
who turn up to the pharmacy efficiently and how do we ensure value for money –
calls to 111 have now decreased so need to ensure no increased pressure.
Revised services recommissioned

7. April 2017
• Recommendation to commission:
– Minor ailments via PGD: Service limited to supply of
POMs to treat impetigo, nappy rash, bacterial
conjunctivitis (for under 2 yrs.), urinary tract infections
(trimethoprim replaced with nitrofurantoin).
– Emergency Supply Service: Available from 6pm
Fridays, over the weekends and Bank Holidays; not
Monday to Thursday.
• Future options considered include IPs and Minor Injuries

8. Minor ailments – logical development
P / GSL
Rationale : Significant numbers of appointments are being taken up for
interventions that require the provision of P GSL medicines that can safely
and effectively be handled in the pharmacy – Pharmacy intervention reduces
system costs and frees appointment spaces in practices
PGDs
Rationale : The use of PGDs creates an opportunity to expand interventions
in the community pharmacy into broader areas of care – evidence has
shown that these interventions have a significantly higher level of
deflection of activity from primary care and urgent care services -
increasingly the PGSL provision in practices is being curtailed with an
increasing focus on self care – Pharmacy services need to align to this
Extended
Provision
/enabling IPs
Rationale : This provides potential to broadly expand pharmacy based
activity and support the broader clinical development of the pharmacy
workforce to maximise its potential in demand management into the
primary care system It could also involve minor injuries in appropriate
locations to reduce urgent care demand
Future
Integration
Rationale : Continue with the approach to maximise demand deflection
from primary care by examining all the activities that can be done in the
pharmacy in support of practices
In addition : Emergency repeat provision that removes demand from out
of hours services

9. info@primarycarefoundation.co.uk
Typical practice 6,700 patients

10. The Practical reality
Case Studies
Next Steps
• Phlebotomy
• Carry out expanded interventions for 111 and
MIU
• Restricted treatment plans for
• Ear Infections
• Respiratory Infections
• Soft tissue infections
• Further future LTC
GP Surgery
Devonport Health Centre
• Pressurised primary care
system (6500 patients list
rapidly increasing as four
local surgeries closing)
• Two GPs, Nurse IP,
Practice Nurse
• Applied for Sessional
Pharmacist Programme
(PCIP – CCG funding)
• Actively referring to
pharmacy for triaging of
Ear and Eye Infections,
Respiratory Infections,
Soft tissue infections,
Urinary tract infections
Devonport Pharmacy
Integrated Health Hub
• Primary Care Innovation
Award for Integrated
Working
• IP in Pharmacy
• Full access to GP notes
• Working sessions in
practice
• Meds Optimisation
• Reconciliation of
Discharge Summaries
• Triaging minor and acute
ailments for practice
saving GP appointments
• Interventions under PGD
• MUR, NMS, Smoking
cessation, Flu vaccination
Minor Injury Unit
• Pressurised nurse lead
walk in clinic with often
no prescriber available
• Carry out expanded
interventions for 111,
but many erroneous
referrals from 111 for
conditions requiring Rx
• Actively referring to
pharmacy for triaging of
acute conditions and
minor ailments, EHC and
Chlamydia Screening and
Treatment

11. Pharmacy First: Lessons Learned
1. Patients are happy to choose pharmacy
– Requests for stock piling, where no need for supply identified and resolved
2. GP practices will actively refer to the pharmacy services to help reduce
appointment demand
3. The service has help facilitate good working relationships between GPs
and pharmacies
4. Use of PharmOutcomes to record activity
5. Aim to increase the NHS111 referrals made to community from 4% (SD &
Torbay CCG) today towards 30%
– enhance the NHS111 directory of services, and integration of a pharmacist
into the NHS111 clinical team
6. This is a gateway to greater integration and opportunity
Pharmacy First in Devon