When the Royal Pharmaceutical Society suggested last year that every care home should have a pharmacist aligned with them, the proposal was greeted with cynicism by some C+D readers. The issue was not whether it would be beneficial for the care homes, but who would pay for the pharmacists’ time?
Meanwhile, advocates have insisted that care homes represent a “huge opportunity” for the sector, and that pharmacists who don’t get involved are missing a trick. So what’s the opportunity and how can you get on board?
Don't stop at supply
The most obvious selling point remains dispensing fees. “You have a huge number of elderly patients on an average of eight to 10 drugs,” says Graham Stretch, senior practice-based pharmacist and independent prescriber at Ealing GP Federation in London. “In business terms, what you've got is a market you can develop. There are clearly substantial numbers of items that can be gained from engaging with care homes.”
Supplying nursing and care homes can involve a fair amount of unpaid work – such as organising dosette boxes – which can be time-consuming and expensive. Yet, says Mr Stretch, this supply function only represents “a fairly basic service”.
“The vast majority of services offered from community pharmacy [are based on the assumption that] the be-all-and-end-all is the plastic trays delivered by the driver. It doesn’t support the nurses and patients,” he says.
There’s no doubt that many care home staff and residents could benefit from more input from pharmacists into their medicines management, but this requires funding for the time and training involved. As Mr Stretch puts it: “How do you solve the money question?”
An Ealing example
Mr Stretch (pictured) began to engage with care homes in the London borough of Ealing in 2010. “Thursday afternoon was my half day. I used to go to visit the local nursing homes.
"I'd engage with the nurses, find out what was going on. I did a bit of training around dementia and increasingly the GPs would ask me to look at [patients’] medicines list, because I was around."
He was still involved when the Department of Health asked clinical commissioning groups (CCGs) to review medicines use in care homes in their areas. The local CCG contracted Mr Stretch "to visit every one, make recommendations and write a 50-page report”, he recalls.
The report led, over time, to a successful tender to provide medical and pharmaceutical care to 23 nursing homes, through a consortium of pharmacists and GPs. To begin with, they had two pharmacy owners working on a sessional basis in GP surgeries, but soon found that they needed to expand.
“It’s a huge amount of prescribing. The only people who had the capacity to deal with that was the pharmacy team – and [only when we started using] pharmacy technicians.
It made all the difference in the world. We have seven technicians [with] one pharmacist who only does clinical reviews at the bedside. The proprietor pharmacists have laptops, which they can use to manage prescriptions from the pharmacy.”
The service was commissioned in 2013, and the group can already point to a reduction in hospital admissions. Key to the success, says Mr Stretch, was being engaged with the CCG, local GPs and the nursing homes, so they were aware of the problems they faced. “It works because we know the people on the ground.
“GPs don’t want to be managing prescribing and medications [for care homes]. They would prefer us to do it. We have the right skill set. Provided you can demonstrate that you can do that more cost effectively than GPs, you actually will succeed with this.”
He says that “like any other business-related aspect”, you need to invest time and resources in order to expand into this area. That might mean training as an independent prescriber, or learning about management of long-term conditions.
"I grew my business"
Leeds contractor Ashley Cohen has taken a different route to monetising his five pharmacies’ relationships with care homes. “I built a care home hub for two reasons – to protect my script volume and grow the business. But I realised we were being asked to do things at care homes that required [pharmacist] skills to do.”
Before buying his first pharmacy, Mr Cohen (pictured below) had worked as a consultant and a health authority advisor, which he believes helps him to spot business opportunities. He is also director of a care home, which gives him the chance to see things from both sides.
“For the first few years we were being asked to do more than just supply – we were doing training, audits, support work, helping them prepare for Care Quality Commission (CQC) inspections, looking at policies and procedures.”
They were offering this support “predominantly for free” to care homes they supplied, until Mr Cohen realised they were also being asked for help by homes they didn’t supply. In response, he developed a basic medicines management programme for all the care homes they supplied, which was free to attend. If care homes wanted more bespoke or specialist training, they could then pay for it.
“We realised that, actually, the free training was not very well received. They wanted proper written programmes for their individual [care home] groups – there was a niche in the market. Not many companies could understand the supply element and also medicines risk in care homes.”
Mr Cohen developed a new offering based around staff training, medicines management policies, risk registers and conducting mock inspections for teams concerned about CQC visits.
“We realised there was an appetite to pay for it. We developed a whole work stream that ran alongside it and allowed us to get an extra revenue [source]. It’s not massive, but it helps. I want the supply as well – because it’s our bread and butter – but I’m not prepared to turn down work.”
The result? They now have contracts with national care providers to train staff across the country. “Training for individual care homes doesn’t make a huge amount of money, but [it] puts us in the right place for the supply function. We go into regional care homes and if they [say] they’re not happy [with] their current supplier, we say: ‘Well, we do that as well’.”
The additional revenue means they are less reliant on prescription income. “We’re maybe 65-70% reliant on FP10, but we’re prepared because we have other models.”
He says his small group of pharmacies have certain advantages over the big multiples. “We’ve competed [for tenders] against large multinationals and won them, because we are cost effective, flexible, local; we’re a family firm and we can be responsive.”
He encourages others to go out and look for this type of business. “We go out to pitch for the work – and then worry about how we’re going to do it."
His philosophy? "Know what you need, pitch, win and put together a compelling argument, then worry about the difficult side."
"What can be more rewarding?"
Both Mr Stretch and Mr Cohen agree that the benefits don’t stop at additional income. Enhanced career progression and job satisfaction are also driving factors to engage with care home work.
“In terms of professional development, you’re becoming a prescriber and managing a case load of patients. And these are patients who most need your help,” says Mr Stretch.
He talks about the difference you can see simply by making a change to a patients’ antipsychotic medication. “You see wonderful examples, like a patient’s daughter coming in and saying: ‘Now we can talk to her.’ These are their last few months or years of life. What, as a pharmacist, can be more rewarding than that?”
Mr Cohen puts it even more simply: “It’s enjoyable. We have recruited good staff because people want career progression. People ask: ‘Can I be seconded to work for a few months within a care home and community setting?’ And we can do that. It differentiates you slightly from other community pharmacies.”
And he too sees the job satisfaction from providing better care to nursing home residents. “People always think somebody else will explain to the resident in a care home [about medicine changes] – but nobody ever does. They are human beings as well. They still want to understand, ask questions and get information to make an improvement to their quality of life.”
"We have to engage"
So what’s preventing better pharmacy involvement in residential care or nursing homes, outside of these pockets of good practice? “We have to engage with commissioners and GPs," says Mr Stretch.
"They have access to funding and patient notes. You can argue that NHS England should be providing money – absolutely they should. But those arguments are already being made. What we don’t have is sufficient engagement locally with commissioners.”
With the current crisis in social care and the knock-on effects on the NHS – highlighted by long waiting times seen in A&E over the past winter – Mr Stretch believes the time is right for pharmacists to push at the door. “There is momentum. The Patients Association [and other] charities are all pushing for that, [as are] GPs,” he says.
“What’s missing at the table is us.”