Basis functions for sparse DSI reconstruction

D. José Martínez Olmos. Secretario General de Sanidad. Ministerio de Sanidad y Política Social.

“SERVICIOS ACTUALES Y ADICIONALES DE LA OFICINA DE FARMACIA” El ponente estima que se ha recorrido un camino importante en Atención Farmacéutica (AF) pero que todavía existe margen para seguir avanzando, por lo que felicita a la Fundación Pharmaceutical Care por la celebración de este encuentro de profesionales.

Manifiesta que la Farmacia Comunitaria (FC) es una parte importante de nuestro Sistema Nacional de Salud (SNS), que garantiza la accesibilidad de todos a los medicamentos y que realiza una clara labor de prevención; sin embargo, indica que todavia es necesario hacer mucho más en un futuro inmediato.

El Uso de los medicamentos en y por los pacientes, presenta un importan- te potencial de mejora. El que muchos de los resultados negativos asociados al uso de medicamentos (RNM) sean esperables, no debe minimizar su impor- tancia;. Justamente porque son previsibles es posible que sean evitados. El porcentaje de RNM que tenemos hoy, demanda que el Seguimiento Farmaco- terapéutico (SFT) sea una realidad en nuestro Sistema de Salud.

Pero la generalización del SFT es difícil por diferentes condicionantes: La incorporación de los Farmacéuticos supone un cambio en la forma de traba- jar en los Servicios Sanitarios, porque no existe una relación formalizada con ellos.

Al no tratarse de una actuación integrada en los Servicios Sanitarios, pue- de condicionar condiciona opiniones desfavorables de los médicos, Además ciertas estrucutras de Organizaciones Médicas no son receptivas, aunque esti- ma que esto es por un problema de desconocimiento.

A pesar de ese desconocimiento, el problema no debe resolverse exclusi- vamente entre farmacéuticos, si no que requiere la necesidad de una aproxi- mación específica entre los distintos profesionales, con un punto en común, que és el beneficio del paciente.

En relación al Modelo Retributivo actual, el ponente estima que el hecho que vaya en función del precio del medicamento es un factor en contra del

desarrollo de la AF. Sin embargo, considera que entre la Profesión Farmacéuti- ca no hay consenso para el cambio del actual modelo retributivo. Por otra par- te manifiesta que es difícil que la Administración pueda disponer de financia- ción específica a corto plazo.

Reflexiona sobre las estrategias que se deberían plantear a medio y largo plazo para conseguir acuerdos, por ejemplo:

Buscar la complicidad y la comprensión de los ciudadanos que cada vez están mejor preparados para entender mejor el uso de los medicamentos.

— Modificar la relación contractual entre Administración y farmacéuticos a fin de priorizar los servicios deberia hacerse a nivel territorial. Resalta la im- portancia de la descentralización en este campo.

— La situación económica actual exige buscar mas calidad y enfocar los esfuerzos no a ahorrar sino a mejorar la calidad.

D. José Martínez Olmos expone que el Nuevo Plan Estratégico de Política Farmacéutica bridará más espacio para el desarrollo de Servicios Profesionales. Menciona explícitamente el Plan de actuación sobre el Paciente Polimedica- do, que dispone de financiación propia y anima a los participantes, como pro- fesionales cualificados a aunar esfuerzos con colegios de pofesionales y socie- dades científicas para la elaboración de Proyectos de implantación y Propuestas de Pilotajes.

Finaliza su intervención ofreciendo a la Fundación su participación en el diálogo para el desarrollo del Plan estratégico de Política Farmacéutica.

Durante el debate con los asistentes, el ponente concreta a preguntas de los participantes que el Nuevo Plan Estratégico estará redactado para aprobación en el verano 2009 y se dispondrá de dos meses más para recibir sugerencias.

A partir del esqueleto del Primer Plan Estratégico, se concretará sobre: — Incorporación de médicos y farmacéuticos a tareas conjuntas — Incorporación de los pacientes

— Incorporación de propuestas para hacer viable el sistema sanitario — Incorporación de propuestas para que el Sistema de Salud, la mayor empresa española, siga siendo el servicio más apreciado por los ciudadanos.

Mrs. Anne Galbbraith. Chair Valuation Tribunal Services. AOL. Autora del documento “Review of Nacional Service Contractual Arragements” “SERVICIOS FARMACEÚTICOS DESDE LA FARMACIA COMUNITARIA: LA EXPERIENCIA DEL REINO UNIDO”

First of all, let me say how delighted I am to be invited to address your con- ference in this lovely city.

Second, I should say immediately that I am not a pharmacist. I was invited to conduct my review as an independent person. I was an academic lawyer for many years, although I had also had a long involvement in the National Health Service in a number of roles. I had conducted a number of previous enquiries for them, usually relating to mental health care, so not in the field of pharma- cy. I hope this makes clear that I am not a specialist in this field, and was appro- aching the task as a genuine lay person.

1. Let me first set the scene about where pharmacy sits in the Natio- nal Health Service in the United Kingdom

Pharmacies run as businesses. Pharmacists are either self employed or em- ployed by one of the large chains of pharmacies such as Boots – thus, phar- macists are not employed by the National Health Service. This could therefore be seen as one of the problems faced by our government’s Department of Health – because there is no direct employment relationship with pharma- cists, it could be argued that it is harder for the Department of Health to bring pharmacists into the “family” of the NHS.

Pharmacists are paid for dispensing prescriptions and reimbursed for the costs of the drugs dispensed. Prescriptions were traditionally written by doc- tors, but a recent trend over the last few years has been an extension to the range of prescribers – permitting nurses to prescribe, and now pharmacists with additional training may prescribe – at present there are only about 1200 such pharmacists in the UK.

One of the important trends now in community pharmacy in England is the move towards pharmacists providing a greater range of services to the public. These advanced or enhanced services need to be paid for, under a new framework agreement negotiated between the government and the pharma- cy profession. Commonly, these services may include

repeat dispensing arrangements, which particularly benefit patients with long term chronic conditions,

medicine use reviews, to improve the patient’s knowledge and use of their medicines,

medication reviews, where a pharmacist considers all the medicines that a person uses, and makes any necessary recommendations for changes,

minor ailment services, which helps to manage the demand made on doctors.

Patients who have been given a prescription take it to a dispensing phar- macist who is on the National Health Service register. At present, in England, patients pay prescription charges — just over £7 per item, unless they are exempt from the need to pay for a number of reasons. Less than 20% of pa- tients need to pay the prescription charge.

Every pharmacy is located within the area of a Primary Care Trust. These are the commissioning organisations for healthcare for a local population. En- gland is divided into 152 Primary Care Trusts, and they serve a population of between 100,000 to 1 million people.

I hope that gives you some necessary background to what I now want to say about my report.

2. You may be wondering — Why was my report commissioned? Let me explain. In 2003, an important report from the Office of Fair Tra- ding had been published, which clearly considered that there should be greater competition in the field of community pharmacy. The government sought to address some of the criticisms made by the Office of Fair Trading and made some reforms relating to the delivery of pharmaceutical services in 2005. After a year, the impact of these reforms was reviewed and this re- opened the debate about how the provision of pharmacy services should be regulated.

The basic framework of the rules was based on an over legalistic test of “control of entry” which regulated when a new pharmacy could be establis- hed. This raised the question whether this was a suitable way to enable Pri- mary Care Trusts to meet their new role, to commission patient led services. The Minister wanted to consider how Primary Care Trusts could be given bet- ter powers to commission pharmaceutical services. So he set up a review to “think at large” about this problem and asked me to chair it.

3. What should any proposals from my review aim to achieve? Of course, my review had terms of reference. And in carrying out my work, I realised that I had to take account of a number of factors;

First, there was an important policy paper published by the government early in 2006 “Our Health, Our Care, Our Say” which aimed to make all health services – including pharmacy services — more patient focussed, and of im- proved quality. The idea was to put people more in control, improve their ac- cess to primary care, improve their access to community services, focus su- pport on the needs of individuals, especially those with long term conditions, and shift care closer to where people live.

I also needed to keep in mind the professionalism of pharmacists and how to use it more effectively.

It was clear that any changes proposed would also need to be in step with other changes taking place in the National Health Service.

And the Minister had made it clear that he would use my report to help to inform a more formal government consultation of the issues.

4. How did I conduct the review?

First of all, I should say that it was a very quick exercise – when I was appro- ached, I was asked if I could complete the review in just three months. I am very pleased to say that I did manage to do it. I think it was a good thing to do the work quickly. It meant that I became immersed in the issues, and could keep all the key aspects in my mind – however, it’s sad how quickly it all went out of my mind once the work was over!!

I needed some regular support for the work, which was provided by a se- cretariat from the Department of Health. I also asked for some expert advisors and was able to appoint two experts – the Chief Pharmacist of a Primary Care Trust, and a former Chief Executive of a health authority who had considerable knowledge of the current pharmacy contractual framework.

Then we had to decide who we would talk to – and in a very short time, we managed to organise meetings with all the leading groups, for example:

the Pharmaceutical Society Negotiating Committee,

the leaders of the Dispensing Doctors – these are general practitioners, usually in rural areas, who are permitted to prescribe and dispense for their patients where a pharmacy might not be viable but patients need their medi-

cines, (we have had this system for over 100 years, but I think you do not have the same in Spain),

big multi national companies of pharmacies such as Boots and Lloyds (again they have been around for over 100 years in our country but not in Spain, as I understand),

the smaller multiples,

representatives of Primary Care Trusts,

representatives of the Office of Fair Trading who deal with issues concer- ning competition in the UK,

representatives from patient groups,

and academics in the discipline of pharmacy. 5. What evidence did we discover?

Taking the various interest groups that we met, we found that generally, patients liked the accessibility, friendliness and expert nature of the service offered by pharmacists. However, it seemed to me that there was no real un- derstanding of what patients should expect from a modern, quality pharma- ceutical service, and I thought their expectations were probably quite low. It was also clear that the public were not well informed about what a pharma- cist could offer by way of services, so encouraging self care was not likely to be achieved until there was a higher level of public awareness.

Commissioners of services (the Primary Care Trusts) tended to feel that they suffered from lack of influence in that they have to pay for services which had been decided at national level, whether those services were a top priority for their area or not. Take for example the area where I live – 500 kilometres from London, close to the Scottish border, in a remote rural area with a very scattered population and virtually no representatives of ethnic communities. Compare that sort of area with an inner city deprived area with a significant ethnic population. The same initiatives could be set up for both areas, whether they are relevant in both or not. The Primary Care Trust serving my rural area would probably have quite different priorities for its population.

Primary Care Trusts also felt that they lacked the necessary powers to drive up quality. They believed that the development of some kind of quality and outcomes framework could be helpful to them in driving up standards and they considered that they should have better powers to deal with inadequate or poor performance.

The providers of services, the pharmacists, felt that they had made signi- ficant investments in their services but had not seen appropriate rewards for their efforts. They noted that there was a tension between matters which were decided nationally and those which were decided locally. Matters decided lo- cally by the 152 individual Primary Care Trusts were a particular concern where the big multi national chains of pharmacies were operating across many PCT boundaries, and they found the application of the same rules varied from PCT to PCT. An example of this was the standards being imposed by individual PCTs about the suitability of space for private consultations.

All of the pharmacists, whether belonging to a large multi national chain or in a smaller way of business, emphasised that they were busines- ses, needing to plan for the medium and long term, and the rules within which they had to operate had to take account of this, and the risk to their businesses.

The Office of Fair Trading would have liked to see full market deregulation as they felt that the operation of a true market would be a means to drive up standards.

6. What were the broad themes which made a strong impact on me? Pharmacy was an under used and under recognised part of the NHS – it seemed to me that there was great scope to give pharmacists a more central role and greater recognition for their professional skills. They spend a long ti- me gaining their professional qualification, and were a very under used re- source.

However, to achieve a more central role and greater recognition of their skills, it would require the right people in the right place delivering the right quality of service, and there must be the money to pay for this.

Taking those four aspects – people, place, quality and money – let us examine them in a little more detail.

People – I did not doubt that pharmacists were well qualified, but it see- med to me that they were steeped in out of date working practices. This often meant that they had little face to face contact with patients. They seemed to be more at ease when dispensing behind the scenes. Many of those I talked to were keen to extend the scope of their services, but they recognised that so- me of their colleagues were stuck in their time honoured, old fashioned way of doing things.

From what I learnt about the way things worked, it also seemed to me that it was very difficult to deal with pharmacists who were performing badly – and the processes for payment actually protected them and allowed them to stay in business.

Place – some of the premises occupied by pharmacists did not have a “cli- nical” feel or look to them. They were more like corner shops, selling a range of goods with the pharmaceutical bits of the business tucked away at the back of the shop. And the question of place was also dominated by very prescripti- ve rules – the “control of entry” rules, — which regulated where new pharma- cies could open. These rules had become a lawyer’s paradise of interpretation, and were quite anti competitive in their effect.

Some liberalisation of these rules had taken place about a year or so befo- re my review, prompted by the views of the Office of Fair Trading – for exam- ple, a new exemption allowed anyone who was prepared to open for 100 hours per week to do so without having to satisfy the control of entry require- ments. This of course allowed the major chains of supermarkets such as Tesco, Asda and Sainsbury to come increasingly into the pharmacy market. Their lar- ge stores were often open 24 hours a day, so they were more readily able to satisfy the 100 hour rule. About 300 pharmacies taking advantage of this 100 hours per week exemption have been set up in England since 2005.

However, even this liberalisation of the rules is still not enough to address concerns about the operation of the control of entry system – that system does not allow a Primary Care Trust (the organisation which is paying for the services) to have any real control of where pharmacies should be established to best ser- ve the local population. The system of control of entry is a big deterrent to the provision of modern, quality services – and that leads on to considering

Quality of service – I have already commented on the difficulty Primary Care Trusts have in dealing with poor performing pharmacists. The PCT may also have other concerns – for example,

 too many pharmacies situated in the wrong places to serve the public,  or the poor state of the pharmacy premises,

 or the lack of privacy of consulting rooms,

 or the unwillingness of some pharmacists to offer advanced and ex- tended services,

 or the lack of control over dispensing by dispensing doctors.

A modern and effective system needs to provide the means to deal appro- priately with issues of this sort.

Money – currently pharmacists are primarily rewarded by being remunera- ted for each prescription item dispensed. My review did not envisage that there would be a bigger or smaller pot of money available, just that it could be distri- buted differently. For example, it would be possible to pay less for the dispen- sing element, and use the money saved to pay for enhanced and extended ser- vices. This aspect of our review was probably the least detailed, partly because of time constraints but also because it was not possible to consider the financial impacts until it was clear which proposals were likely to find favour.

7. What would a good pharmaceutical service look like?

If proposals for change were recommended, it seemed to me that I would have to be able to say what I thought a good pharmaceutical service would look like. It seemed to me that the following points would all be reflected in a good pharmaceutical service: