PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Proposals for change in community pharmacy 17 December 2015 marked the start of our consultation with the PSNC, other pharmacy bodies and others, including patient and public representatives, on changes to community pharmacy, achieved within the £2.63bn funding cap described previously. Our aim is that these changes will: - Integrate community pharmacy and pharmacists more closely within the NHS, optimising medicines use and delivering better services to patients and the public. - Modernise the system for patients and the public – making the process of ordering prescriptions and collecting dispensed medicines more convenient for members of the public by ensuring they are offered a choice in how they receive their prescription. - Ensure the system is efficient and delivers value for money for the taxpayer. - Maintain good public access to pharmacies and pharmacists in England. The following slides provide more information on our proposals to achieve these objectives on which we would welcome your views. DH – Leading the nation’s health and care 16
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Bringing pharmacy into the heart of the NHS Pharmacists’ skills make them invaluable to patients and the public, but too often those skills are not used effectively, resulting in avoidable hospital admissions, medicines wastage and sub-optimal care. NHS England has taken important steps to integrate pharmacy into the NHS and the Government would like to make further progress. We will work closely with the PSNC, other pharmacy bodies and others, including patient and public representatives, on how best to introduce a Pharmacy Integration Fund (PhIF). This will be the primary means of driving transformation of the pharmacy sector to embed medicines optimisation and the practice of clinical pharmacy in primary care, bringing clear benefits to patients and the public. The proposal for year one will be to focus particularly on the key enablers to achieve integration of community pharmacy. It will be spent primarily on supporting the deployment of clinical pharmacists in a range of primary care settings, including GP practices, multi-speciality community providers, urgent care hubs, care homes and NHS 111. We believe this will be fundamental to fully integrating community pharmacy into the NHS through the creation of clinical and professional links to community pharmacists, together with referral pathways. In addition, it is envisaged the fund will support a range of activities, including: - Developing the delivery of high quality, clinically focussed pharmacy services that are integrated within wider primary care, including community pharmacy; - Integration of the seven principles of medicines optimisation into care pathways for long term conditions such as diabetes, COPD, asthma and hypertension including opportunities for health improvement and wellbeing; - Developing, collaboratively with Health Education England, the whole pharmacy workforce to make patient facing roles the norm; - Supporting the development and implementation of digital technologies for community pharmacy so that it has the infrastructure to achieve integration with clinical pathways and medicines optimisation for patients; - Developing clinical pharmacists working in GP practices, care homes and primary care urgent care hubs (e.g. NHS 111); - Evaluation of innovative clinical pharmacy services, including those already provided by community pharmacies and those developed through the PhIF; - Working with Public Health England to develop the value proposition for community pharmacy to encourage the commissioning of local health and wellbeing services by local authorities with a focus on the Healthy Living Pharmacy model. DH – Leading the nation’s health and care 17
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Bringing pharmacy into the heart of the NHS (2) We welcome views on these proposals, and further proposals from the pharmacy sector, and others, including patient and public representatives, on bringing pharmacy into the heart of the NHS to deliver better quality services to patients and the public. What are your views on the introduction of a Pharmacy Integration Fund? What areas should the Pharmacy Integration Fund be focussed on? How else could we facilitate further integration of pharmacists and community pharmacy with other parts of the NHS? DH – Leading the nation’s health and care 18
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Modernising the system to maximise choice and convenience for patients and the public Online ordering, click and collect and home delivery are all growing significantly in other sectors and online retail sales grew by 16% in the UK in 2014. However, the uptake of digital ordering, click and collect and home delivery in community pharmacy remains low. The Office of National Statistics estimate that less than 10% of adults ordered their medicines online in 2014. Because of this, the Government wants to ensure that the regulatory framework and payments system facilitates online, delivery to door and click and collect pharmacy and prescription services. These services already exist to an extent within the community pharmacy sector. As part of our consultation we want to consider how we can promote patient choice and convenience when ordering prescriptions, creating a seamless digital journey for all patients, where the choice of delivery or collection is made upfront. Specifically we want to consider proposals to: - ensure patients are offered the choice of home delivery or collection when ordering their prescription; - introduce a new terms of service for distance-selling pharmacies in recognition of the difference in their service offering, and thus differentiated payment. To what extent do you believe the current system facilitates online, delivery to door and click and collect pharmacy and prescription services? What do you think are the barriers to greater take-up? How can we ensure patients are offered the choice of home delivery or collection of their prescription? DH – Leading the nation’s health and care 19
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Making efficiencies The Government wishes to work with the PSNC and pharmacy organisations to deliver a more efficient and innovative system. As part of this, we want to consider proposals to: - Simplify the NHS pharmacy remuneration payment system . The current system is complex and does not promote efficient and high quality services. For example the establishment payment – of around £25,000 per year – is received by all pharmacies dispensing 2,500 or more prescriptions a month, a relatively low prescription volume. This incentivises pharmacy business to open more NHS funded pharmacies, adding costs to the taxpayer. We therefore propose the establishment payment is phased out over a number of years. - Help pharmacies become more efficient and innovative through, for example, modern dispensing methods. We will separately consult on changes to medicines legislation to allow the ‘hub and spoke’ dispensing model across different legal entities. This could allow independent pharmacies to capture the efficiencies stemming from large-scale, automated dispensing, reduced stock holding and economies of scale in purchasing and delivery of stock to the hubs, freeing up time to concentrate in the spokes on delivering patient centred services designed to optimise the use of medicines by patients. These efficiencies could help pharmacies lower their operating costs and enable pharmacists and their teams to provide more clinical services and to improve and support people’s health . - Encourage longer prescription durations, where clinically appropriate . Where there is no clinical need for a 28-day repeat prescription, this represents inconvenience to the patient and an avoidable cost to the taxpayer. As part of stable long term condition management, many prescribers already prescribe 90-day repeat prescriptions where it is clinically appropriate. With a wider range of interested parties, we will be looking at steps to encourage optimising prescription duration, balancing clinical need, patient safety, avoidance of medicine waste and greater convenience for patients. The above are initial proposals. The Government is open to any proposal that will drive efficiency and innovation in community pharmacy. What are your views of the extent to which the current system promotes efficiency and innovation? Do you have any ideas or suggestions for efficiency and innovation in community pharmacy? What are your views of encouraging longer prescription durations and what thoughts do you have of the means by which this could be done safely and well? DH – Leading the nation’s health and care 20
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Maintaining public and patient access to pharmacies Access to pharmacies in England is excellent - 99% of the population can get to a pharmacy within 20 minutes by car and 96% by walking or public transport. Access is greater in areas of highest deprivation. The Government is committed to maintaining access to pharmacies and pharmacy services, and is consulting on its proposal for the introduction of a Pharmacy Access Scheme, based on a national formula by which qualifying pharmacies, according to an index based on geography and other factors, will be required to make smaller efficiencies than the rest of the sector. The proposal is for a national formula to be used to identify those pharmacies that are the most geographically important for patient access, taking into account an isolation criteria based on travel times or distances, and also population size and needs. The population needs variables that we propose should be included are as follows: · Index of Multiple Deprivation (2015) · Proportion of population >75 years who are >85 years · Proportion of population >70 years claiming disability living allowance · Standardised Mortality Ratios (SMR) by middle super output area · Generalised fertility rate · Age-sex standardised proportion non-white · Age-sex standardised proportion tenure social · Age-sex standardised limiting long term illness Once an index of isolation and population needs is determined, we would then need to determine the means by which pharmacies would qualify, such as a travel time threshold or similar. The index would then be combined with the chosen qualifying criteria to generate a list of qualifying pharmacies. What are your views on the principle of having a Pharmacy Access Scheme? What particular factors do you think we should take into account when designing the Pharmacy Access Scheme? DH – Leading the nation’s health and care 21
PROPOSALS FOR CHANGE IN COMMUNITY PHARMACY Further discussion Do you have other views you would like to feed into the consultation process? We welcome feedback from these stakeholder briefing sessions. Please respond to this first phase of the consultation by Friday 12 February 2016, which will allow us to collate all views received during this initial period and input them into the ongoing discussions with the PSNC. We are expecting individuals to input to the consultation via the PSNC and other representative bodies. We will then hold further stakeholder meetings during March in advance of the consultation period closing on 24 March. DH – Leading the nation’s health and care 22
CONSULTATION PROCESS The consultation process Body Description Engagement method Pharmaceutical Services The body recognised under section 165(1)(a) - From January to March DH and NHS England Negotiating Committee of the NHS Act 2006 as representing all are planning to meet regularly with the PSNC to community pharmacies providing NHS discuss the proposals, seek input and iterate pharmaceutical services in England. the thinking. - In February, collated views from the ongoing consultation process will be formally fed into the PSNC discussions. Pharmacy stakeholders Other pharmacy stakeholders the - Initial briefing sessions during Department is choosing to consult with under January/February. section 165(1)(b) of the NHS Act, given the - Second round of meetings during March, at potential impact of these proposals: which additional information that has emerged Pharmacy Voice as a result of ongoing consultation with PSNC Royal Pharmaceutical Society will be shared. Association of Pharmacy Technicians UK General Pharmaceutical Council Other bodies We will also consult more widely, including: - Initial briefing sessions during January. - Healthwatch England - Second round of meetings during March, at - National Voices which additional information that has emerged - Local Government Association as a result of ongoing consultation with PSNC will be shared. DH – Leading the nation’s health and care 23
CONSULTATION PROCESS Consultation process: timings The consultation process started on 17 December, 2015 with the publication of the open letter to the PSNC and other stakeholders. It will end on 24 March, 2016. The timetable for the process, and the expected implementation of the finalised package is as follows: Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug Sep 16 Oct 16 16 Announcement Views from Discussions with PSNC stakeholder sessions fed into PSNC discussions Initial consultation sessions Consultation with other stakeholders Secondary consultation sessions to take into account emerging views from the PSNC discussions Decision Implementation Further areas for consultation Separately to the consultation period on the proposals outlined in this presentation, we will also run a formal government consultation on proposed changes to the Human Medicines Regulations 2012 to remove the legal impediment to ‘hub and spoke’ dispensing model across different legal entities. This will not be part of the above consultation period, but does form part of the overall reform package. DH – Leading the nation’s health and care 24
Quintus Liu Founder, Serket Technology Click here
Sue Sharpe Chief Executive, Pharmaceutical Services Negotiating Committee
The Future of Community Pharmacy Sue Sharpe Chief Executive
Times article
Understanding the role and value of the community pharmacy • Dispensing and associated support • Advice on problems; health and wellbeing • Reducing burdens on GPs and urgent care • Relieving pressure at times of crisis • Future role development
How patients and the public perceive community pharmacy • Important local resource, conveniently available • Strong positive value and trust • Part of the social fabric of the local community
Why the NHS persists in under- valuing or ignoring the sector • No appreciation at policy-making level of the role • Primary care policy centred on General Practice • Two small references only in 5 Year Forward View • Lack of data – if not captured it is ignored
Three essential components to developing the services provided by Community Pharmacies • Commitment and skills of the sector • Identified value and business case for the NHS • Commitment by the NHS/ government The third appears to be absent
PSNC’s 5 point pharmacy plan Able to make a big impact in two years by: 1. Access to urgent medication 2. Advice on symptoms/ 1 st port of call 3. Care for frail and elderly people 4. Supporting long-term condition management 5. Identifying undiagnosed respiratory disease
Specific examples of pharmacy services Flu vaccination service • Nationally commissioned 2015/16 • By 30th October 8,040 (68.5%) pharmacies had signed up to provide the service • Over 483,000 flu vaccinations administered so far (service commissioned until the end of Feb ’16; n.b. excludes those not recorded online)
Minor Ailment Service • 84 services commissioned locally across England • Analysis from 30 services and 473,327 patient consultations showed: – Over 50% of consultations were for individuals under the age of 16; – 92% (432,723) of patients would have gone to their GP if MAS was not available; and – Only 2% of patients would have purchased medicines if MAS was not available • “ The new unified scheme has delivered, on average, two hours per week per practice of additional GP appointment capacity as well as a 46% reduction in costs in comparison to the same quarter the previous year.” NHS England Birmingham, Solihull & the Black Country, Pharmacy First evaluation
Emergency Supply of Medicines • Up to 30% of all calls to NHS 111 services on a Saturday are for urgent requests for repeat medication. This is an increase of 13% over 12 months in some areas • In Kent, Surrey and Sussex, 3,040 requests were handled during April 2014 which resulted in 2,199 being referred directly to GP out of hours services for a 2 hour appointment to arrange a prescription. Only 60 patients were referred to their own in-hours GP with 781 patients referred to other services NHS England, Urgent Repeat Medication Requests: Guide for NHS 111 Services (2014)
Emergency Supply of Medicines
COPD Case Finding (Community Pharmacy Future) • 21 community pharmacies screened 238 patients over 9 months • Potential COPD patients were identified who might have otherwise remained undiagnosed & gone on to progress to severe disease states, including associated acute care costs • £264m potential annual saving * from diagnosing patients earlier • £215m potential lifetime savings from stopping smoking All savings based on delivery of equivalent services from 11,100 pharmacies across England with similar results seen. * Savings based on the differences between treating moderate-to-severe COPD and reduced productivity losses. 215m potential lifetime savings from stopping smoking
Reablement Service (Isle of Wight) • 37% reduction in patients admitted • 67.5% reduction in hospital bed days • 48.43% reduction in average length of stay • 8,850 bed days saved • £1,885,050 saved in excess bed days • Recognised by Healthwatch England • Shortlisted for HSJ Primary Care Innovation Award 2015
The letter of December 17 th • No proposals for developing ‘more clinically focussed community pharmacy service’ • Cuts in funding using volume measures – incompatible with stated objective • Incentives to commoditisation of dispensing • No clarity or coherence in the contents of the letter
Conclusion • The threats and challenges raised by the current consultation must be examined and addressed • The current and potential value of the sector to the NHS must be recognised • Institutional prejudice against community pharmacy must cease • This will improve community pharmacy’s future, and that of the NHS.
Karen Borrer Head of Reputation, ABPI
Disclosure of transfers of value to healthcare professionals – the countdown to June Karen Borrer Head of Reputation, ABPI
What, when and how? www.abpi.org.uk
Europe-wide initiative 33 EFPIA countries Of which 10 countries disclosing via a central database Portugal Netherlands Denmark France Of which, 6 have platforms set up using industry self-regulation UK Belgium Czech Republic Greece Sweden Ireland www.abpi.org.uk
What will be disclosed? Individual disclosure Aggregate disclosure Transfers of value to individual, Transfers of value to HCPs who named HCPs cannot be named for legal reasons • • total annual amount paid to all such Annual total • Broken down by 4 categories – individuals • total number of individuals in this Events (registration fees) aggregate group • proportion of this aggregate group of Events (travel and accommodation) HCPs as a percentage of all HCPs Consultancy and Services (fees) Consultancy and Services (expenses) Transfers of value to HCPs and HCOs in connection with certain R&D Transfers of value to HCOs activities including clinical trials • • Disclosure on a per-activity basis total annual amount • All HCOs will be named www.abpi.org.uk
What will be disclosed? • Companies will seek consent to disclose individual, named data from the HCPs they are engaged with • Under UK data protection laws HCPs must give consent for this data to be published • If consent is not given the amount (£) and number of HCPs this relates to will be shown in aggregate • Industry ambition is to achieve the greatest amount of individual disclosure as possible in collaboration with the HCPs companies are working with www.abpi.org.uk
What will be disclosed? Down from 89% in 2013 www.abpi.org.uk
What will be disclosed? Up from 70% in 2013 In line with EFPIA www.abpi.org.uk
When and how? Disclosures have to published on the central platform: • By 30 June 2016 • On transfers of value made during 2015 calendar year Disclosures have to remain in the public domain for 3 years after date of disclosure • And records held by companies for at least 5 years after the end of the calendar year for which they relate To disclose on the UK central database, companies will have to submit two documents: • UK data collection template • Methodological note www.abpi.org.uk
Central platform • Hosted on ABPI website • Fully publicly accessible • Containing: • Background and rationale for industry disclosure • Database search engine • Individual company methodological notes • Contextual information – how data can be used and interpreted • Downloadable in a safe, interpretable format – date- stamped, certified excel file www.abpi.org.uk
Central platform workflow By 30 31 March 16 June 2016 www.abpi.org.uk
The HCP checking period Query direct to company • Automatic invite for • Within 14 days amend HCPs to check ALL made on database • HCPs may: data • After 14 days HCP • 28 days to check - Request to amend moved to aggregate data while query resolved - Opt out • Company has 14 days Amend to resolve HCP/HCO alert database www.abpi.org.uk
How does this fit with the ‘Sunshine Rule’? www.abpi.org.uk
‘Sunshine Rule’ 23 August – Jeremy Hunt announced the introduction of a ‘Sunshine Rule’ following a Daily Telegraph investigation
‘Sunshine Rule’ • Intended to improve transparency between HCPs and various industries – not just pharma • Ensure greater consistency of the collection and publication of information relating to conflicts of interest, gifts and hospitality • Being delivered within existing legislation • Linked areas of work aimed at ensuring consistent, clear guidance on managing the collection and publication of information relating to conflicts of interest, gifts and hospitality, based on current best practice: o Internal NHSE standards of business conduct and guidance to Clinical Commissioning Groups (CCGs) o NHS standard contract • The ABPI believes this is a complementary activity to the industry-led disclosure project and in engaging with NHSE on both initiatives www.abpi.org.uk
Preparing for disclosure • Intensive stakeholder engagement – professional bodies, HCOs, government, media etc. o Prepare – what we are doing and why o Understand – limitations of the data • We should expect increased media scrutiny o US, Netherlands etc. • Shared agenda • Knowledge is key to preparedness www.abpi.org.uk
Finally… Any questions? www.abpi.org.uk
Further information ABPI Disclosure Network – E-mail disclosure@abpi.org.uk to register – Disclosure Bulletin – Regular webinars Disclosure pages - ABPI website www.abpi.org.uk – click on ‘Our Work’ and ‘Disclosure’ PMCPA website - Code; UK data collection template www.pmcpa.org.uk EFPIA’s information website: www.pharmadisclosure.eu www.abpi.org.uk
Stephen Goundrey-Smith Consultant Pharmacist, SGS PharmaSolutions
Stephen Goundrey-Smith MSc MRPharmS – SGS PharmaSolutions SGS PharmaSolutions
Pharmacist with experience in hospital pharmacy, community pharmacy and the industry Electronic prescribing software design analyst Pharmacy informatics advisor to the Royal Pharmaceutical Society Experienced consultant in pharmacy informatics Experienced trainer and mentor Author of “ Principles of Electronic Prescribing ” and “ IT in Pharmacy: An Integrated Approach ” SGS PharmaSolutions
SGS PharmaSolutions
6 million people visit pharmacies every day 99% of the population can get to a pharmacy within 20 minutes by car/96% by walking or using public transport (PiE) Advice from “qualified” professionals Services provide opportunities for community pharmacists to exercise clinical skills Pharmacists in GP surgeries Many stakeholders see the value that pharmacists can bring SGS PharmaSolutions
Dispensing workload is increasing Pharmacists not adequately remunerated for the services they provide For many public, a) pharmacist value is dependent on speed of collection, b) pharmacist is perceived as being “too busy in the dispensary” to provide a convenient source of advice (PDA Focus Groups) SGS PharmaSolutions
SGS PharmaSolutions
SGS PharmaSolutions
What is a technology?...if informati rmation on technology, then.. Pharmacy PMR systems Electronic Prescription Service (EPS) Electronic ordering EPOS systems Service support systems (Pharmoutcomes, Webstar, Sonar) SGS PharmaSolutions
Hi High gh quali ality ty pharm armaceu aceutical ical care More patient-focused services More services that support our primary care colleagues Better remuneration for services provided And…respect from our patients and peers SGS PharmaSolutions
SGS PharmaSolutions
Electronic Prescription Service (EPS) Summary Care Record (SCR) Hospital Electronic Prescribing E-Discharge/E-Referral Hub & Spoke Dispensing Robotics EU Falsified Medicines Directive (FMD) Standards Initiatives Mobile Technology/Telecare SGS PharmaSolutions
Oct 15 – 98% pharmacies live, 29.7% of all items via EPS, and 15.6 million nominations “Phase 4” – EPS becomes the default prescription system – token if no nomination, CDs by EPS Release 3 – 2017 onwards – a) owings management, b) patient tracker, c) dispenser messages Exploratory work – use outside primary care, homecare, Open-source, Rx push, protocol supply SGS PharmaSolutions
Summary healthcare record – 97% of England population Contains – allergies, current meds, previous ADRs May contain - significant medical history, care plans, patient wishes/preferences Benefits for hospital medicines reconciliation POC Study in community pharmacy – prevented medicines errors, reduced the need to refer elsewhere SCR to be rolled out in community pharmacy SGS PharmaSolutions
Electronic prescribing and medicines administration (EPMA) in hospitals Care - non-product-based prescribing and complex medicine administration Currently low – but hospital EPMA will increase to > 50% of acute hospitals due to Technology Fund investment SGS PharmaSolutions
E-discharge systems developed to improve hospital discharge process How can community pharmacy be involved? Development of e-Referral systems Refer patients discharged from hospital to community pharmacy for Medicines Use Review (MUR) and New Medicines Service (NMS) SGS PharmaSolutions
Some pharmacies – large Rx throughput, so difficult to develop services (NMS, MUR) In future – dispensing of medicines could take place at a central “hub” Medicines would be supplied to patient, along with services and advice at “spoke” pharmacy Change of law so that hub and spoke can be different legal entities Where does responsibility for medicine lie? SGS PharmaSolutions
Pharmacy robots have the potential to reduce dispensing errors, streamline the dispensing process and enable “re - engineering” of pharmacy services Audit Commission “Spoonful of Sugar” Report (2001) – widespread use of robots in hospitals Slower uptake in community pharmacy – although some independents have installed robots to enable service development SGS PharmaSolutions
An EU-wide industry-led initiative to prevent medicines counterfeiting Medicines must have tamper-evident packaging and a unique identifier Authenticity of a medicine must be verified at the point of supply to the public Could it enable additional benefits? - accuracy checking, product information, expiry date checking and drug safety reporting SGS PharmaSolutions
Need standards for joined-up systems and services dm+d – medicines terminology SNOMED-CT – disease terminology Dose syntax Standards for format and content of clinical records – PRSB SGS PharmaSolutions
Mobile phone use is now almost universal the UK – are we making the most of them? Alerts (repeat Rx collection) & appointments But what about disease monitoring and adherence monitoring? More data…privacy…look what happened to P2U SGS PharmaSolutions
Adherence is a real issue for all stakeholders 20-50% of patients do not adhere to medicine (depending on regimen etc) Smart packaging – Aardex MEMS, Stora Enso Smart pills – Lifenote Barriers to implementation – a) data & communication standards….b) privacy SGS PharmaSolutions
Telecare – patient-centred healthcare Remote consultations – greater patient convenience and service access Housebound, isolated, palliative patients Mobile phones and digital televisions as interfaces Broadband infrastructure in rural areas is key factor Effects on access - but also health outcomes and personalised medicine? SGS PharmaSolutions
Lots of technologies are available, and may be in use for some purpose in some industry For pharmacy – is it useful ful, is it lega gal, is it vi viable? People, not systems – technology should support us and our patients, not vice versa It will open up new possibilities – with unintended consequences Open- source….? SGS PharmaSolutions
Increase targeted MUR/NMS? Develop screening services or flu vaccinations? Deal with hospital discharge situations better? Manage care home services better? Improve communications with patients? Choose ose the right technology for the job, implement ement well and monitor tor progress SGS PharmaSolutions
Stephen Goundrey-Smith (sgspharma@hotmail.com)
Chris Howland-Harris Medicines Optimisation Pharmacist
The Madness of Community Pharmacy Chris Howland-Harris FRPharmS Community Pharmacist Medicines Optimisation Pharmacist & Independent Prescriber NHS Bristol
Future of Community Pharmacy • Where have we come from? • Where are we going? • Are we nearly there yet?
What the public What the NHS think I do thinks I do What I actually do What I think I do
Future of Community Pharmacy • Communication • Information • Clinical Skills • Consultation skills
• 6,000 items/month • 50 diabetes • 150 asthma • 500 hypertension • 50 recently discharged • 750 pensioners
Why pharmacists? • Intervention • Finance • Safety • Waste • Admissions • Patients
Medicines Optimisation
Medicines Optimisation Emergency supply service
Medicines Optimisation NOACs
Medicines Optimisation Traffic Light Schemes
Medicines Optimisation Medicines Optimisation Medicine Use Review/New Medicine Service
Skills & Training
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