After two days of intense deliberation on the future of community pharmacy at Punta Cana in the Dominican Republic, the scene was well set Andrew Lane to speak his mind and reflect on some of the challenges facing the sector.
Usually a man of calm demeanour, great optimism and intense passion for community pharmacy, there was an unmistakable frustration is his tone, a sense of resignation and weariness, when he spoke of his recent meetings with some bureaucrats who either didn’t get pharmacy at all or just refused to pay attention to the sector’s repeated plea – despite all the sound and fury that had gone on across the country since community pharmacy pulled it socks up to showcase its true worth and value during and immediately after the pandemic.
“How is it that a sector that was held in such high regard by the public, politicians and even the King (who hosted a reception for pharmacy teams at Kensington Place), can be allowed to be feel so sickly and stretched,” he asked?
Mr Lane recalled a conversation he had – just before the pandemic – with a senior government minister about how the sector desperately needed adequate funding to remain viable. “You will be alright – you get so much money from shampoos and toiletries,” the senior politician told him.
“I had to describe to him that that was less than 5 per cent of our business and we were reliant on the NHS for 95 per cent of our income. If a past health secretary didn’t understand how our model worked, then I think we do have a problem.
“I think whether you’re an MP, minister, member of the public, you actually determine what a community pharmacy is by your learned experience as a patient. Doesn’t matter who you are. And if you don’t get good service for your prescription journey, or it’s more complicated than it needs to be, you will have a different view. You’ll also have a different view from the way we look and feel when you walk into a pharmacy. Because for most people, it would appear that we sell lots of things that are retail products, we still refer to ourselves as owning shops rather than practices or pharmacies… and we then wonder why we get treated like shopkeepers.”
Community pharmacists in England and the devolved nations have all been urged to operate more clinically but unlike in England they are paid for the services they provide both in Scotland and Wales. While Scotland has a very successful national minor ailments scheme, there is no such thing in existence south of the border, barring sporadic instances where things have worked locally but that is very patchy and down to local LPC relationships where they work well.
On reflection, Mr Lane said: “I don’t think we’ve made enough of the relationships and the contract development that’s happened in the devolved countries like Wales and Scotland.
“PSNC would be wise to look over the borders in Wales and Scotland, and just look at how it’s developed over there. When you look at Wales there’s an acute sense across the country that pharmacy is part of the community asset bank and to some extent that’s the same in Scotland too.
“Andrew Evans (chief pharmacist in Wales) has gone on record and said many times that he wants to make sure community pharmacy has a fair return for the investment that’s being made in it. Contractors in Wales seem to be happy with that approach, it’s never going to be perfect everywhere.
“In Scotland, Harry McQuillan, CEO of Community Pharmacy Scotland, and their Chief Pharmaceutical Officer Alison Strath have a good relationship: they collaborate with each other and work together to determine where community pharmacy is going. They have a vision and they are both aligned to it and the whole sector is behind them. There is no obvious sector divide in the devolved nations.
“In England, with the 42 ICSs (integrated care systems) still in the early stages of development, the playing field for PSNC is more difficult to work within. But nevertheless, there are models out there in the UK that have worked for patients. We’ll need to take a leaf out of those success stories and spread them across the country, using valuable networks created and still being created by LPCs.”
NHS England has emphasised the need to improve value through integration of pharmacy and clinical pharmaceutical skills into patient pathways and the emerging new care models which will be spearheaded by the ICSs.
Mr Lane looks at it as an opportunity, but they don’t come without any challenges. The biggest challenge, particularly for PSNC, will be to support LPCs in developing local relationships, local development and local progress on commissioning of new services that are coming locally. But he regrets PSNC currently “doesn’t seem to have the bandwidth to get involved at the local level where support is needed now, not in a year’s time when Pathfinder IP sites will be evaluated”.
First port of call
Mr Lane recalled meeting a lady in an A&E hospital environment about a month ago. She had come in with a child who had essentially been diagnosed with conjunctivitis. He said that was something that could have been easily dealt with in a community pharmacy setting. There was no need for the lady to queue up for four hours in A&E to get her child seen for conjunctivitis.
“This means there’s a job that the NHS needs to do to ensure that they message, like they very cleverly did during the pandemic, to direct patients to community pharmacy – that worked really well during the pandemic. It worked because we were open and everybody else was closed. People go to where the doors are open. The doctors closed their doors but we were open so they came to us.
“The NHS missed the trick by not marketing our continued availability, post pandemic, to keep the momentum up. But in the current environment this is now a double-edged sword: we want people to access the care we offer, but we’re overwhelmed and under-capacity due to the funding cuts.”
“The government clearly recognised that we are a solution or could be a solution to the GP crisis. There’s an acceptance that there is a challenge and we can help with the challenge by being part of the solution, but I’m not really seeing any detail of how this is going to be funded. The Treasury hold the purse strings on everything we do because they genuinely have the NHS budget in their hands.
“But I don’t think we have made our health economic case to the Treasury of where we sit in the NHS as the financial solution to some of the woes of the health system. We talk about the clinical stuff and accessibility but we actually never get down to the revenue line –how we genuinely save money in the system, patient time, GP time, A&E time – we haven’t shown the financial details or made a business case which puts all that together. I see that as PSNC’s job”
With the NHS having to deal with a backlog of people waiting for over 52 weeks for elective care against an 18-week wait target, where does community pharmacy find itself fitting in?
Mr Lane said: “We did reset the dial with the work we’ve done with NHS Confederation and by making sure that we were embedded in the ‘Fuller Stocktake’ which cited community pharmacy in primary care as part of the clinical pathway – that was crucial, and that’s by no means come to the end of its journey. I think what we need to determine is how long it will be before we are absolutely seen as pivotal to the financial pressures that the NHS finds itself under and project a timeline for delivery against the sector’s vision.”
Because of the backlog and because of people on long-term conditions not being treated for over two years, there has been an extra pressure on the NHS that was unprecedented before the pandemic. For community pharmacy to exert its influence and build on what it’s already been achieved, the government needs to follow through on some of its deliverables around inclusion of community pharmacy in the clinical journey.
“But we haven’t seen enough of a movement, if I am honest. We’ve got this Pathfinder IP development programme where we’ll probably see the direction of travel in maybe two years’ time. But we haven’t got two years to wait to get the funding right. That’s the problem we have as a sector, it’s falling over now.”
When asked what he would like to see in the new national contract, he said: “A fundamental rethink is needed if the sector is to recover, thrive and deliver for patients. We can’t wait until the end of the current framework in 2024 before giving serious thought to what should replace it.
“We would like to see pharmacy contractors empowered. The contract must allow contractors to be the master of their own destiny to far greater extent than it is now. Current contract arrangements of pharmacy owners are at the mercy of circumstances beyond their control – be it wholesale price rises or the reluctance of some GPs to refer into services like the Community Pharmacist Consultation Service.
“Our vision is a clinical service-based future as the ‘front door’ to the NHS. However, this cannot mean abandoning the medicine supply function, which pharmacies have performed with resilience for so long. A mixed service and supply model could deliver a structural change that both improves the clinical offering and puts us into a much stronger financial position.
“We would like pharmacies to be paid in a timely fashion. The current system of ‘excess margin’ and ‘clawbacks’ are a barrier to investment in forward planning. They undermine confidence to modernise and implement new clinical services. If the future vision is not clear, then nobody will invest in it.
“And lastly, I want to talk about rebalancing power. As the years go by, and one one-sided negotiation follows another, the argument for some kind of independent arbitration becomes ever stronger.
“The Department of Health and Social Care and NHS England should consider introducing a degree of independent financial regulation that mitigates the risks of a monopsonistic purchaser using its power to achieve short-term gain at the cost of sustainability.
This idea was actually first suggested by Ernst & Young, who the NPA commissioned to look into the pharmacy finances in 2020. EY understood that the imbalance of power between the parties to contractual negotiations serves no one in the long term.
Community pharmacy’s national representative bodies, including the NPA, have collaborated in several ways during the Covid-19 pandemic but there is a sense among contractors that their “show of unity” has since dissipated. Meanwhile, the UK’s four chief pharmaceutical officers have committed to establishing a pharmacy leadership council, sensing perhaps that disjointed voice of pharmacy was holding back the sector from making the best contribution to UK healthcare.
When asked to comment on the prevalence of one upmanship among professional bodies, Mr Lane said: “We have a cross-sector comms group. All pharmacy bodies are involved in that and that’s the channel we push everything through and we are united on 90 per cent of the things that we talk about. I like to think that the NPA sets a good example by working collaboratively wherever it makes sense to do so.”
He described the leadership council as a significant attempt to grow the standing of pharmacists and pharmacy technicians, in line with evolving public expectations.
“If this is to be genuinely broad and inclusive, professionals working in community pharmacy – who form the large majority – must be seriously engaged in the process of change,” he added.
Mr Lane chairs a 17-member board of management which is elected by its members on a regional basis across the UK. Each member can stay on for up to 10 years, but the association churns the board every two years (following a recent modernisation of the NPA’s constitution).
Asked how inclusive his chairmanship has been and why women are underrepresented in his board, Mr Lane said although it was ethnically diverse, he would like to see more women come forward for the board in future.
“Immediately before my chairmanship we didn’t have any women on the board. It’s an election process and I always encourage anyone who feels they have something to offer to put their hat in the ring. My board member colleague Reena Barai has done a fantastic amount of work to engage women in NPA activities and is an inspiration.”
Andrew Lane’s 6 Top Tips
- Take existing opportunities: As far as it is possible under current work pressures, try to deliver your full quota of those pharmacy services such as NMS that provide an income for you as well as benefitting patients.
- Diversify: Develop your private service offering (if it’s appropriate for your local area), to expand the range of support available beyond the NHS and bring in new income streams.
- LPCs: Keep an eye on your LPC and hold them to account. Are they fully engaged with the new ICS structures? What are they doing to make sure community pharmacy is in the conversation within the local NHS?
- Your staff: We know money is tight, to say the least, but don’t neglect the future of the business by failing to develop and train your staff.
- Your own mental health: Look after your own wellbeing and that of your staff. At a time when pharmacy finances and pharmacy teams are under immense pressure, it is easy as a contractor to take on more work than it is healthy to do. Access the wellbeing support that is available from pharmacy charities and the NHS.
- Be proud: Remember when people we’re clapping for health care workers during the pandemic? As far as I’m concerned they were clapping for you. As pharmacists we’re quite modest about what we do but never forget you play an integral role in the health of the nation.