So, the much awaited NHS Long Term Plan is finally with us and is a must read for anyone running a community pharmacy. The plan, albeit a high level and aspirational one, sets out a new model of care for the 21st century:
- how the NHS will move to a new service model in which patients get more options, better support, and properly joined-up care at the right time in the optimal care setting
- new, funded action the NHS will take to strengthen its contribution to prevention and health inequalities
- how current workforce pressures will be tackled, and staff supported
- how the 3.4% five year NHS funding settlement will help put the NHS back onto a sustainable financial path
- the next steps in implementing the plan.
The good news is that it’s not all about hospitals and GPs with a focus is on primary care which explicitly includes an essential role for community pharmacy within that network. With an intention to shift a third of outpatient activity out of hospital and getting upstream on prevention and reducing health inequalities, community pharmacies are well placed to take on much of this work if we are ready willing and able to do so. This releases an already struggling general practice system to focus on what it should be doing to deliver against other elements of the plan.
No one can ignore that after 70 years the NHS faces some major challenges. There is concern about funding, quality, staffing, access, increasing inequalities and pressures from a growing and ageing population. The plan talks of the need to accelerate the redesign of patient care, a broad consensus about the changes now needed, and that almost everything in the plan is already being done successfully somewhere in the NHS, just not consistently.
Equally, no one within community pharmacy will deny the extreme level of challenge it faces to continue the desired level of professional patient care whilst trying to remain sustainable. The sector is also experiencing increasing demands on it, stock shortages, inconsistency in quality with some behaviours driven by the current outdated contractual framework and exacerbated by the funding cuts. However, there are those who are embracing change and developing a future plan of their own. One which may be less dependent on NHS funding but is also preparing for the potential opportunities that the new NHS could bring if collectively we get this right.
The Role for Pharmacy in the Future NHS
So where does pharmacy fit into the plan? Well, for those who like to count such things, it seems quite a lot with over 20 mentions and more than 10 specific references to community pharmacy’s role.
The reaction so far has been mixed with some welcoming a greater role for pharmacy, the first real indication of vision from government since the Pharmacy White Paper (Building on strengths, delivering the future) in 2008. Of that vision, only Healthy Living Pharmacy has really come through, but not everyone has truly embraced and hence benefitted from the HLP model. We are now finally seeing some other emerging threads from that 2008 plan such as DMIRS (Digital Minor Illness Referral Service).
Some key areas that could be positive for community pharmacy and encourage those with a half-full glass include:
- make greater use of community pharmacy’s accessibility and skills
- establishment of Primary Care Networks with £4.5 billion investment
- out-of-hospital and urgent care
- supporting self care and self management
- promoting good health
- prevention of lifestyle-related illnesses including cardiovascular disease, stroke, diabetes, cancer and respiratory conditions
- greater involvement in provision of Health Checks and their outcomes
- support to improve mental health and wellbeing
- involvement in social prescribing
However, some are looking through the bottom of a different glass at what the plan doesn’t say or interpreting some of the language as threatening. Areas which are perceived as negative include:
- expansion of digital healthcare and use of technology including automation
- reducing waste and exploring alternative reimbursement and supply arrangements for medicines
Digital healthcare and the increasing use of technology is here and now and is only going to grow rapidly, so we either adapt and adopt or be side-lined. The government doesn’t have a good track record of managing communication and implementation of alternative reimbursement and remuneration arrangements so one can’t really blame those who look through this particular lens. However, we have been asking for a better, fairer system so let’s ensure that we make it work better and fairer?
One often divisive issue is the continued use of the term Clinical Pharmacist which, by some, is seen to be a role in either hospital or general practice. This is more about what pharmacy is commissioned to do and what it actually does wherever practiced. No other profession differentiates itself in this way. However, there is undeniably a current perceived lack of confidence in clinical practice competency amongst some, from both within and out-with the profession. This partly reflects undergraduate and post-graduate training, currently under review, but also a lack of understanding and appreciation of the value of a community pharmacist and their team in the clinical care of people and patients.
We must actively and urgently explore and develop potential solutions for the NHS that can both support a sustainable sector and improve population health. We must not focus on negative interpretations and semantics and we certainly cannot continue to keep doing what we are doing and expect a better outcome for anyone.
What Must Happen at a National Level
Ask not what the NHS can do for pharmacy, but what can pharmacy do for the NHS.
Collaborative leadership is a must do for the pharmacy bodies. Whilst they all have their own remit and melody, the words on the song sheet must complement, not contradict, and move all areas of pharmacy practice to a better and sustainable place in a future health and care system.
PSNC should be knocking on the door of NHS England and DHSC and have the right people asking the right questions of the right people to understand how community pharmacy can play a key role in the achievement of the plan’s aspirations.
A new, fairer contractual framework must be developed quickly and support for its implementation and consistent quality delivery against the NHS needs to help address health inequalities. A framework which is sustainable, equitable and drives the right behaviours and quality outcomes.
What Must Happen at a Local Level
Integrated Care Systems (ICS) are due to be in place everywhere by April 2021. As they are to be central to delivery of the plan, there is a major influencing and leadership role for Local Pharmaceutical Committees (LPCs). They must work closely with ICSs and CCGs to ensure that community pharmacy is firmly embedded and active within the new Primary Care Networks and the additional £4.5 billion attached to them. Some LPCs have made progress, others need more support to understand the system levers and language.
An LPC representing a relatively small number of contractors will probably not have the resources or capacity to make this happen. The footprint of an LPC, or an effective collaboration of LPCs, should mirror that of an ICS. This scaled-up approach should provide the necessary funding, capacity and capability to influence local commissioning and other provider organisations to achieve the required integration and development of community pharmacy services. We should be thinking about provider alliances as no one provider is likely to be the complete solution to a local problem.
In addition, many pharmacy contractors will need leadership and support to understand the new landscape and what that means to them. Contractors and their teams must then consider how they can play a key role within the emerging local networks and what they need to put in place to do so.
It is now ten years since the Healthy Living Pharmacy initiative was developed in anticipation that community pharmacy could and should play a bigger and better role in improving the health and wellbeing of the communities we serve and support. It was predictable then that a supply-based contract would not be sustainable in the long term and a shift to a quality-led, service-based contract including pharmaceutical care, supply and prevention would come. Hence the focus on organisational development with enablers based on developing the pharmacy team, engaging with the community, commissioners and other providers plus ensuring that premises and the adoption of technology is fit for the future. That was then, and it is even more germane today.
Whilst this a very challenging time, pharmacy must constantly adapt to the evolving needs of healthcare to remain relevant and compelling to commissioners and consumers of our services. We missed the chance to respond appropriately to the needs in the NHS Five Year Forward View. Let us not miss this opportunity both for community pharmacy and the health and wellbeing our local populations.
Michael Holden, FRPharmS FRSPH, is Principal Associate at Pharmacy Complete, a training and consultancy business specialising in community pharmacy.