‘Making it happen’ was the appellation for this year’s Sigma Pharmaceuticals conference…which revealed there was actually quite a lot for community pharmacy to make happen if it is to have a future in the NHS. Neil Trainis reports from Borneo…
Familiar challenges and not-so-familiar opportunities confronted those community pharmacists who braved the long flight to Borneo for the latest Sigma conference staged in the Shangri-La Tanjung Aru Hotel before an assortment of leading figures from the world of healthcare and politics.
There they congregated to discuss a range of issues that will decide the fate of community pharmacy, including funding cuts, hub and spoke dispensing and service commissioning.
Hemant Patel, the secretary of North East London LPC, took the bull by the horns in typically brusque style, warning that for almost two decades pharmacy had been preoccupied with medicines and “forgotten about what is happening in the rest of the healthcare system.”
Pharmacy, he added, knew “nothing about community services.” He questioned whether the pharmacists in the room were ready to get involved in sustainability and transformation plans (STPs), the government’s way of moving care out of hospitals and into communities. In fact, he questioned whether they even knew what they were.
STPs, Patel insisted, were “really important organisations. This is not reorganisation. This is a serious re-engineering of responsibility and new roles will be developed. There is quite a lot of virgin territory not occupied at present and we have an opportunity to grab that.”
Graham Jones, a Conservative councillor at West Berkshire Council and a community pharmacist, was also supportive of STPs, insisting they can encourage a move away from competition.
Yet the question, he said, was not so much about STPs but whether community pharmacy will be on the inside or outside of accountable care organisations – structures that will encourage NHS providers to merge or commissioners to use competitive procurement to invite bids from organisations to deliver services.
That might have had those fearing NHS privatisation running for cover. Dr Etheldreda Kong, chair of Brent Clinical Commissioning Group, was more interested in encouraging co-operation between pharmacy and general practice.
“If we really, really, really, had to be brave we can go into joint ventures and alliance contracting…to take on bits from local authorities or CCGs,” she said. One took alliance contracting to mean joint GP-pharmacy contracts. One wondered what those at the Royal College of General Practitioners (RCGP) and British Medical Association would make of that one.
Dr Kong went on. Pharmacists and GPs, she said, must work together when it comes to immunisations and vaccinations and resist competition. Recent history had not been encouraging on that count. Dr Kong, however, was not to be shunted from her stride and insisted it was important for general practice and pharmacy to work together on the prevention agenda. No argument there.
As she spoke about commissioning she offered a critique of community pharmacy. “The commissioning influencing role, I think community pharmacists, you have to try harder to get into part of the governing body structure. If you cannot be at the governing board level, be at the sub-committee level or have a contribution to STPs because by doing that, you’ll be able to get your views heard more locally.”
Graham Phillips, the owner of Manor Pharmacy Group, was intent on ripping apart Jeremy Hunt, Keith Ridge, Simon Stevens, Philip Hammond and any other ‘enemies’ of community pharmacy before suggesting somewhat diplomatically that Helen Stokes-Lampard, the chair of the RCGP, “gets pharmacy.”
Telling the conference that pharmacists needed to make every political contact count, Phillips went on to suggest that pharmacy should be treating hypertension rather than “dumping” it on GPs. It was a sobering way of putting it but perhaps harsh language is now the only way to penetrate the minds of community pharmacists some of whom are failing to do their medicines use reviews and new medicine service consultations as Carole Alexandre and Fin McCaul suggested.
Listening to the speakers, the impression was that time was running out for community pharmacy. Yet negativity did not prevail. Community pharmacy’s fate remains in its own hands.
Its destiny, Trevor Gore from Maestro Consulting said, would largely be decided by its ability to tell engaging stories about how it ameliorates the health of local communities.
“Storytelling works. Data is good. But tell your story with emotion and resonance,” he said. And the conference was lavished with inspiring talks from community pharmacists Bernadette Brown, Terry Reid, Sonia Shah and Amish Patel who had uncovered new revenue streams instead of relying on NHS funding.
Bernadette invested in staff training with a strong focus on independent prescribing, Sonia introduced an online booking system for her travel clinic to improve patients’ accessibility to the service, Terry had taken customer care to new heights and Amish had delved into the world of aesthetic pharmacy including botox and dermal fillers.
That was taking community pharmacy care to new levels.
Days of division in community pharmacy are coming to an end
Ian Strachan, the chairman of the National Pharmacy Association (NPA), insisted the days of fragmentation within the community pharmacy sector is coming to an end.
Strachan suggested that five main pharmacy organisations in particular, the NPA, PSNC, Royal Pharmaceutical Society (RPS), Pharmacists’ Defence Association (PDA) and Company Chemists’ Association(CCA), were moving in the same direction to ensure community pharmacy has a future in the NHS.
“It’s been said many times that the bodies need to be aligned, NPA, PSNC, the RPS, PDA, CCA. They all have to play a part in delivering confidence that community pharmacy is a major solution,” he said.
“I reached out at (the Sigma) conference in India in 2015 in Mumbai and I asked for that. And I asked for it again in (2016) and (2017).
“Today, and this is where it has changed because there is a strategy in play, there is more of a willingness to talk openly across the bodies, share the responses, communications, consultations and that’s happening now.
“The common denominator, all our ambitions, has got to be for a vibrant community pharmacy network because without it, all these other models of pharmacy care will not develop either.”
One sign that the community pharmacy sector had become more united was the joint campaign launched by the NPA and PSNC aimed at stopping the Conservatives’ funding cuts.
Strachan added: “We have a cross-sector strategy in play now and I’m proud of that. During that campaign I had Mike Smith (Alliance Healthcare’s non-executive advisor), Cormac Tobin (former managing director of Celesio UK), John D’Arcy (outgoing managing director of Numark), all coming to me with ‘what can we do to help with distribution?’
“They helped with the petitions, 2.2 million petitions. We got delays to the cuts, we delayed the dangerous hub and spoke proposals.
“I’m not saying they’ve gone away but we delayed it. We’ve binded the together. The PSNC has developed focused service frameworks. We’ve ensured pharmacy has a bigger voice at Westminster. We’ve now got premises on the doorstep of Westminster to be able to influence media, stakeholders, policy-makers, politicians.
“And we’ve stood tall to the large multiples and said ‘your business model is not our business model and it’s not for us thank you.’”
Community pharmacy is not doing its MURs and NMS
Fin McCaul, a committee member at Greater Manchester LPC, accused community pharmacy of failing to carry out sufficient numbers of medicines use reviews (MURs) and new medicine service (NMS) consultations in what was a damning critique of the sector’s ability to rise to the challenges facing it.
McCaul warned community pharmacy, which is having its funding slashed by the government to the tune of £320 million over two years, that it must demonstrate that it is focused on patients particularly those with long-term conditions. Yet so far, he insisted, pharmacists “throughout the whole of the NHS system” were failing to prove this.
“What we’re not doing is we’re not focusing on patients well enough. We’re not doing our MURs. We’re not doing our NMSs. We are not giving value to our patients,” McCaul said.
“Throughout the whole of the NHS system, that’s what is going on. And we need to reduce that variation. And we need a new contract or a new change to how we’re delivering stuff to reduce that variation otherwise, as a national service, we won’t be able to continue.”
He added: “Patients are what we’re really all about. If we don’t have patients, we don’t have a business.”
Claire Ward, the director of public affairs at the Pharmacists’ Defence Association, said community pharmacists had largely failed to engage with the key players in healthcare commissioning.
“We haven’t engaged with the people who can help us. We haven’t gone out proactively and talked to commissioners, to talk to GPs. We’ve got people who are fantastic advocates for us, people in politics, people in GP land, people who are commissioners, people out in the industry and of course patients,” said the former Labour MP.
“But we haven’t engaged with them enough and that has got to change. When the bad times have come along we wanted to talk to them. We wanted to talk to patients about what they might lose. We wanted to talk to politicians, we wanted to talk to the GPs.
“But you can’t leave it to the bad times. You have to be there in the good times too to talk to them so they understand the value of pharmacy and the pharmacy profession.”
Where is extra money going? I genuinely can’t say but we all have suspicions
Peter Ballard, the chairman of the British Generic Manufacturers Association (BGMA), insisted he was “genuinely” unable to say where the money generated by the gap between concessionary prices and manufacturers’ drug prices is going although he did suggest that “we all have some suspicions.”
Ballard, who stepped in as a replacement at the conference for BGMA director-general Warwick Smith, was challenged by one delegate who said: “It’s very interesting to see manufacturers’ price and concessionary price. There’s a massive gap. Where is this money going?”
The BGMA chairman replied: “To be perfectly honest, I genuinely can’t say. It is in the supply chain. It is somewhere between the purchase point from our members, and we supply to a whole bunch of different companies, and the reimbursement price as agreed as a concession price.”
Ballard added: “I genuinely, genuinely cannot say. I think we all have some suspicions. I can’t say, I’m sorry.”
Prime Minister: Community pharmacies are at heart of patient care
The Prime Minister Theresa May raised hope at the Sigma Pharmaceuticals conference in Borneo that community pharmacies have a long-term future under the Conservatives by expressing her belief in a letter shown during the event that pharmacists and their teams across England “remain at the heart of patient care and community wellbeing.”
The week-long event at the Shangri-La Tanjung Aru Hotel drew leading figures from the world of healthcare and politics to discuss a range of issues including funding cuts, hub and spoke dispensing and service commissioning.
Yet it was May’s letter in which she gave the impression that the sector has an integral role to play in the NHS going forward that caught the eye.
“Community pharmacies remain at the heart of patient care and community wellbeing. I know there is great importance in ensuring the improvement of health in communities, helping individuals to live, work and travel with the best service,” she wrote.
“Sigma’s mission to providing an exceptional customer experience in changing times is commendable and, I am sure, highly valued by many.
“As we are in the midst of national change, I hope the conference allows partners within the community pharmacy sector to discuss how to further shape their businesses for the future.”
Steve Brine, the pharmacy minister, added to the sense that the government is keen to ensure community pharmacy plays a central role in patient care by insisting it is “an essential part of primary care.”
“We celebrate community pharmacies and the work they’ve done to improve the health of the population,” he said via recorded video message from London.
“Community pharmacies play a pivotal role as a community and health asset and are often embedded in some of the most deprived and challenged communities, providing daily contact for people seeking health advice.
“Since taking up this job it has become clear to me the passion that pharmacy professionals have for their role in optimising the use of medicines and providing advice and support to their local communities.”
Labour MP attacks ‘ridiculous’ cuts to community pharmacy funding
The Labour MP Sir Kevin Barron criticised the Conservatives over what he described as their “ridiculous” cuts to community pharmacy funding.
“To describe the last few years as challenging for pharmacy would be the world’s probably biggest understatement. This government has made many bad choices but the decision to decimate pharmacy budgets has to be up there as one of the most ridiculous,” he said.
Barron, who is also the chair of the All-Party Pharmacy Group, said community pharmacy’s clinical expertise should be “better used.”
“Dispensing prescriptions should not be the be-all and end-all of community pharmacy. I know that (pharmacists’) income is now 90% coming from that source and that is something that needs to be addressed,” he said.
“The supply function should be a platform from which you provide a range of important, valued services.”
The Pharmaceutical Services Negotiating Committee recently said it would press the DHSC and NHS England for a service-based pharmacy contract that will cultivate community pharmacy’s role in providing care for people with long-term conditions. Community pharmacy has not had a new contract since 2005.
Pharmacists warned not to forget about revalidation
Leyla Hannbeck, the chief pharmacist at the National Pharmacy Association, reminded community pharmacists to fulfil their obligations to meet the criteria for revalidation.
The General Pharmaceutical Council (GPhC) has said revalidation, which is designed to help pharmacists keep their professional skills and knowledge updated, will begin on March 30.
Pharmacists will be required to record and submit four CPD records during the first year they submit revalidation records. In the second year and all following years they submit revalidation records they will need to carry out, record and submit four CPD records, a peer discussion record and a reflective account record.
“You need to include a specific learning objective and make it clear how the learning is relevant to your role,” Hannbeck told the Sigma conference in Borneo.“You’ll need to explain how the learning will affect individuals using your services, you need to describe the learning activities and explain how the learning has been applied.
“You’ll also need to provide examples of the benefits of the learning to service users, provide any feedback or evidence and include any next steps.”
In relation to the peer discussion, Hannbeck said: “You must include a description of why this peer was chosen and explain how the peer discussion has helped you reflect on your practice.
“You’ll also need to describe changes made to your practice as a result and provide examples of how the changes have positively impacted and benefitted your service users.”
Independents’ MUR payments trail other channels – NMS remains static
Independent pharmacists significantly trail other channels when it comes to fulfilling their potential for medicines use review (MUR) payments while their monthly new medicines service (NMS) remuneration has remained static, the latest data by IQVIA revealed.
Figures shown during the Sigma conference in Borneo revealed 87% of independents were behind in MURs which Carole Alexandre, director, information offerings at IQVIA, described as “huge potential that is being untapped.”
In terms of the number of MURs being provided versus the maximum potential for MUR roll-out, independents lagged behind supermarkets, managed chains, regional multiples and national multiples.
Alexandre said: “When you look at services, why is it that independents are trailing behind the market for MURs? I don’t know the answer to that. I was quite surprised when I saw this. (Independents) are basically achieving half the potential for MURs.
“If you compare that across the board, everyone else is doing much more in terms of MURs than independents as a whole. That’s an area that should be looked at.”
The data also highlighted that independents’ monthly NMS payments have remained static for the current fiscal year-to-date.
“New medicine service, really it’s just flat. I don’t know what that says. Does that say you’ve set it up and some pharmacies are doing it and others are not doing it?” Alexandre said.
Managed chains were found to be doing more on the NMS compared with independents which Alexandre said once again “looked like an untapped resource.”
She revealed that although the retail market in the UK is declining, independent pharmacy’s market share is growing.
Data also revealed a reduction in the number of GP practices in England in the 12 months to October 2017 while the number of items dispensed in England dropped by 1.1% and 61% of all prescriptions were EPS (electronic prescription service) prescriptions.
We’ll ensure funding no longer recognises just volume but pharmacy services
Sue Sharpe, the outgoing chief executive of the PSNC, said the negotiator will press the government to ensure community pharmacy funding reflects not only its supply function but the services it provides through a new care contract.
The PSNC said last month it was intent on achieving a care-focused package of services within the contractual framework and Sharpe reiterated that desire in Borneo.
“We have a start in 2005 with medicines use reviews, with new medicines services. We have developed a lot of evidence in recent years through the community pharmacy future work with the analysis, the evidence we’ve got from the government’s own analysis of the value of the new medicine service,” she said.
“This new care contract is building on that to make sure that the core role of the community pharmacy is recognised as that advice and support to patients who have long-term conditions or acute conditions to make sure they get the best outcomes from their medication.
“It is absolutely fundamental we do this and that we change the funding to ensure that it no longer recognises just volume but recognises the role that you all provide and develops a stronger framework for delivery of that role.”
Sharpe revealed the PSNC and NPA’s appeal against the High Court’s verdict on the cuts will be heard in May “unless the government changes its position sufficiently for us to decide that it’s just not worth continuing with it.”
Last community pharmacy in NE London will close in 2025 under current model
Hemant Patel, the secretary of North East London LPC, grimly predicted the last community pharmacy in his area will close by December 31, 2025 under the current model and warned pharmacists to find out how sustainability and transformation plans (STPs) are playing out in their locality.
In typically frank fashion, Patel said pharmacy “for the last 17, 18 years” had been preoccupied with medicines and “forgotten about what is happening in the rest of the healthcare system.” He added that pharmacy knew “nothing about community services.”
“If the current model of community pharmacy carries on, then on 31st of December 2025 the last community pharmacy in our area will close. The current model is unsustainable,” he said.
“Some of the things we have been told are a pack of lies and it’s important that we see the truth. The NHS is not running out of money. If you look at NHS spending in the last 10 years, each year spending in health has gone up. Social care costs are going gone up but it needs to be managed differently and the strategy that is being developed is not working.”
STPs are five-year plans covering a range of themes, from prevention and primary care to specialised services in hospitals. They are the government’s way of moving care out of hospitals and into the community, with 44 areas identified as geographical footprints on which the plans are based.
“I believe the national health system is being divided into 44 local health services and each health system will deliver care differently and they have made it abundantly clear to everyone that’s the way they are going to move forward,” Patel said.
He added: “(STPs) are really important organisations. This is not reorganisation. This is a serious re-engineering of responsibility and new roles will be developed. There is quite a lot of virgin territory not occupied at present and we have an opportunity to grab that.
“We need to find out at a local level how to influence strategy. How do you develop systems that are linked up in the rest of the area?”