A first ever survey on community pharmacy engagement with sustainability and transformation plans was carried out by Pharmacy Business in association with the PSNC. As far as pharmacy is concerned it revealed much work is still to be done. Neil Trainis reports…
Considering community pharmacy has had to fight tooth and nail for everything it has, be it funding, reimbursement, commissioned services, getting involved with sustainability and transformation plans (STPs), the government’s way of moving care out of hospitals and into the community, was never likely to be simple.
STPs sound inspiring in theory. They were created to alleviate the pressure on hospitals and reduce the cost burden on a health system that is not so much creaking as close to breaking point. Forty-four STP footprints formed in England in March 2016, each one designed to bring local health and care systems together to create their own plans around the needs of their populations.
Those plans cover a wide range of areas, from prevention and primary care to specialised hospital services, and will ensure NHS and social care services are closely aligned with patients’ needs. Community services, such as pharmacy, should be integral to this given that one of the aims of STPs is to encourage people to live healthy lives through lifestyle change.
As community pharmacists eagerly wait for the PSNC to begin negotiations with NHS England on funding for 2018-19 they will know they cannot afford to take their eye off the ball. That means making sure they are involved with STPs. Or as North East London Local Pharmaceutical Committee (LPC) secretary Hemant Patel described them during the Sigma conference in Borneo this year, “a serious re-engineering of responsibility.”
Pharmacy, he insisted, knew “nothing about community services” and he went on to question if the pharmacists at the conference were ready to get involved in STPs. In fact, he asked if they even knew what they were.
Trying to enlighten those pharmacists, he said: “They are really important organisations. This is not re-organisation. 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.”
With a proverbial punch to the jaw of community pharmacy, he said that for nearly two decades pharmacy had been preoccupied with medicines and “forgotten about what is happening in the rest of the healthcare system.”
With STPs, however, community pharmacy had a chance to prove how valuable it is as a community health profession embedded in an NHS that cannot afford to be without it.
Yet one wondered what obstacles confront LPCs as they attempt to establish themselves on these structures because STPs are by some accounts not perfect. They are usually led by heads of NHS trusts and clinical commissioning groups such as GPs who, as was witnessed with the national roll-out of flu vaccinations, can be resistant to pharmacies providing the odd service.
STPs are, of course, supposed to encourage collaboration rather than competition but Dr Chaand Nagpaul, chair of the British Medical Association (BMA) Council, was quoted in the BMA News last month as saying that legislation underpinning contracts for the provision of services demands procurement. And that, he said, could “thwart the ability to create the sort of collaborative arrangements meant to occur through STPs.”
“What we find is that each contract provided is subject to a procurement which is laid down by law. As a result, contracts are being awarded and outsourced,” he said.
“In these footprints the commissioners are acutely aware of the fact that when they are looking at provision of care they have a legal system which tells them there has to be procurement. That gets in the way because there is huge discussion around how to get a workaround – that is thwarting the approach in STPs.”
Competition can be healthy. It can force everyone to raise their standards. But there have been anxieties that community pharmacies are being ignored by STPs. Gareth Jones, head of corporate affairs at the National Pharmacy Association, said “pharmacies are too often overlooked by STPs.”
So Pharmacy Business wanted to find out what progress, if any, pharmacies were making as they try to get on to STPs. Working with the PSNC, the magazine sent a survey to all 71 LPCs in England to gauge not only how far they had got but what obstacles were in their way and what support they needed to make inroads.
The one-month survey, which ran from January 22 to February 22, was designed to be a constructive exercise aimed at revealing the state of play nationwide and not meant to point the finger of blame at anyone. It found that while some LPCs have been relatively successful many have struggled to gain a foothold. There were five simple questions, some multiple choice, some requiring more descriptive answers.
Of the 43 LPCs who responded, 42% said they had met with some of those involved in the STP structure but were not formally represented and 12% said they were not involved with the STP at all.
When asked what barriers, if any, the LPC had encountered when trying to work with the STP, 31% said they had been unable to secure a meeting, 62% said they had not been invited to participate, 45% said they could not find the right people to talk to and 55% said the STP was not interested in community pharmacy.
Good progress was being made in some areas, with 63% insisting they were represented on STP groups/other structures under the STP board, 5% had a community pharmacy representative on the STP board and 9% had made a presentation to the board.
When asked what barriers were preventing collaboration and engagement, one LPC said their STP was “too secondary care-focused and playing politics as ICOs (integrated care organisations) come into play.”
Another said: “We have had a few meetings with STP leads but there has been no significant engagement with the profession locally.”
One problem, another LPC said, was “the system’s general understanding of community pharmacy, what we do and what we could do in the future.”
What barriers, if any, has LPC encountered when trying to work with STP?
• 31% – unable to secure a meeting
• 62% – not been invited to participate
• 45% – could not find the right people to talk to
• 55% – the STP was not interested in community pharmacy
However, on a more positive note, one LPC said it was “made to feel very welcome and included during meetings. People want to learn more about what community pharmacy can do.” However, it stressed it needed the “time to attend meetings, do the pre-reading and any follow-up actions.”
Noticeable encouragement was found in Dorset where the LPC there said it was “being asked to become involved and look at ways of improving patient care and building community pharmacy into patient pathways.”
Despite cautioning that “it is early days in terms of getting community pharmacy recognised,” Dorset LPC said it was making progress, including getting involved in the “elective care collaborative for diabetes and dermatology” and being asked to be part of the working group.
One LPC said it was “heavily involved with the STP through the medicines optimisation workstream” and although it was not represented at board level, it said it had “influence and pharmacy is recognised at an STP level.”
- 63% of LPCs are represented on STP groups/other structures under STP board
- 5% have community pharmacy representative on STP board
- 9% have made a presentation to STP board
Another said: “Our STP is very interested in what community pharmacy can offer. Actually, there is an increased workload for the LPC attending STP meetings and events.”
Yet despite the successes of some LPCs, the survey continued to reveal that many were struggling to engage with STPs because of factors outside of their control. One LPC noted that “community pharmacy is not integrated into NHS nor social care structures” while another claimed their STP “does not understand how to commission from pharmacy and we have no funding to contribute at a local level.”
Concerns that pharmacy is not valued by STPs were raised by an LPC who said it had met with “the initial STP” and sent them “two or so pages” on what community pharmacy can do to integrate. However, the LPC reported that once the STP had published its plans “we had about two lines relating to community pharmacists.”
Another LPC claimed “community pharmacy is there but way down the agenda,” one said its STP “is still finding its feet and embroiled in big discussions about getting commissioning partners around the same table” while another described its STP as “an amorphous organisation.”
Somerset LPC said its STP had changed “due to CCG brewing in special measures, stalling the good work (that) begun last year.”
When asked to rate the level of their contractors’ engagement with the work of the STP, 74% of LPCs said it was negligible, 21% said some contractors are involved with the STP but it is patchy and 5% said it was generally good.
When asked to rate STPs’ understanding of what community pharmacy has to offer local commissioners, 7% of LPCs said none, 35% a little, 37% a reasonable amount, 19% quite good and 2% said excellent.
The study also attempted to gauge what additional support LPCs may need to help them in their work with STPs. One LPC said it needed “cases to submit with (the) STP to meet their needs” and “some direction regarding subgroups as they are all different.”
Another wanted mandatory membership of its STP board and more money for primary care and public health. “Hospitals rejected (the) Darzi recommendations and we are now paying for that error as too much NHS spend is on secondary care,” it said. Another said it wanted the Department of Health and Social Care “to mandate the STP to include all providers.”
There was also a call for clarity of what initiatives come under STPs and what relate to the formation of accountable care organisations while the Department of Health and Social Care and NHS England (NHSE) were urged to issue instructions to have community pharmacy represented on STP working groups.
One LPC said its STP was “very focused on secondary care and GP practices” while another said it did “not have the time/resources to attend and contribute to the number of meetings to make a case of the full value community pharmacy can offer the STP.” Another said it wanted “some sort of mandate to force STPs to engage.”
The LPC added: “Fundamentally the issue is STPs are still just trying to sort out the basics – they are not even legally allowed to make decisions let alone commission – everything has to go back to the constituent organisations such as CCGs and they still have no money.”
How do LPCs rate STPs’ understanding of what community pharmacy has to offer local commissioners?
• 7% – none
• 35% – a little
• 37% – a reasonable amount
• 19% – quite good
• 2% – excellent
Norfolk LPC said: “(We have) been working with our Anglian colleagues on engagement with the NHSE regional team and its locality director to relate the potential for community pharmacy with the Next Steps Forward View agenda.
“This has resulted in strong encouragement from NHSE to our STP boards to fully include the potential of community pharmacy in their plans. This is perhaps something which other areas may find beneficial.”
Alastair Buxton, director of NHS services at the PSNC, said: “These survey results confirm once again that STPs have a lot of priorities to juggle, but that hard work from LPCs to engage with them has really been paying off in some areas.
“We’re pleased to see that so many LPCs have managed to get some engagement with STPs, and this makes sense as community pharmacy has a huge amount to contribute to many key local health priorities.”
What are sustainability and transformation plans?
STPs are five-year plans covering all aspects of NHS spending in England. Forty-four areas have been identified as geographical footprints on which the plans are based, with an average population size of 1.2 million people (the smallest covers a population of 300,000 and the largest 2.8 million). Most STP leaders come from clinical commissioning groups and NHS trusts or foundation trusts but a small number come from local government.
The plans cover a broad range of themes, from prevention and primary care to specialised services in hospitals. All STPs include proposals to strengthen primary and community services and to integrate NHS and social care services more closely around the needs of patients. The plans also seek to encourage healthy behaviours in their local populations.
Source: The King’s Fund
STP Engagement Case Study: Hertfordshire LPC
Hertfordshire LPC has been working hard to ensure involvement of community pharmacy at an STP level. Helen Musson, Executive Officer of the LPC, explained that although community pharmacy is not represented at board level, Hertfordshire have still been able to input into the STP’s working groups to recognise the value of community pharmacy. This has been achieved by:
- Working together as LPCs. Many STPs map to more than one LPC region, and Helen notes that it would have been more difficult to engage effectively with the STP had Hertfordshire and Essex LPCs not worked together so well. The local STP also includes the West Essex region, so working together to create a unified community pharmacy position is crucial to securing influence. STPs have limited capacity, so engaging with a single point of contact for community pharmacy is likely to help.
- Focusing on working groups. A particular success of the STP in Hertfordshire and West Essex has been the development of the Medicine Optimisation group as an STP workstream, an area where the LPC is heavily involved and has been from inception. The community pharmacy voice is represented at the STP through this forum so there is no need for the LPC to be represented at STP board level currently. For Hertfordshire, clear plans for interaction, forging good relationships with key stakeholders locally and working as part of a pharmacy collaborative team across different settings has contributed to the strong pharmacy voice at STP level.