In January 2019, the NHS Long Term Plan laid out the Government’s aim to have all parts of health and care systems working together as integrated systems by April 2021. Towards the end of last year, NHS England revealed how it thought this could progress, publishing Integrating care: next steps to building strong and effective integrated care systems across England as a short term consultation which closed in early January.
In response, on 11 February the Department of Health and Social Care (DHSC) published legislative proposals for a Health & Care Bill as the White Paper Integration and Innovation: working together to improve health and social care for all. This lays out how it plans to reach its goal of joined up care for everyone.
With a stated aim to “focus on the people and communities that are most in need of support”, the proposals look set to sweep aside many of the measures introduced in the Health and Social Care Act 2012, with a stated move away from competition and internal markets towards integration and collaboration between services.
Instead of working independently, DHSC’s intention is that every part of the NHS, public health and social care system should “continue to seek out ways to connect, communicate and collaborate” with the triple aim of better health and wellbeing for everyone, better care for all people, and sustainable use of NHS resources across all NHS organisations and providers.
Announcing the changes to MPs, health secretary Matt Hancock said this new way of working would bring together the NHS, local government and health sector partners to make decisions about local health together through the mechanism of integrated care systems (ICSs).
the proposals look set to sweep aside many of the measures introduced in the Health and Social Care Act 2012
The proposals will place ICSs across England on a statutory footing through both an ICS NHS body (including representatives from local authorities) and an ICS health and care partnership, with a duty to promote collaboration across the healthcare, public health and social care systems. The ICS NHS body will be responsible for the day-to-day running of the ICS, NHS planning and allocation decisions – including the commissioning of pharmacy services. The ICS health and care partnership will bring together the NHS, local government and wider partners, such as those in the voluntary sector, to address the health, social care and public health needs of their system. There are currently 42 ICS geographies; the final number in April 2022 may be slightly fewer.
Certain new powers and duties for the secretary of state will be introduced, including the ability to intervene in service reconfiguration changes without the need for a referral from a local authority. There will also be a duty to publish a report in each parliament on workforce planning responsibilities across primary, secondary and community care, as well as sections of the workforce shared between health and social care, such as district nurses.
Procurement is also being shaken up, with proposals including repealing section 75 of the Health and Social Care Act 2012, which sees providers and private companies compete to win contracts to run services. This would be replaced by a new procurement regime in which the NHS and councils collaborate to pool resources and run services.
With only two mentions of pharmacy in the consultation document, and none in the White Paper itself, Nuffield Trust senior fellow Stephanie Kumpunen says the impact on community pharmacy from these proposals “remains a little unclear, but there should be opportunities”.
“[Community pharmacies] have already proven they have a significant and increasing role in allowing patients to self-manage health conditions and provide urgent and minor illness treatment to support local services,” says Ms Kumpunen. “Through emerging primary care networks, there is the potential for even closer collaboration as they seek to further develop the role of pharmacies.”
When it comes to involvement with the ICS, the proposals state that both the ICS NHS body and the ICS health and care partnership “will need to draw on the experience and expertise of frontline staff across health and social care”, which surely opens the door. Indeed, if new services are to be determined at ICS level, front line pharmacy staff should have the chance to engage with these new bodies as true local provider partners who are just as deserving of investment as other health sector colleagues.
However, while the invitation to collaborate sounds promising, the system-wide NHS Confederation raises a red flag, pointing out that the proposals “make no statutory provision beneath system level, instead relying on the removal of legislative barriers as well as forthcoming guidance to foster collaboration”.
PSNC chief executive Simon Dukes is similarly wary, saying: “We understand that Ministers see this new White Paper on health and care services as a really positive opportunity for community pharmacies, but history tells us that it will not be easy for the sector to gain a foothold in newly reformed local healthcare systems, and we will continue to work closely with LPCs and contractors at a local level to ensure that this happens. We had called for the Government to specify that community pharmacy must have a place in the new systems, with all primary care providers part of their governance, and we will continue to push policy makers and parliamentarians to ensure that pharmacy is given a proper voice in all local systems. PSNC will also work to protect contractors from any risks should the new proposals impact on the Community Pharmacy Contractual Framework”.
Michael Lennox, the National Pharmacy Association’s local integration lead, says it is vital that community pharmacy is able to deliver “as an integral part of the system rather than being seen as an adjunct to the main action. Services like the Discharge Medicines Services and the Community Pharmacist Consultation Service could be the start of a truly remarkable journey getting us closer to the heart of the NHS. What’s more, new services determined at ICS level could scale up to become the ‘new national’, acting as a catalyst for positive change”.
On the theme of collaboration, Association of Independent Multiple Pharmacies chief executive Leyla Hannbeck says AIM is also urging the new bodies to “work pro-actively on breaking down the barriers and misunderstandings that currently exist between general practice and pharmacy and encourage effective collaboration”, as well as to “engage with community pharmacy leaders at a very early stage in any planning of commissioning services so that we can help with forming relevant services that can be delivered efficiently for the benefit of patients in the communities we serve”.
for the public to get the maximum benefit from community pharmacy, it needs to be embedded in decision making
Malcolm Harrison, chief executive of the Company Chemists’ Association (CCA), has also warned about the blurred lines around commissioning, saying: “It is not yet clear how the national and local commissioning of services will work in this new system, but it is vital that everyone can access consistent care across the country, and that the good intentions of the White Paper do not lead to a healthcare ‘postcode lottery’”.
Mr Harrison notes that community pharmacies “need fair funding for both the services they currently provide and for any additional work they are ready and willing to deliver”. This is a point that RPS England chair Claire Anderson echoes, saying: “Steps to facilitate more efficient ways of working are welcome, but must be backed by investment and a comprehensive workforce strategy. These changes must help, not hinder, our health and care staff, who are already under pressure. I’d urge the Government to ensure they get the help they need, supporting their wellbeing, boosting recruitment, and investing in education and training.”
Mr Lennox says that community pharmacy’s experience of working collaboratively across systems – especially during the Covid-19 pandemic – should give it a solid seat at the collaborative table, to meet the proposed Bill’s triple aims of better health, better care, and better use of NHS resources.
“The development of integrated care systems gives us a new opportunity to ensure community pharmacy is appropriately represented in leadership and accountability arrangements,” he says. However, he stresses that for the public to get the maximum benefit from community pharmacy, it needs to be “embedded in decision making – both having visibility and being visible”.
While acknowledging that “a duty to collaborate will be compulsory for all partners within the system, including local authorities and primary care”, he says the sector knows “from long experience that it cannot take it for granted that genuine, heartfelt engagement necessarily follows from the legal obligations”.
Since ICS membership will be left to local determination, the NPA sees it as “critical” that local community pharmacy leadership is included via local pharmaceutical committees, says Mr Lennox. “It’s now clearer than ever,” he adds, “that the current national review on roles of LPCs and PSNC as representative structures must deliver strengthened, not depleted, local leadership, optimising local structures to leverage the emerging ICS opportunities.”
Mr Lennox adds that the NPA has already begun a constructive dialogue with senior NHS managers, including NHS England’s director of systems transformation, Roger Davidson. “We will continue to reach out to those shaping ICS development, building bridges across the NHSE&I directorates, driving transformation,” he says. “Ultimately, the new ways of working that are envisaged could open the door for community pharmacy to become more involved, integrated and influential, and translate into an expanded role and revenue.”