Socrates said: “The secret of change is to focus all of your energy not on fighting the old, but on building the new.” Simon Dukes arrived at PSNC in May last year after a career in security and defence and five years leading Cifas, the UK’s fraud prevention service. PSNC had lost a judicial review against the Government in the High Court, and was about go back into court with an appeal it was destined to lose. Relationships across the negotiating table were shot.
Community pharmacy was entering the second full year of funding cuts to the global sum, with little end in sight of the increasing pressure being felt by contractors. And the reimbursement mechanism for medicines was considered by many to be broken, with shortages on the rise, and general dissatisfaction among contractors about the fairness of a system that could result in price adjustments to reflect over or underpayments calculated from years earlier.
Energy has been focused. With the announcement of the five-year contract agreement on 22 July, Mr Dukes has seemingly turned around the ‘dysfunctional’ relationships he inherited and agreed a multiyear settlement which he says creates a basic platform to explore change to the funding and reimbursement mechanisms that are long overdue.
He knows it’s not perfect. “You’ve got a five-year flat cash settlement, everyone’s cost base is rising, business rates, general inflation,” he says. “This deal takes no account of that despite us arguing hard, negotiating hard for acceptance that we cannot, unlike other retailers, push prices up to deal with rising costs.” He says the Treasury’s response was: “This is a flat cash deal; you deal with the costs by building in efficiencies.”
this is arguably the most important thing you will read this year about the future of your business, so please read it
Simon is clear on the implications. “That is going to be really hard for contractors; large multiples and small independents equally,” but he says that while automation and making better use of the pharmacy team might free up pharmacists’ time for more, different services, there is also the Government’s underlying view that there are too many pharmacies, in clusters. “I know the arguments, but that’s what we are going to have to deal with,” he says.
“Everyone has been very open and wanting to have better collaborative relationships: with DHSC, within the sector, between PSNC and contractors in general. So, has it been difficult? It’s been a matter of trying to build up trust and make those fresh relationships as good and robust as they can be. That takes time. It’s about spending time with people, getting to know them, getting people to understand where you are coming from and why.
There will be differences of opinion, but they are professional differences. They are not personal. Right from the start we’ve said that we should not, do not make personal comments about any individual involved, from the Government, the wider group of stakeholders and/or contractors. We have had a very positive response to that. People want to make this sector as good as it possibly can be. That goes for the Government, the CEOs of the other pharmacy bodies, and contractors in general.”
Those are the key messages he and his team took on the road, for seven successive Sundays, often two events a day, morning and afternoon. Travel in between. The last one was at the Pharmacy Show in Birmingham on 6 October. He expects the cumulative audience to top 1,000, with LPC officer attendance creating a multiplier as they run their own events later.
We’re speaking just after the programme began. “I’ve been pleased with the way it’s kicked off,” Simon says. People have been interested in all aspects of the agreement, but the absence of detail has caused some frustration. “They want to know why we did what we did, and it gave us a chance to put that into context.” He’s surprised how many people have not read the agreement, but says this does not imply any criticism. “What I continue to say is that this is arguably the most important thing you will read this year about the future of your business, so please read it. It’s not huge, but it has all the detail of what the future is going to look like, and how it’s going to affect you.”
Simon says he expected the initial mixed reaction to the announcement of the agreement. “It’s the same with any deal. There are things people are going to be concerned about and not like, I get that, but overall I think the coverage has been fair.”
I ask whether he thinks community pharmacy is ready for what could be a very different approach, and whether there’s an implementation plan. “I think there are significant parts of the sector that are very keen and up for change,” Simon says. “We have five years of protected funding as a platform. I’m not saying the efficiencies the Government thinks are built into this deal are necessarily going to come out in those five years, but I feel that we have to start engaging and addressing them, and looking at ways we can build in capacity to deal with services that we have wanted for years.
“There are aspects which are not solely within the gift of PSNC. This is about the sector coming together to make this work. The Community Pharmacist Consultation Service (CPCS) – a fantastic opportunity. There are 20 million GP appointments for minor ailments per year that should go elsewhere. The opportunity for us to build community pharmacy into the heart of primary care, the NHS, is there. But we’ve got to deliver it.”
An implementation group for urgent care, which includes the CPCS, draws from across the sector, as well as including representatives from NHS England and NHS Improvement (NHSE&I) and the Department of Health and Social Care (DHSC). “The NPA, CCA are there,” Simon says, “we all have to be working as one to help their members, contractors, constituents deliver it. Because if we deliver it, then more will follow. You can see the pilots that are coming up: hypertension, AF identification etc. If we can nail those there will be more.”
You can see his point. Apart from major service entries like Medicines Use Reviews (MURs) in 2005 and the New Medicine Service (NMS) in 2011, annual negotiations have created little trajectory for the community pharmacy contract in England. ‘The new contract’ of 2005 stalled early on, while the Building on Strengths, Delivering the Future White Paper programme got lost in the 2010 election result which was compounded by a less than optimal implementation of NMS a year later. A five-year deal allows for a different approach.
“It starts with what we call a mandate – a proposal document from the Department of Health (DHSC). It’s a rough outline of what they and NHS England (NHSE&I) want to cover during the negotiation. It gives a rough timescale – very rough in this instance because there were other political pressures – and an opportunity to come back with our thoughts on the initial mandate and how we, the PSNC negotiating team, want to structure the discussion.
The negotiating team is elected from the committee. There are seven of them, my directors and me. The team is given delegated responsibility by the 31 people of the committee to negotiate on their behalf. There is a responsibility to keep the committee informed of how it’s going, and at key points to say, ‘do you agree’? It’s the committee that says yes or no.
The process continues in themes. You have working groups with DHSC and NHSE&I that break down the mandate – you might have something on urgent care, prevention, patient safety. You can even break down to specific topics – there was a working group on the consultation service. The working groups discuss, negotiate and agree the details in the different areas that come together to form the document that ultimately came out. The negotiating teams from DHSC, NHSE&I and PSNC come together in milestone plenary sessions to agree staging points and markers. I can understand why it all looks a little bit complicated and a bit opaque from the outside.
We received the mandate at the end of March and from then we were doing nothing else. This is my day job; you would expect therefore for me to spend whatever time it takes for me to nail the deal. The elected negotiating team members have day jobs. It is incredibly impressive that they effectively devoted their lives, from April through to July, for no payment, to getting this deal right.
Every negotiation gets a bit more fraught as the deadline nears. There were a couple of nights we didn’t get home, but I don’t want to overstate it. The deal was signed off at 9.28 on the morning of 22 July, so it could have been slightly embarrassing as we had an 11am press conference. It was just making sure we were all happy with the words and terms reflected the conversations, discussions and negotiations we had had.”
“We fought for and got annual reviews built into the contractual framework,” Simon Dukes says, “specifically to look at capacity, costs and other issues coming from delivery. That gives us the chance to say, ‘we’re full, we can’t do any more’, and ‘ok, that’s going to cost you x’ if DHSC or NHSE&I come to us and say, ‘actually we need you to do this’. It’s milestone driven, allowing both sides to review where we are each year, and for them as the customer to review our progress and performance on delivery.”
The CPCS differs from the individual patient services that have gone before. Patients will be referred into it, and it has to be delivered. The difference is not lost on Mr Dukes, nor is the destination. “It is community pharmacy taking on patients that are referred to them, but it leads to starting to change the behaviours of patients in England so if you are unwell you go to your pharmacy.
“To start with that will be because you are pushed there, through 111 or triaged by your GP, but in time because of the brilliant service patients will get, they will be walking straight into their pharmacy. The challenge for us, as PSNC, is when you have started to change patient behaviour, the pharmacist is not going to be remunerated. I’m talking two years down the line, but it is something we have to start to look at now. That means collecting the baseline data for walk-ins, so that when we see those graphs changing, we have the business data to say we need to talk about how we remunerate for people walking in.”
He says a recent personal experience when seeking advice for an allergic reaction while gardening brought the potential service to life after a discussion with a pre-reg. “I bought a selection of products and within two days it was all good. I came out impressed, and as a patient satisfied that I had been listened to. I felt the whole process was a clinical experience. We were in the middle of the negotiation at this point and I thought ‘that is the consultation service’. I’m sure that’s replicated many thousands of times across the country every day, but that was the first time I’d experienced it as a patient since I started this job.”
“The main question at the roadshows has been ‘You’ve agreed £13bn over five years, but what about the detail’?” Simon accepts the approach is different. “We did not lose any part of the MUR money – it’s all there. That detailed discussion is going on right now,” he says. “That includes how the first block of the transitional fund, £60m or so, is going to be distributed, making sure we are rewarding and reimbursing effort. We have agreed the framework. It’s a continual process of negotiation for each subsequent financial year.”
The next 12 months is a sign of what’s to come. “We have the CPCS roll out by October. We are finalising what the sign up looks like [contractors who sign up by December can claim £900, by January £600]. By the time this comes out contractors will have the details of what they need to do for the Pharmacy Quality Scheme and the other aspects of the framework that need to be put in place, not only for the rest of this financial year, but from the 1 April 2020 onwards.”
PSNC and NHSE&I both have roles in achieving success, particularly of the CPCS. He explains: “From our point of view we want to make sure that as many community pharmacies as possible are signed up. Their responsibility, absolutely, is making sure that NHS111 providers are briefed, and are actively triaging patients to community pharmacies. We will be monitoring that process carefully because, unlike 400 MURs providing a sort of guaranteed income, you only earn your £14 if a patient has been directed to you. We want to ensure that as many patients are being directed to community pharmacies as possible.”
The challenge for us, as PSNC, is when you have started to change patient behaviour, the pharmacist is not going to be remunerated
Contractors might feel particularly sceptical about GP triage, given the history of competition within primary care. “The challenge is to the NHS,” Simon says. “First, how you can make 111 into a really effective triage system for the CPCS, to make sure we get the patients we need to see. And then from 1 April 2020, how you ensure that general practice has the most effective triage system that gives us the patients that we need to see. Community pharmacy can’t just sit there and wait. They have to ensure their relationships with general practice are as strong as they can be.”
He says local pharmaceutical committees, who as well as the new national contractual framework, have the new primary care networks (PCNs) to deal with locally, are pivotal to successful delivery. “LPCs have got to be ready and able to guide their contractors appropriately. Encourage them to work together in PCNs. To talk to each other, to deal with differences and the issues that might arise between them.”
“We’ve tried throughout my tenure here to be more open and transparent. We’ve done that with the committee minutes. The first annual report from PSNC will give everyone, contractors, pharmacies, a sense of what we’ve done for them in the year.
Communication and visibility is really important. For too long PSNC has been seen as remote from front line community pharmacy, which is odd given we work every day for them, fighting for them. Arguably the most enjoyable part of the job is to get out of this office and see people on the front line, because those are the people who are paying for PSNC and what we do here is for them.
Quite rightly, because they pay for us, contractors and LPCs demand of us a whole range of things. Of the £10m raised from contractors for LPCs, just over £3m comes to PSNC. We, I believe, account for every penny. The annual report will say this is what we’ve done with your money: we’ve reviewed literally millions of prescriptions. We’ve found thousands of errors. We’ve saved you millions of pounds in concession prices. That’s not counting the work that we did on Brexit, on flu, and all the other things we do.
And contractors should be asking LPCs: what value do you provide us with?”
He looks forward to the days when GP and pharmacy contracts might be properly connected. “It must be right that eventually we get to where the GP and community pharmacy contracts are being negotiated in parallel, so where there are interdependencies, they can be identified and dealt with. That must make for more joined up primary care.”
Our conversation so far has focused on remuneration, but many of the frustrations for contractors lie with reimbursement, and day-to-day dealing with the shortcomings of the supply chain, including shortages. A five-year agreement might provide the space for some radical thinking, particularly with the NHS increasingly focused on medicines optimisation and polypharmacy.
Let’s explore different types of funding models and reimbursement mechanisms which reward what and where we are trying to go
“Coming in with fresh eyes in May last year there are a number of things that hit you,” Simon says. “The dysfunction in the relationships. I felt a multiyear deal – I hoped for, but didn’t think we’d get five – was essential to give us a basic platform to make changes on. The funding model. It’s complex, and it rewards volume. The five-year platform is a great opportunity to say OK, we’ve got a protected sum here. Let’s explore different types of funding models and reimbursement mechanisms which reward what and where we are trying to go. All ideas welcome.”
What would you say are you greatest personal achievements?
In this role negotiating the best possible deal that we could, and establishing better relationships with stakeholders – contractors, Government and others. In my previous job I headed up the fraud prevention service. We were successful in getting economic crime and its prevention as part of the national curriculum, so young people who spend a lot of time online have more understanding of the economic threats out there. This was about giving kids an awareness of fraud to help better protect them when they leave school. Prevention is better than cure, as every pharmacist knows only too well!
Do you have any unfulfilled personal ambitions?
I have been a beekeeper for many years. You get points for your honey based on taste obviously, but also clarity, colour etc. I have yet to win an award at a honey show.
If you weren’t doing this, what would you be doing?
This job lured me away from the last one, so I’d probably still be at Cifas, but when I was contacted by the recruitment consultants about this job, the clear logic of why on earth we are not using this network of medically trained people to help with the increasing issues in GP surgeries and A&E etc. I thought I could do something.
Does anything keep you awake at night?
No. I sleep very well. One thing did keep me awake on 19 July, and that was that we weren’t going to get this across the line.
What gets you to work in the morning?
Other than the Greater Anglia? This job is about relationships; you can’t negotiate with people you don’t know. So right from the start I’ve spent a lot of time getting to know the Department, NHS England and my colleagues here. But it’s also got the most phenomenally challenging intellectual aspect, and not just on funding. We have 11,600 different businesses with different issues, capacities and skill sets. A most amazing group of people. I learn something every day going out to contractors or meeting people here. I love that combination.
How do you relax?
I spend time with the family. I’ve got a correspondence course with a gym – they take my money and I occasionally go along and look at some shiny machine that I don’t do anything with.