With the Health & Care Bill still progressing through Parliament, the structure of integrated care systems (ICSs) is becoming a little clearer, although still not set in stone. What we do know is that the commissioning mechanism will open up opportunities for community pharmacy because ICSs will:

• Have delegated responsibility for direct commissioning functions in primary care (community pharmacy along with general practice, primary dental services and general ophthalmic services)
• Have some level of more specialised commissioning at their disposal. Creating capacity and making services closer to and more convenient for patients could be an opportunity for community pharmacy
• Assume responsibility for a raft of public health services (screening and immunisation being the most relevant for community pharmacy).

This has to be good news – if you are ready to grasp the opportunity.

At a recent Westminster Health Forum policy conference on 'The future of pharmacy services in England', the overarching theme was that community pharmacy needs full integration into ICS delivery plans if it is to show it is about more than simply the supply of medicines. Speaking at the conference, James Roach, managing director of healthcare consultancy Conclusio and former CEO of NHS West Essex ICP said: “Community pharmacy can help shape the optimal care pathway across ICSs... It is one of those few service models that give us reasons to be positive.”

Noting how the pandemic has “highlighted the value of working collaboratively across systems”, National Pharmacy Association (NPA) chief executive Mark Lyonette said: “Community pharmacy can deliver the most and the best by being a full partner across the ICS.” But the NPA has stressed that community pharmacy needs more support at a local level in order to bring fresh service roles and revenue growth through ICS local commissioning.

In an era for pharmacy that feels very much like ‘if you don’t ask, you don’t get’ – and of late, ‘if you do ask, you still don’t get’ – what does community pharmacy need to do to be included in ICS discussions, and then in the wider strategy and roll out?

developing the community pharmacy offer in the county is a way of increasing the overall capacity within primary care

As chief executive officer at Somerset LPC and local integration lead at the NPA, Michael Lennox has a broad view of the situation. “At the moment, it feels like LPCs are on their own out there and not getting the coherent guidance they need to overcome inertia,” he says. 

“It’s my view that we need 42 ICS development plans, each one owned by the relevant existing LPCs. We need a development matrix to guide us, along with the winning approaches being trialled that can be lifted and shifted. But one pre-determined game plan doesn’t fit all ICSs. For example, the nature of Somerset is likely to be different to our colleagues in, say, Cheshire and Wirral.” 

The flip side of this, of course, is how an aspiring ICS might welcome and enable community pharmacy to be part of its delivery, and Mr Lennox says the power of representation will be “truly felt when we get all 42 ICS enabling LPCs and community pharmacy contractors play the fullest integrated role possible”.

Five year mission

Over the last five years, community pharmacy in Somerset has made significant progress regarding integration at the local system level with its single Clinical Commissioning Group (CCG) and forming ICS.

“Somerset CCG has clearly recognised that developing the community pharmacy offer in the county is a way of increasing the overall capacity within primary care,” says Mr Lennox. “The CCG has outlined its strategic direction of travel in a recent paper to the Primary Care Commissioning Committee, which fully endorsed this approach, while the emerging ICS leadership also recognises the opportunities that community pharmacy offer as part of integrated system working.”

The LPC also works within the whole matrix of representation in Somerset, developing close ties with general practice via the Local Medical Committee (LMC), the primary care network (PCN) clinical director network and the Primary Care Board (PCB). This is being translated into positioning community pharmacy within the emerging leadership structures that will ensure community pharmacy is an active partner in creating new models of provision.

“For example,” says Mr Lennox, “while it is recognised that the Community Pharmacy Contractual Framework will still be negotiated nationally, delegation to local ICS level will enable optimised deployment of the services within it. An example of this is the partnership working between Somerset CCG and LPC to design and deploy an implementation programme to successfully fast-track delivery of GP CPCS (the GP referral pathway of the Community Pharmacist Consultation Service).”

According to Mr Lennox, only 800 out of the 6,500 GP surgeries ‘switched on’ for CPCS have registered any activity so far. “Nationally, there were 12,000 GP CPCS referrals in September,” he says, “but set this against the initial plan of some 20 million appointments a year being transferred and it doesn’t look very impressive. And why are the numbers so low? Because it was not set up to be embedded and run locally.” 

Out of the ICSs or CCGs that have made a start on GP CPCS, Somerset makes up 1 per cent of the population of England but, says Mr Lennox, it is doing 8 per cent of the country’s GP CPCS referral run-rate because the local system recognised the opportunity, owned and invested in it. 

“The system appointed the LPC to be the agent of implementation and has funded us to deploy it, switch on and train the GP practices, and the CCG commissioned the IT platform which transfers the appointments to PharmOutcomes in the pharmacy,” says Mr Lennox, “although not everyone is doing it this way. We only started in June, and should be at 2,000 a month before Christmas and 4,000 by Easter, thanks to the joint approach to delivery enabled by the funding allocated by the CCG to the LPC. And this is also why having community pharmacy embedded in ICSs, when we get the delegated community pharmacy contract into ICSs, will be a game changer from April 2022.”

Working together 

At a time when PCNs are looking to fulfil an enhanced role within ICSs and resources are stretched to a maximum, a recent roundtable hosted by the NHS Confederation’s PCN Network, the Primary Care Federation Network and the NPA brought together key players in the PCN and community pharmacy world to explore the barriers to making the best use of all available clinical capacity on the ground, and how they can be practically addressed. 

The resulting report looking at how community pharmacy will work as part of ICSs, lists seven key requirements to ensure that the benefits of involving community pharmacy are realised:

• Community pharmacists must be given the time and space to get involved in working through the development of local services with their primary care colleagues
• Community pharmacy and general practice need to work through some of the historical perceptions of their relationship as providers being one of competition and move to a position of collaboration and a single voice for primary care 
• To achieve change at scale, service developments must be translated into a national contract specification for local adoption with the ability for some local flexibility to be applied to meet the specific needs of a local population
• Nationally specified services should be properly resourced, recognising that commercial viability is a valid request by contractors in the NHS
• ICSs must support the implementation of nationally specified services backed up with appropriate mechanisms to involve community pharmacy in decision-making at all levels with resources available to enable this
• An appropriate information technology and information governance framework is needed to support data sharing and facilitate the development of local services and the implementation of national services
• An appropriate medico-legal framework is needed which recognises the role of pharmacists as independent prescribers and resolves issues relating to conflicts of interest.

Dr Graham Jackson, a GP and senior clinical advisor at the NHS Confederation who chaired the discussion said: “We urge PCN clinical directors, primary care federation leaders and others locally to support community pharmacists to navigate the emerging NHS structures and thoroughly consider what pharmacies can bring to the table in terms of urgent care, public health, medicines optimisation and more.”

Ahead of the game

Reflective of Somerset’s forward-thinking approach, Kat Dalby-Welsh – clinical director of Yeovil PCN and a board member of the Confederation’s PCN Network – has plenty of first-hand evidence of how empowering community pharmacy in PCNs and systems can improve population health.

“With demand from patients growing and becoming more complex as a direct result of the pandemic, it is important that we empower pharmacy to seize the opportunity to improve our collective offer across the system,” she says.

“Within Yeovil, all five practices are using the GP Community Pharmacist Consultation Service and are finding the collaborative working increasingly helpful, both in terms of supporting general practice workloads and hastening patient access to the appropriate medication. One example is a lady with a migraine who required a repeat prescription. Her surgery referred her to the community pharmacy, who were able to work with the surgery to understand the need and issue the medication. 

“In Yeovil, during a three-month period, more than 1,500 people were also referred via the Discharge Medicines Service, with 70 per cent of them having a successful intervention. This is an example of an excellent closed loop referral system, meaning that patients gain a quick and complete episode of care.”

Fundamentally though, Ms Dalby-Welsh sees the barriers and the potential solutions to empower community pharmacy as a need to enable community pharmacy to play an active part in decision-making across the ICS and become integral to its clinical and professional leadership. “I’ve seen in my area what can happen if we collaborate well,” she says. “It has been hugely positive for our local populations. Now we need to do more of it, and on a bigger scale.”

Michael Bainbridge, head of primary care development at Somerset CCG, is also reporting significant improvements from addressing what he calls “a number of historic blocks to joint working”.

more than 1,500 people were also referred via the Discharge Medicines Service, with 70 per cent of them having a successful intervention

“The development of the ICS gives us the opportunity to review how community pharmacy is placed in the Somerset system,” he says, “and the potential delegation of the remaining primary care provider contracts to ICSs has opened the conversation about how we can best maximise the opportunities available to us within community pharmacy. Whilst some risks have been identified in hosting the delegated contract, we believe that the opportunities available outweigh these risks and it is beneficial to the system as a whole to explore these opportunities to their fullest.”

Simple isn’t easy

Despite all the positive talk, back at the LPC, Mr Lennox says there is still a risk that the road to ICSs is paved with good intentions. “The Health Bill being passed and the direction of practical policy travel set by NHS England and NHS Improvement needs to include community pharmacy by all sensible means,” he says. “While the idea of ‘integration’ sounds simple, it isn’t easy. How do you land a rocket on the moon? Build a rocket, fly the rocket, land the rocket sounds simple, but it isn’t easy – and it’s the same with integrating community pharmacy in an ICS.”

Mr Lennox’s core stance is that you cannot invent a national framework that works at a local level without local involvement. He sums up his pharmacy call-to-arms with ‘the five Is’. He explains: “Firstly, you have to get involved, which leads to being lightly integrated. Then you dial up your influence because you are there as a system player. From there, as you grow your influence, you can increase your impact, and then what you get is the investment for community pharmacy, which leads to an enhanced role and increased revenue – and then you are in a more resilient business.

“Be heard, and everything else follows from that. But to be heard, you have to get out there and listen. LPCs should approach their local CCGs and PCNs with a responsive mindset as opposed to seeming reluctant or even reactionary to change or investing in collaborating. That way, we demonstrate that community pharmacy wants to support the system, playing a positive and productive provider partner role. In the longer term, this is what will keep community pharmacy relevant in terms of its role and resilient in terms of revenue.”