Does pharmacy need a more collaborative model?
Pharmacy faces change from two directions. A five-year national deal introducing a new community pharmacy contractual framework which includes at least one new service to be rolled out across the country. And in primary care, the emergence of primary care networks (PCNs) which aim to integrate services to deliver more personalised and appropriate care, which may have novel community pharmacy-led components.
PSNC has already warned the sector that if community pharmacy is not part of the PCN, the system may bypass it and opportunities to make better use of community pharmacy’s unique benefits will be lost. The NHS Long Term Plan has also put a focus on local leadership and commissioning, with the overall objective of bringing care closer to home.
So, are the existing structures in pharmacy representation appropriate for supporting change within a national contractual framework and in an increasingly localised NHS, and where the development of the service is being driven nationally and locally?
Collaborative working was one of the topics on the agenda at PSNC’s recent Local Pharmaceutical Committee Conference, where chief executive Simon Dukes talked about the importance of cross-sector collaboration and PSNC’s efforts around “rebuilding trust with the Government” and working “more and more” with politicians, the British Medical Association and other pharmacy bodies. He suggested such engagement needed to happen at all levels.
Claire Ward, a pharmacy veteran and chief executive of the Institute of Collaborative Working (ICW) since January 2019, believes it’s a good start that there are local and national structures in place, but there needs to be “a will” to adapt those structures to the new landscape which includes PCNs.
Key to all of this is the attitude and behaviour of contractors, who need to have a will to work collaboratively
The way to do this, she believes, is via a clear focus on what good looks like from a local perspective, deciding where pharmacy fits in and then working out the tools needed to deliver that. “LPCs can help to develop the narrative of what community pharmacy offers to the PCN and they will also be a crucial part of the relationship with the Local Medical Committee (LMC) to understand what they hope to get from the PCN,” she says, adding: “Key to all of this is the attitude and behaviour of contractors, who need to have a will to work collaboratively with each other and other health care professionals. The LPC has a crucial role in supporting these behaviours.”
Michael Holden, principal associate at Pharmacy Complete and former LPC chief officer, agrees, stressing the need for “collaborative leadership at every level”.
“Much, if not all, new funding will come through integrated care systems (ICSs) via PCNs. LPCs need to be effective in engaging, leading and supporting contractors and their teams and working at a system level with ICSs and CCGs, but they cannot do everything”, he says, explaining the flow of collaboration. “At a PCN level, local contractors must collaborate and agree a pharmacy PCN lead to represent them. Individual pharmacies should start or continue working with their local practices and other healthcare colleagues.”
However, overarching this, he adds: “We need a single body – PSNC – effectively representing the upstream interests of pharmacy contractors at a national level [with] by all means, other organisations (including the National Pharmacy Association, Association of Independent Multiples and the Company Chemists’ Association) supporting their members and feeding into that body so that government, the NHS and the Department of Health hear one voice and have evidence-based business cases to seek appropriate funding and expand pharmacy services.”
Mechanisms elsewhere in primary care
Existing mechanisms by which other primary care professions have sought to engage in service change and development may well provide useful examples from which to explore the fitness for purpose of the current pharmacy model. The national representative and negotiating machinery in medicine and optometry has formal links to local representative bodies, for example.
In medicine, LMCs are formally represented on the General Practitioners Committee (GPC) of the BMA, the body that represents all NHS GPs (whether or not they are BMA members) and agrees their national contract.
GPC England members are elected through a number of routes and together represent all GPs in England. Most are elected by regions which cover a number of LMCs. Others are elected through the UK LMC Conference, the sessional GP and GP trainees’ committees, and the BMA’s annual representative meeting. Some are appointed by other bodies such as the Medical Women’s Federation, Medical Practitioners Union and the British International Doctors Association.
LMCs are independent statutory bodies and as the local representative committees of NHS GPs, represent their interests in their localities to the NHS and other organisations. LMCs interact and work with – and through – the General Practitioners Committee as well as other branches of practice committees, and local specialist medical committees in various ways, including conferences. However, LMCs are not regional BMA offices, nor part of the BMA regional councils.
Each year, there is a conference of English LMCs (and the same for each of the devolved nations) where delegates propose motions and they are voted on. If passed, these motions become BMA GPC England policy. There is also the LMC UK conference, and motions passed here become BMA GPC UK policy. Once a year there is the BMA annual representative meeting, where BMA-wide policy is debated and passed.
This year’s GP contract constitutes a larger change to the contract than previous years, with agreement for £2.8bn investment over the next five years – the most significant increase for the last 15, but builds on the existing contract structure.
In optometry, the Local Optical Committee Support Unit (LOCSU) goes a stage further. LOCSU has been preparing for a world in which local commissioning and decision making is fundamental to the development of the professional service for more than 10 years.
This preparation follows both a nationally agreed strategy for the profession in primary care, and a collegiate approach to deciding how best to give effect to that strategy. LOCSU was established by the national optical bodies specifically to support Local Optical Committee (LOC) engagement with local commissioners. It has a board comprised of leaders from the national optical bodies, representing optometrists, dispensing opticians and the optical chains, with LOC representatives elected on a regional basis. This balance ensures that strategy nationally not only recognises and fosters progress in a local commissioning environment, but that developments are informed by what LOCs say they need.
it's right to review our structure of representation to ensure it gives contractors the best chance
LOCSU has gone through a number of organisational changes since its launch. Its inclusive board, clinical director, regional optical lead and common provider company template structure and operation have proven significant in driving change.
Its strategy has been focused on the adoption of nationally developed, locally commissioned services, such as the Minor Eye Conditions Service (MECS). These are based on a clinical services pathway framework model, designed to reduce the scope for local variation, and allowing for the rapid collation and dissemination of national service episode and outcome data via a single web-based platform.
Bridging the gap in pharmacy
It’s hard to disagree that community pharmacy needs to be working towards some kind of national change plan, but at the moment it does not have the right connections within the representative layers for this to happen easily. There’s still a gap between PSNC nationally and LPCs locally, which are not formally represented at PSNC, although many members of PSNC are also members of one or more LPC.
So how do we bridge this gap? Adam Irvine, chief executive officer of Community Pharmacy Cheshire & Wirral, says: “In terms of the changes to the community pharmacy contractual framework, there’s a clear message that local engagement is more important than ever, and it’s right to review our structure of representation to ensure it gives contractors the best chance.”
He sets out four levels of engagement that he believes are necessary:
- National, which PSNC discharges on behalf of the LPCs
- NHS sub-regional (at the Sustainability & Transformation Partnerhip) level, where there’s a variety of measures – some LPCs have had more success than others
- Local authority/Clinical Commissioning Group level, which is the place most LPCs have focused historically – this is still important but he expects this to devolve further over the next five years
- Local, where LPCs must lead, support and govern groups of contractors to engage with their local health system to best serve their patient populations.
Encouragingly, some LPCs are ahead of the game when it comes to realising their role is getting bigger than just supporting local meetings of pharmacists.
Mike Holden says Pharmacy Complete is currently working with some LPCs to support their and their contractors’ knowledge on the changing NHS and contractual landscape, and the required skills for effective communication, engagement and influencing, which he says is “landing very well” with contractors who are keen to collaborate and engage locally but didn’t know where to start or how to go about it.
“It’s really important to realise that nowadays an LPC’s role is not to do everything for, or on behalf of, a contractor, it’s to support engagement as a provider part of a multi-disciplinary approach,” agrees Mr Irvine. “Ultimately all of this should lead us to a point where wider pharmacy teams can operate together to best deliver care to patients in a more sustainable manner: sustainable for the system, for GP practices, and making community pharmacies an important, embedded, and vital part of primary care locally.”
PSNC and LPCs - the current structures
Leadership of the development of the community pharmacy service has been moderated, since 1948, within a national contract framework. As such, the effective leadership of change (and capacity) has been vested in the PSNC. However, there is no formal representation of local leadership within the PSNC structures. While PSNC draws its funding from Local Pharmaceutical Committees through the mechanism of the voluntary levy, it can exercise no real control over what LPCs do, even where LPC action might be vital to the performance of the national contract.