Something's missing


Something's missing

By Rob Darracott

The debate over whether pharmacy staff are key workers kicked things off. Eventually, there was £300 for personal protective equipment (PPE) and other safety measures, and nothing since. Finally, there was thanks from the Government podium for the sector’s work. The cash advances/loans to recognise additional medicines costs and workload have gone ‘to the wire’. There was the battle for inclusion in the Government’s death in service benefit. Now we are back to arguing why community pharmacies are not able to directly access the NHS priority channel for PPE. 

Community pharmacists can be forgiven for the frustration they feel that their hard work, the abuse they have endured from some, the additional work they have taken on – most of it unmeasurable – is not being properly recognised. Some are clear, and single out officials at NHS England for criticism on social media, or use the statement from 2016 that the Government would like to see 3,000 pharmacies close as justification for claiming there is a grudge against the sector.

That community pharmacists and their teams have put themselves in harm’s way by continuing to serve the public is indisputable. Some in the community pharmacy workforce have died – at least five at the time of writing. In the most recent survey by CIG Research for Pharmacy Magazine, readers reported that 30 per cent of staff were missing from work self-isolating because they had contracted the virus, or had been in contact with someone who had it. 

Yet, at times, engagement with the sector has appeared stilted. The first NHS England webinar for community pharmacy back in March drew widespread criticism and some anger for what many perceived as a lack of empathy for what community pharmacy had been through, and the concerns within the sector for staff workload and safety in particular. Later ones were better. 

Of course, early on in the course of the pandemic, community pharmacy was not alone in feeling out of the loop. There was clearly a widespread shortage of PPE and, as the graphic on p4 of this issue highlights, the talk of a lockdown and the rise in coronavirus cases spooked the public. In increasing numbers, they ordered medicines to see them through, turned up in droves at pharmacies to collect them, and some reacted badly to the need to queue or keep their distance.

So, does the sector have an image problem? Do the powers that be want to shut a quarter of it down? Many point to the NHS in Scotland and in Wales, where community pharmacy appears to be very much part of an integrated primary care solution, as evidence that this is an English and NHS England issue. So is there something more fundamental behind what often looks like antipathy towards building community pharmacy’s place in primary care in England? 

When Simon Dukes took over as chief executive of PSNC, he said one of his first priorities was to rebuild relationships. He wasn’t wrong. PSNC was still in the middle of litigating the contract funding cuts – the appeal to its judicial review case was still pending. If there wasn’t enough trust between the two sides before the court case, there must have been precious little left afterwards, especially given some of the things said, from both sides, in arguing the case. 

is there something more fundamental behind what often looks like antipathy towards building community pharmacy’s place in primary care?

In the last week, a couple of things struck me about pharmacy’s priorities that might provide at least part of the answer. First of all, on the day I spoke to Cegedim’s Steve Bradley and Gian Celino (see here) about whether pharmacy was genuinely interested in technological transformation to enable integrated care, the NPA was preoccupied with more mundane matters, press releasing its concerns about prescription direction. 

Yes, that is a problem, particularly if it’s your pharmacy that’s being destroyed by the activities of a GP-linked distance selling [sic] pharmacy down the road. But to those who want to see it that way, it reinforces a prejudice that community pharmacy is only interested in supply and cash, not care and outcomes. The lead story in another pharmacy magazine this month is a 14 paragraph piece on community pharmacy needing £200m to “stay afloat”, quoting no fewer than three community pharmacy trade associations. (As an aside, we do round numbers in pharmacy a lot – FMD was going to cost £100m, remember? If you want to provide a reason to be cynical…)

Second, my colleague Richard Thomas interviewed RPS president Sandra Gidley for Pharmacy Magazine’s Talking Covid podcast (downloadable from here). The president highlighted the RPS’s plans for a summit on 9 June to discuss the future of community pharmacy. She said the RPS in interested in what people “want to do going forward”. All ideas welcome.

And that’s the point. Do we actually know what community pharmacy wants? Does community pharmacy even have an underpinning philosophy? Because I think the NHS has one, and I’m sure that chief pharmaceutical officers across the UK have one each. We don’t do context either, and that’s important. You might be a great batsman on the cricket field, but that’s not a lot of good if the NHS wants a ball-winning midfielder.

The pandemic experience provides a perfect excuse to take stock, but do any of the national bodies have a clear idea of what they want community pharmacy to look like in 2025, or in 2021, let alone in three month’s time when, fingers crossed, the “new normal” is a little clearer? 

According to its website, one of the NPA’s core beliefs is “face to face care is vitally important”. It adds: “Even more in this age of increasing automation and digitalisation, the face to face relationship between health professionals and patients matters”. Sure it does, but there’s nothing here about how the face to face relationship between pharmacists and patients will continue as patients increasingly get used to different technologies, a factor now massively accelerated with the pandemic. Which is precisely the point Steve and Gian were making. 

Timing is important

PSNC’s last major statement of future intent, made in April 2018, had positive proposals, including for a Community Pharmacy Care Plan (CPCP) and a Universal Community Pharmacy Care Framework. It was partly built on published research too – the Community Pharmacy Futures work undertaken by a collaboration between the four largest multiples and a couple of LPCs. Those proposals are built on the kind of conversations meant to happen in the now abandoned MURs and the New Medicines Service. They pick up on the challenge of polypharmacy and antimicrobial resistance – all good stuff – but at the time of launch, PSNC was heading into court, so it’s perhaps no surprise that little progress seems to have been made.

We think we know what the Government wants, at least in part. There is clearly a view that a more consolidated network would mean medicines distribution would cost less. The “problem” of pharmacy “clusters” goes back to the National Audit Office’s 1992 report Community Pharmacies in England. We can’t say we haven’t had fair warning. There is also clearly a view that community pharmacy, unlike other sectors in the economy, is not making the most of technology to improve efficiency. They want to see capacity released in pharmacy for ‘more useful’ cognitive work designed to impact other big ticket issues, like over-prescribing, non-adherence and optimising the use of medicines. The seminal UCL/York waste medicines study was in 2010. That’s 10 years ago.

I believe Government and the NHS want something more than “potential” – things that could be done if the money was right. They want pharmacy to see the big picture, understand the direction of travel. They want pharmacy to work out where it fits as the NHS becomes more locally focused on supporting patients in living longer, healthier lives at home, out of hospital. They want pharmacy, as a liberal profession, to carve its own space, while recognising that in the NHS, as in life, change is a constant, as is doing more for less. 

Lastly, if pharmacy can identify things that need to be done, and the Government and the NHS want them because they improve outcomes for patients or deliver capacity elsewhere in the system, then it needs a plan for doing them, and what must happen to make the plan work.

But, I’d go further. I don’t just believe this last bit. I know it. 

A grumbling appendix 

Back in 2016, Pharmacy Voice (RIP) and PSNC published the Community Pharmacy Forward View (CPFV), a piece of work that was also endorsed by the RPS. You can still find a link to it on the PSNC website.

The CPFV was originally produced as a joint response to the infamous December 2015 letter that introduced the funding cuts.  It was originally submitted to the DHSC and NHS England in May 2016 as a response to a consultation. The version submitted by Pharmacy Voice was different to that submitted by the PSNC, since it included a second appendix entitled Making it Happen. This was not the same as CPFV Part II – Making it Happen, which was published at the end of 2016. That only appeared after considerable horse trading between the bodies that followed the last minute rejection of the original appendix by the PSNC office. But that original appendix was the bit which, we heard anecdotally, government officials were most excited about.

Now I don’t know for sure why they liked it, but I suspect it was because it recognised upfront that turning good ideas into reality would be hard work. Because it recognised the context in which the CPFV proposals would sit, so what others around the system thought about them would be important. Because it came with a commitment from community pharmacy to facilitate change. It said: “Community pharmacy owners and community pharmacists need to develop, set out and sign up to their own ambitions for the sector and help create the right conditions for their team members to deliver them, as full members of the wider community-based healthcare system.” It continued: “In return, pharmacy team members will be supported, trained, led and incentivised to work more closely with patients and the public.” And finally I think they liked it because it set out how community pharmacy intended to strengthen relationships with service users, build partnerships across the health and care system, empower its own workforce, harness technology and develop local representation, support and delivery. Delivery. The most important bit of all..

One final point. While the bodies argued over the contents of appendix two, Pharmacy Voice took the first steps to implementing the plan it contained. Work on joint appointments with NHS England, paid for by the Pharmacy Integration Fund, was lost when PV closed in April 2017. 

They want pharmacy to carve its own space, while recognising that in the NHS, as in life, change is a constant, as is doing more for less

As the editor of P3pharmacy, I’ve interviewed key thinkers and innovators from community pharmacy, public health, tech, pharma, the OTC industry, distribution and general practice for the magazine's front cover. Understanding their perspectives is vital if community pharmacy is to make sense of the world in which it is going to be operating in five, 10 years time.

The experiences of the pandemic will shape the future, so I wish the RPS well for the summit in the second week of June. The sector has shown, through this crisis, that it has resilience, can be transformative when it has to be, and can deliver in spades for the public, who by and large are thankful for what it has done.  

What community pharmacists and their teams feel about the future, given the experiences of the past three months, is one thing, but the pandemic has highlighted how far outside the NHS system community pharmacy is. If that prompts a more positive approach to working with the NHS on what it says it needs, that can only be a good thing. As long as we remember that the ‘how’ is the most important part. And while it might need an update, a lot of that bit has been written once already. 

Note: Rob Darracott was the chief executive officer of Pharmacy Voice until the organisation was closed down in April 2017. As such, he is inevitably biased. This is not the last you will hear about implementation planning, though, since he insists it remains key to community pharmacy’s future. 

Record my learning outcomes