Aiming high for influence

A reception at St James’s Palace, where more than 200 pharmacists, pharmacy staff and health service representatives were hosted by HRH The Prince of Wales, provided a fitting climax to the National Pharmacy Association’s centenary year celebrations. Rob Darracott asked chief executive Mark Lyonette to take stock

“We have a proud tradition; we’re just finishing our centenary year,” says National Pharmacy Association (NPA) chief executive Mark Lyonette. We’ve been sitting in his office in Mallinson House – the listed building in St Albans named after the first secretary of the organisation that began life in 1921 as the Retail Pharmacists Union – putting the world to rights before the formalities.  

Officially, the not-for-profit NPA is “the representative voice of independent community pharmacies across the UK and a leading provider of services to the entire sector.” It fulfils its aim of supporting independents “to succeed professionally and commercially for the benefit of their patients” by working as a ‘full-service’ trade body, providing its members with a range of products and services, including insurance, learning and development, advice and support, and business services from a range of partners and providers.

“Being a strong trade body in the 21st century is about helping people survive the 21st century,” Mark says. “How do we help our members become more digital? How can we help them cope with online pharmacy, which is fundamentally driven by patient and customer expectation? Some things are harder to achieve as independents than larger players who have more capital, more resources to draw on and can take bigger risks.” 

On the representation side, Mark says: “A trade association speaks on behalf of its members. Our job isn’t always to repeat everything that every member is saying to us, because members, reasonably, do not always make their comments understanding the context of where government or NHS management is coming from, but it’s crucially important we reflect their needs, advocate and promote them, and play our part in getting a better deal for them.” Promotion of the sector has long been part of the NPA’s DNA – the first incarnation of the now annual Ask Your Pharmacist week occurred in 1929. 

We will come back to the organisation later, but I start by asking Mark, who is now four years into the job (and what a four years it has been) where he assesses things are for community pharmacy across the UK.

Whole UK focus

“It’s different in different countries,” he says. “It would be very bad to talk about the challenges of community pharmacy and assume everything is English-shaped and focus only on England. I visited Edinburgh a couple of weeks ago with Janice Oman, our Scottish manager. Janice was showing me around some member pharmacies. It was inspiring – great pharmacists, great teams exercising high levels of skill, delivering care, making complex choices at great speed, focused completely on patients’ needs and all this on a Saturday morning after a long week. Having said all that, there are some things that challenge everyone all over the UK; workforce is the biggest – finding the right people to do the right things at the right price.

“We published something in February about how much locum rates have gone up in the last six months of 2021, for example. Now that might affect most of our members less than corporates who rely more heavily on locums, but it’s a very real pressure. Locum rates and salaries are a subsection of what the country itself is talking about at the moment – the cost of living crisis, or we could call it in our case the ‘cost of doing business’ crisis. Those things are right across the UK, changing and challenging the model of trying to break even being a quality, healthcare provider.” 

"There isn’t any way we can do a good job for our members if we don’t have the trust and confidence of the people we work with in UK Government."

Mark says he tries to ensure the NPA does not only consider England by default. “I’ve got a big team – 140 people or so – mostly based in England, and a handful in Scotland, Wales, Northern Ireland,” he says. “We have to work against that, not least because we have really solid numbers of members we want to support in all four countries of the UK, and of course there is great practice and innovation that we want to highlight to all.” 

The organisation recently announced the appointment of UCL’s Professor David Taylor to look at the impact of inflation on pharmacy to provide a benchmark that can be revisited from time to time. While the study will be UK-wide, Mark says the fixed, in reality declining five-year funding deal in England has additional pressures: “When that was agreed, nobody could foresee the levels of inflation we’re running at the moment. Brexit, the pandemic, lots of factors have played into that. The smaller you are as a contractor, the less time and capability you might have to predict and model the impact on your business.” 

“We can use that information with governments, but we’ll share it first with our colleagues in the ‘Community Pharmacy’ bodies,” he says. “There’ll be some really important lessons about how you need to fund pharmacy. We used the EY report a couple of years ago to talk to senior Department of Health and NHS England people before we published, so that they got the first reflections on it. 

“At the end of the day, we don’t publish things in the NPA just to shout loudly so our members can see we’re doing things.The purpose of doing this piece of work is ultimately to get change. And if shouting loudly about stuff gets in the way of that then you’ve got a tension there. Sometimes, it’s best to have quiet conversations. While we’re not fully sat down at the negotiating table, it’s a useful tool for those that are.”

Mark says that from his conversations with NPA members, the current mood in the sector is variable around the UK. “What’s the same is the burnout from the pandemic, that sheer, unrelenting nature of the work,” he says. “How do you find a way of recovering and recharging the batteries with your team when it remains full on? I feel that eventually we will find a way to adjust. 

“Where it’s very different country by country is the extent to which there is medium-term, longer-term confidence. Do we feel we’re on a good road here? Do we feel that the commissioners value us and, to the extent that you can see ahead to the next five years, can we have a confidence about funding that will allow us to invest in the quality of care we provide? In Wales as much as in Scotland, that’s much clearer than in England; Northern Ireland is different again, because there's also the challenge and impact of the wider politics.” 

Mark says being clear about what the vision is in England is clearly one of the challenges, but there are grounds for optimism, with a significant change of personnel, with a new chief pharmaceutical officer in David Webb and changes on the contractual team in NHS England. “David has recently come to speak to our board; we don’t think that’s happened with a CPhO for more years than anyone can remember. We’ve heard and learnt from the other CPhOs in the devolved countries in the last year so it was great to have David sharing his approach and early priorities. Obviously, he doesn’t have a huge background in community pharmacy, but he seems to be emphasising the right things. He also talks a lot about the need to build trust and confidence. That’s fundamental to being successful in serving your members,” Mark adds. “There isn’t any way we can do a good job for our members if we don’t have the trust and confidence of the people we work with in UK Government. And when people say we need to build trust, I remind them that that means we need to be trustworthy. 

“For a trade association, that means a number of things. There are times when you hear things in confidence. You need to respect that. Putting it into the media or on a WhatsApp group the next day destroys trust; people will think twice about trusting you with information in the future. There’s always a fine balance; we need to show members that we’re doing good things on their behalf. It’s very easy to become a trade body that makes lots of noise, that appears to be fighting the good fight, but isn’t necessarily taken very seriously or trusted by the people you have to work with.” 

Mark says the NPA now invests considerable effort in trying to have conversations with more senior people in Government and the NHS. His reflection on joining the sector four years ago was that: “There were an awful lot of people in the sector asking what was it that ‘they’ want. That shows we didn’t have a deep understanding of where the Department or NHS wanted to go in England. That’s much clearer in Wales and Scotland. 

“Andrew Evans [chief pharmaceutical officer in Wales] makes the vision for community pharmacy across Wales really digestible,” he says. “Three or four PowerPoint slides. Nice, short, this is what we want. In Wales, dispensing is obviously at the core of what they want pharmacies to do, but progressively less and less money will be attached to it. They’re very clear that the growth in services fees will be where pharmacies will earn a growing part of their income, probably as much as 50 per cent in time. That might be quite ambitious, but at least it’s clear and they are working to make sure the other ingredients are in place, the skills, the right incentives and a plan.  

“In Scotland and Wales, there’s lots of innovation and change. Inevitably therefore, more of our advocacy focus is on England, not because we don’t support the community pharmacy bodies in other countries, but because 80 per cent of contractors are in England, and it’s the bit of the UK that’s often lagging behind. 

“Even before the pandemic, we were focusing quite a lot on the Whitehall side – how do we get more senior relationships? How do we understand what Whitehall is trying to achieve as the NPA and not always have that translated through the national negotiating body? Whitehall has more operational power than Westminster, but does it help to have a secretary of state interested in something they’ve seen in a pharmacy, maybe even when we got them in there for the flu jab or the Covid jab more recently? Of course it does. 

“We put a lot of energy into building good relationships with MPs, with ministers. We got to know Maria Caulfield about a year before she became our minister. She knew who we were. She’d been talking to us about some of the thinking she’d been doing. And of course having a registered nurse as a pharmacy minister brings great insights to how the health service works to the heart of government. 

“The pandemic, while being full on and challenging for pharmacies to deliver day to day every day, allowed us to show how the sector was working. We put a lot of energy into helping make sure that UK Government did pay the Covid costs of pharmacies. That was a huge victory. Simon Dukes was on record several times about the lobbying and campaigning the NPA did, doing things in cabinet ministers’ constituencies – one of them got a little upset with what was happening – but sometimes you have to make those points in high profile but respectful ways.” 

Unity and representation

Mark says that while the profile and the perception of community pharmacy’s value across the UK has probably never been higher, it was still a salutary lesson for him to see how often the profession was overlooked during those two years. 

“It felt like every other day there was a new issue, often with pharmacists left out,” he says. “I don’t think it was a conspiracy, but, for example, how do you draft a death in service benefits scheme and leave community pharmacists, clearly they’re one of the most visibly open care providers, out?”

I suggest the continual issue of whether the sector is united, or can act as if it were, might be a problem. “There are lots of different business models in running pharmacy. They’re not good or bad, they’re just different,” he says. “When you aggregate all of that up, I don’t sense that the split in the sector is 90:10 or 80:20. It’s probably more like 50:50. 

"more of our advocacy focus is on England... it’s the bit of the UK that’s often lagging behind"

“One of the arguments we made to the recent representation review in England for keeping a balanced approach is that when the split in different business models or priorities is about 50:50, you run the risk that a small majority will determine something that is not in the best interests of the large minority. That could be either way round, of course. 

“Somebody has probably done a piece of work to show that sectors with coherent single voice, or even a single body at the helm are more successful with government than where there is lots of fracturing, but we can only start from where we are. We need to find something that, from our point of view, works well and serves the interests of a wide range of independents.” 

He sees the recently announced result of the vote on proposals to begin the process of transforming contractor representation in England as just the start of a big piece of work, given the things the Pharmaceutical Services Negotiating Committee (PSNC) and local pharmaceutical committees in England need to do now. Some fundamentals still need to be put in place, in his view. 

“I’ll give you one example,” he says. “We’ve talked a lot about the value of incorporation for PSNC. People think that’s a little prosaic, but most healthcare representative bodies are incorporated and accountable under company law with all the mechanisms the courts have determined over the years. That’s important. 

“An incorporated body has members in the legal sense and that adds another level of accountability. We think Community Pharmacy Scotland’s model for this is quite good. It has the CPS Board, but it also has a bigger Council which can hold that board accountable, made up of people from different health boards across Scotland. Add into that an absence of term limits and you’ve got something that isn’t as good and accountable as it should be. It’s very tempting in any organisation to think you’ve got a great board member, let’s keep them there forever. But while that works to a degree, those board members are no longer the independent challenge to the executive, and you’re starving the sector of the ability to regenerate and bring forward new leaders.

“I’ve always worked in trade bodies where members can choose to pay their fees or not. If you’re not doing what the members want, then you might find that some of them go away; that’s another form of accountability. But if I’m a pharmacy contractor, I have no choice whether I pay my representative body or not, so it’s important those levels of accountability are there, because I can’t exercise my veto by withdrawing my levy. 

“In the same way, we don’t think it’s a ‘given’ that putting an extra one and a half million pounds into PSNC, particularly extra money from contractors locally, will automatically produce a commensurate change in the contract. It’s tempting to believe that, but David Wright’s report talks about it not just as a question of resource and money, but of capability and negotiating skills. 

“There needs to be an equity as to how the different parts of the sector are involved in the body too. I could be persuaded that all trade bodies should be in, or that all trade bodies should be out. But if one’s in, you’ve all got to be in, and you’ve got to be in in a consistent way. 

"we’ve tried to face into the NHS in England particularly and understand their dynamics. And the Fuller Stocktake is one of the things I’m proudest of in the last few years."

“There’s also something in the nature of independents versus corporate people sat round that table. If you don’t address some of those challenges, it’s deeply inequitable. The RSG process was a fantastic example of this. I know how hard every single one of those four independent reps had to work to even get to virtual meetings, never mind the face-to-face meetings later in the process. Inevitably, corporate reps also have the resources of very large, sometimes global businesses to draw on too, to help analyse situations, take legal advice etc. Even if you’re a larger national business or a regional multiple, you’ve got more capacity to be able to participate. It’s not about treating all these bodies the same, because that isn’t equitable.”

Leadership and engagement

One area where the NPA has recently demonstrated considerable leadership is in leading the sector response to the ‘Fuller Stocktake’. Mark says community pharmacy has come a long way in the last four years. “Four years ago, I went to the NHS Confederation Conference – the Expo – when I started,” he says. “I was in learning mode. Over two days, pharmacy was barely mentioned in 30 sessions or so; community pharmacy not at all. 

“Contrast that with last month’s 2022 Expo where community pharmacy was mentioned a lot. We had NHS chief executive Amanda Pritchard announcing the cancer screening service, and we had the secretary of state mentioning us in a positive way too. The Fuller Stocktake session was community pharmacy reference heavy too.

It’s very tempting in any organisation to think you’ve got a great board member, let’s keep them there forever. But while that works to a degree, those board members are no longer the independent challenge to the executive, and you’re starving the sector of the ability to regenerate and bring forward new leaders.

“In that four-year period, we’ve tried to face into the NHS in England particularly and understand their dynamics. And the Fuller Stocktake is one of the things I’m proudest of in the last few years. It’s a very good example where one of our team, Michael [Lennox, the NPA’s integration lead], aided by colleagues and some of our board members, spotted an important bit of thinking that Amanda Pritchard [CEO, NHS England & NHS Improvement] had herself commissioned from a trusted colleague. 

“They saw the opportunity to get involved on the terms of the NHS. We don’t do that very often; we tend to want to get involved on our terms. But you need to listen, you need to understand, you need to engage. It wasn’t part of our original plan for the year, but we had to respond very quickly. We put a lot of energy and effort into being part of every one of those working groups, tried to put across the best case we could for community pharmacy and ended up getting plaudits from the authors, who said we had been great as a sector to work with.

"those board members are no longer the independent challenge to the executive, and you’re starving the sector of the ability to regenerate"

“When I look north of the border and I look to Wales, I see people on that journey already. Harry McQuillan and the team at Community Pharmacy Scotland working with the NHS, with Scottish Government on their terms, as trusted partners helping them solve problems using community pharmacy. That’s so important and it is such a powerful way to work.”

Mark says the challenge now is to build on the engagement, particularly following Claire Fuller’s review. “We have seen for some time that the way to impact policy is very rarely to respond to a consultation. We need as a sector to get further up to the start of the thought process to be influencing as people are thinking through problems. We were delighted to have Amanda Pritchard come to the St. James’s Palace event. In all that joyous celebration of what front line pharmacists had done, she was also also meeting people in the sector. Getting into somebody like that’s thinking long before they ever formulate policies is so important. And it can be a long-term game. Relationships are how all of this changes, not formal responses, not actual negotiations around the table either – they’re an endpoint generally.” 

Mark sees a gap between LPCs that are well engaged with system level leaders in different parts of the health service and already finding opportunities and other areas where that’s not happening. “Somebody needs to help the local be effective and consistently effective in all of those relationships, as well as focus on the national contract. 

“The challenge can look different for national bodies, national contractors and for independent pharmacies.” He says Covid vaccinations is a perfect example. “The sector in England, Wales and Northern Ireland did a of staggering number of vaccinations. That’s a real strength – set the incentive, people do great things.” It’s also a story of independents versus corporates. “Where I live, my independent pharmacy was superbly well positioned to understand the needs of that community, to get hold of the tennis club because of the relationships they have, draw together volunteer teams. The Covid vaccinations in those clinics were a really good example of the strength of the independent sector. 

“Does that group of two or three pharmacies have the same clout as a big national player? Of course it doesn’t, but it has a capability large corporates don’t. Different parts of the sector would prefer to have more or less of whatever funding is available coming through a national contract, versus something that might be arranged locally. To the extent that independent pharmacies can benefit from local commissioning, which is different to what’s going on nationally, we would want to support that because those are opportunities for our members to stand up and be recognised. 

“What the contractual nature of that is, is secondary to recognising the need. Fuller points out those needs aren’t going to go away. So we would like to work with those, whether it’s the LPC, some of the officers, drawing that together or even sharing good practice, that is no small task.” 

Future view

The NPA has held a longer term, broad, high-level view for the last five or six years – community pharmacy as the front door to the health system; clinical skills are too valuable to not have everyone working at the top of their licence. “In many ways, that thinking has taken root – we’ve been delighted the health secretary has come to our conferences in recent years to echo that message. People will say, I’m fed up of just being patted on the head when there is no new money. But I don’t think it’s a binary choice. Clearly, the contract has to be sustainable, the funding has to work. But I would argue that you’re not likely to get to that point unless people have patted you on the head many times. And it’s better than being ignored. 

“The proof of the pudding is how does all this get funded, of course it is. But you won’t get to that point unless you build that recognition for what the sector does and have those relationships. They take a long time to build well, and can easily be damaged. If we’re in this for the long term and a sustainable future for our members, there’s no alternative to putting the energy into building those relationships, understanding what it is commissioners want to buy, and then trying to deliver that. 

“We need to make sure that the way in which contracts are remunerated works in the short term, medium term and long term. We don’t want to find ourselves losing out on the back of a seismic change in the NHS. People have said before there will be a reduction in items and it hasn’t always happened. But you need to guard against those things. You need a funding mechanism that is sustainable when the health service changes its approach. 

Mark says that everything the NPA does is funded by the membership fee or pay as you go services such as insurances or training sessions, so thinking about member benefits is crucial. “We sometimes take for granted that we have this fantastic insurance. It’s incredibly rare today for a trade association like the NPA to still wholly own a fully UK regulated, insurance company and for it to be successful and for the membership body to be successful alongside it,” he says. “We’re very proud of that. Members do genuinely see that as a phenomenal benefit of belonging to the NPA.

“Hopefully, most people don’t have to use it too often, but when you do you realise that insurance isn’t just a commodity, what really matters is how people look after you should you ever need to make a claim. I hold my hand up, we don’t talk about how good it is as often as we should. And of course that means the NPA is well positioned to both understand new risks like independent prescribing from a professional practice and from an insurance point of view. And of course, we also provide insurances for individuals, for companies, who aren’t eligible for membership.” 

There’s much more competition in most other parts of the membership package such as its service offer, where recent investment in a service development pharmacist role is already paying off. There are new partnerships with companies like Tympa Health, for example, and resources being brought in from different parts of the organisation to create ‘wraparound’ services where you get all the elements you need without having to face the challenge of navigating the whole organisation.  

“Our training offering is now all online, with a state-of-the-art learning management system,” Mark explains. “We’ve got a long list of trusted business partners; we try to pick the best in the space, those who will be best for you, not best for us in terms of commission. One of the big successes in recent times is our ProDelivery Manager software, where we are part owners. A million deliveries a month now are using that software, it’s integrated with the core PMR systems.

“We might do other things in that space. I don’t think we or the sector generally have always been at the forefront of technology or innovation and there are things that could solve real world problems in pharmacy that we’d like to think members could make use of. 

“However tempting it would be to run an organisation with guaranteed membership income – the negotiating bodies are an example – you can get a little complacent when the money is guaranteed. It’s incredibly important for trade bodies that we live by whether we’re delivering for members. Our membership is as healthy as it’s been in years. Inevitably, as in any trade body, we lose some members; sometimes people go for 20 years and return. For example, in the last six months a number of members in Scotland have come back after a very long time of not being part of the NPA. 

“We’ve still got 80 per cent of the people who are eligible to join, and that includes a majority of the independent multiples. That’s a good figure in any sector, particularly one with so much competition. We have one or two people leave, you always do, but even those that leave tend to want to buy our services, albeit not at the lower, member price. Without that choice, you don’t have that appreciation of whether your services are valuable or not. That’s the thing that keeps trade bodies honest.”