Interview: Nick Kaye, NPA chair

Third generation pharmacist Nick Kaye says his new position as NPA chair requires vision, as well as collaboration. His goal is to make community pharmacy a place where people want to work, finds Arthur Walsh

I speak to Nick Kaye just after he gets off a recording with LBC for a segment on ‘NHS at 75’, in which he spoke of the deep links between his family and the nation’s pharmacies. As a third generation pharmacist, he tells me: “My family has been working in community pharmacy since before the inception of the health service.”

Kaye was appointed to the role of National Pharmacy Association (NPA) chair in April, replacing Andrew Lane. I ask if this family pedigree was on his mind when he took on the position, and whether he feels it gives him a particular skin in the game. “I think so,” he says. “I’ve been really surprised at how much being chair has affected me. This organisation that’s been around since 1921 and which my family always looked up to – I feel a huge amount of responsibility.

“My son is in pharmacy school at Swansea, making him the fourth generation in the family. My paternal grandfather had a pharmacy in Leeds. Then, in 1972, they moved down to Cornwall, where my maternal grandfather was one of the pharmacist employees. My uncle and aunt were both pharmacists and my brother’s a hospital chief pharmacist.”

When it came to Kaye’s pre-reg year, he didn’t get accepted at Boots – “I’ve still got the rejection letter” – and wound up at Rutter’s in Leeds. He told his father, whose reaction was disbelief. “He said, ‘I was born in that store.’ I had no realisation that it was my grandfather’s shop.”

As vice-chair of the NPA – a position he held until April – Kaye was very much involved in the day-to-day running of the organisation. Is he required to take a wider view of the sector as chair? “That’s an interesting question,” he says. “As chair, you have to not only set a strategic vision but also get buy-in from others, which is its own skill set. You have to bring people with you. You can’t just steam ahead.

“And the conversations you have are at a different level, so you always need to be on top of your brief. In the last week, I’ve been to a garden party where I saw the King chatting to Lionel Richie – that’s a different kind of day. And then you go to a meeting with [NHS England chief] Amanda Pritchard, or with Department of Health.

“The NPA has access to those types of people, and we can’t always shout about that – it can be kind of frustrating. For example, we’d like to think we played a small part in the £645 million coming to community pharmacy [with the May announcement of the Pharmacy First service].

As well as being chair, Kaye is still very much a coalface pharmacist at Hendra Pharmacy in Cornwall, which he part owns. “I’m a contractor myself and know how difficult it is out there,” he says. “It can be strange to balance these different roles.”

Kaye’s NPA responsibilities take up around two days a week on average, which he fits between his work on the coalface. Does he think it’s important for pharmacy representatives to have a foot in the sector? “One hundred per cent. Looking at the NPA board, we’ve got lots of great frontline practitioners who’ve built up amazing businesses. They’re living it every day; that brings a reality to it. The responsibility, not just for your own family but for your team, is huge.”

He tells me how he brings this lived experience into meetings with decision makers. “I was in a meeting with the NHS and told them I didn’t know if I’d get paid this month.

“I told them, ‘With the greatest respect, ICB budgets might be running over, but you’ll all still get paid at the end of the month. I’ve got five kids and a mortgage, work 60 or 70-hour weeks sometimes, and I think I’ll get paid but I can’t be sure’. They were genuinely shocked.”

He has also come across some surprising gaps in NHS knowledge: “Simple things like category M – I tell them it doesn’t work in an inflating drugs market, they ask what I mean and I have to explain that pharmacists are carrying costs – that an increase in dispensing volume is actually destroying contractors’ cashflow at the minute. It’s important that this is articulated to the people who make these decisions.”

Acute pressures

What are the key items on his agenda? “Funding, workforce, supply, capacity – these are all issues we’ve talked about for some years, but I think now the pressures are more acute,” he says. “From both a personal and a strategic point of view, clinical decision making has never kept me up at night – but financial decisions do.”

He mentions that his second item on the NPA board was “to think really hard about whether or not we were going to support the contraception service – at the end of the meeting, we all knew that although community pharmacy is the right place for the contraception service, there’s just no money left. It was a hard decision.”

While the problem might be especially acute in Cornwall, Kaye believes rising locum rates are also taking a toll. “I’ve got no issue paying locums £40-45 an hour – that’s what I’m doing now,” he says, “but the contract in England doesn’t support you to pay it.

“As far as workforce is concerned, I’ve said for a long time: If you want true transformation and a bigger role for us in primary care, community pharmacies should be able to access ARRS funding. Having been a partner in a GP practice for five years until I left last year, I know what some of the pharmacists there are doing – and the difference these people could make in community pharmacy. If I can – in any way, shape or form – I want to make community pharmacy a place where people want to work.”

Despite the current pressures in the sector, he finds his work deeply satisfying. “Community pharmacy is pressured at the moment, but I love the buzz of people. You see somebody who’s really poorly and you have direct accountability to them.”

He seems to take a more nuanced position on ARRS than those (Community Pharmacy England chief Janet Morrison, for instance) who just want the whole thing scrapped. “There’s a whole thing about enabling transition,” Kaye says. “I do think it’s not been well thought out and that it needs a dose of reality. I see it from my brother’s perspective in hospital pharmacy as well; it’s not just us being affected.

“General practice offers people another place to work, and there are pluses and minuses to that. But if it’s going to exist, I would rather be allowed to benefit from it. Not just pharmacists – could we have pharmacy technicians? A manager?

“If it’s done in the right way, you can enable transition through workforce via something that’s funded, without putting more pressure on a sector that’s already under strain. It would promote integration, but also the transformation that the NHS says it wants.

“If I know I’ve got an extra pharmacist for 40 hours a week, they can max out the NMS, hypertension, contraception, walk in consultations. Then in two years’ time, I have actually built up a funding stream that means they stay. At the moment, I just haven’t got the cash flow to hire that person because I’m spending so much on increased medicines cost, but NHSE could help us get there.”

Kaye mentions the £645m announcement. What is the NPA view on the common conditions service – and the money attached to it?

“The funding has to be done properly,” he says. “In my personal view, it would be great to have the funding split so that a pharmacy knows they’re going to have ‘x’ appointments per week, they get a set amount of money and the appointments can be filled. How the money is used and how quickly it gets out – that’s key to everyone.

“I think seven conditions is good – it allows proper channel shift. From our experience operating a minor ailments scheme in Cornwall, they seem to be the right conditions – we have data that people come to us for these conditions. My main worry is that people won’t deliver it because they’re so pressured. If we don’t get this right, I think the opportunities in the future are going to be limited.

Scotland’s Pharmacy First scheme covers around 20 conditions; would that overload English pharmacies? “It wouldn’t overload the clinical skill set of the teams, but it may be overloading as far as system messaging is concerned,” Kaye believes. “It’s a start, and in terms of PGDs and prescribing, it will be a positive development.

“The seven PGDs could show we can do it properly and what we could do with independent prescribing. It’s a good building block to show what we can go on to do outside those seven conditions. We’ve got a local PGD that says we can’t prescribe UTI treatments for patients over 65, whereas when I worked in general practice, I was quite often prescribing to women in their 70s and 80s.”

Crucial links

And it all helps to build those crucial links with commissioners. “We’ve had a request from our local system to think about something slightly different, where community pharmacies would be attached to the wait times on the NHS app,” says Kaye. “It might say the A&E wait time is ‘x’ hours long, but to see an IP community pharmacist it’s 10 or 20 minutes. That was the director of urgent care in Cornwall asking if we could do things differently, which was interesting to see.”

With the establishment of Integrated Care Boards (ICBs), does Kaye see an opportunity for pharmacy to have more influence than when commissioning was more centralised? “There are a couple of things here,” he says. “Systems that were previously well connected will continue to be well connected. Those that weren’t may be more disadvantaged. We hear about a ‘postcode lottery’ quite often at the NPA. Someone will say that in another region, people are getting paid for minor ailments, whereas they are doing it for free. If the well-connected systems can spread great practice and that becomes national, that’s really important.

“My worry is that with delegated commissioning, there may be people making decisions without having the complete expertise, which can have unintended consequences. For example, what if someone decides to change the dispensing interval from 28 days to three months – it might reduce work, but it would collapse cash flows even further.

“ICBs are overspent – not because of pharmacy but because of a rising drug budget. They’re looking at ways to change that, and I think LPCs have a real role in making sure there are no unintended consequences. If I’m a medical director, I don’t really understand how community pharmacy is funded. So I might say, they’re really busy, I’ll change it to three months. Delegated commissioning has benefits for systems that are really proactive, but there are risks too.”

What is the NPA view of changing ownership patterns in the sector, as independents snap up the branches multiples seemingly can’t get rid of fast enough? “It’s showing that the independent sector will be a place where you get innovation,” Kaye says. “People are seeing opportunities to grow and grab market share or consolidate at a time when pharmacies are basically at the bottom of the market as far as value is concerned.

“There are two things I’d say – the first is that people with the cash are buying them now because they are good value for money in the scheme of things, and they’re doing it in the faith that something better is coming – the £645m is seen as a sign of that, I think. And it’s great to see young people buying their first pharmacy. But people need to be aware of what they’re getting.

“I worry people will get tied up with cash flow, as some of these stores have been underperforming for some time. “It’s great that the independent and mid-sized sector is growing – I just hope it’s sustainable for them.” It could also lead to changes in representation, he argues. “I come from an LPC which is very CCA-dominated; with the multiples closing and consolidating, we may see a shift from a representational point of view as well as ownership – it’s a really interesting time.”

It’s also a time of change for the NPA itself. For one thing, says Kaye, it’s seen membership rise in the last few years. It has also introduced governance changes that will limit board terms and require anyone who has been on the board for 12 years or more by March 2025 to stand down at that time – something that will affect Kaye directly.

“It’s like turkeys voting for Christmas,” he says – but he’s proud of it. “At the end of 12 years, as a past chair, I’ll probably understand the organisation the most. I can absolutely see why people would want to carry on, but it’s the right thing to do, to move aside.”

Challenges ahead

What are the key challenges for the organisation now? “The main issue is ensuring we stay connected to our members,” says Kaye. “We’re looking at creating member WhatsApp groups, regional forums – it’s about connecting back to the member base as opposed to people’s own interests.

“We want to help make the contract in England more sustainable. I want people to feel their businesses are sustainable, that it’s a place they feel happy to invest their time and money – and because they’re not being kept awake at night by finances, they are freer to make better decisions clinically and strategically. The other thing is, I would love community pharmacy to be seen as a place where people want to work.”

Some would argue that there are too many competing voices in community pharmacy. What is Kaye’s view? “I would prefer collaboration wherever we can,” he says. “But I’m also very happy for the NPA to stand alone and say, these are the people we represent. We are looking at doing things differently as a sector, but I don’t think that’s the reinvention of Pharmacy Voice. Everybody needs their own influence, but I’m happy to be a part of joint messaging.

“The NPA board is more connected to its members than ever before. We want to be representative, and collaborative where we can be.”

2030 vision

In July, the NPA published a prospectus for the rest of the current decade, in which it set out new ambitions for the independent sector. Making changes, meeting needs takes its lead from the evolving needs of the NHS and patients, and calls for the introduction of an ‘NMS+’ to allow IP-qualified pharmacists to tackle adherence issues, among many other recommendations.

“There’s a lot in there that I’m really proud of,” Kaye tells me. “It’s based on what we hear from our members, but it also paints the reality of where we are now. We built it around what commissioners and patients want, and what we think community can achieve – with the right investment.”

The prospectus argues that pharmacists should have a stronger role in managing long-term conditions. “If we get the right technology to communicate properly and be joined up as part of the primary care system then it’s not a big leap,” Kaye says. “I don’t envisage that every long-term condition is going to be managed by every community pharmacist, but I do see a place where people can have some of their long-term condition reviews done in the community.”

The report also calls for sweeping changes to the current reimbursement structures in England to help pharmacies meet the heal service’s stated ambitions for the sector. “There is a huge responsibility on NHSE to get the funding right, but we at the NPA also have a responsibility to engage with them and help them understand why it’s important to the longer term ambitions.”