Neighbourhood watch

Ash Soni, president of the National Association of Primary Care and two-time president of the RPS shares his passion for integrated care and tells Arthur Walsh that it’s time for a more forward-thinking approach at the top of the profession

Entrenched attitudes can be hard to shift, National Association of Primary Care (NAPC) president Ash Soni tells me when we sit down for our interview. He relays reports of a meeting (he didn’t attend himself) where GPs were discussing what to make of the newly launched Pharmacy First service. “They were all talking about antibiotics,” says Soni, explaining that they were fixated on the idea that “these pharmacists are just going to hand them out willy nilly”.

While this may sound depressingly predictable, there is another, more hopeful side to the anecdote. “What was interesting was that a young doctor stood up and said there are really clear protocols around when antibiotics can be given out and when they can’t,” Soni tells me. “He saw the value of it, whereas an older generation might see it as treading on their toes.”

Despite the suspicions expressed by some practitioners, Soni takes heart from the young GP’s remarks and is adamant that the profession will acquit itself well: “Pharmacists know they have to be able to demonstrate their competency and justify themselves to the public and their regulator,” he says.

Readers will be most familiar with Soni as the two-time former president of the Royal Pharmaceutical Society – but since late 2022, he has been heading up the NAPC, an organisation that is focused on promoting the ‘neighbourhood care’ concept, and which Soni has been involved with for over a decade.

Soni, who was “honoured” to be the first non-doctor to be asked to lead the NAPC, also holds non-executive roles with Oxford University Hospitals Trust and Sussex ICS. But most importantly, he is still a pharmacist, owning and running Copes Pharmacy in south London. “It’s my bedrock,” he says.

His NAPC role gives Soni an oversight of how the different elements of primary care weave together. What are the big-ticket items on the organisation’s agenda in 2024? “It’s all about integrated neighbourhood care,” says Soni. One of the questions that comes up most frequently is around how to ensure patients can access care. “When you think about it properly, you realise that who is on the team will depend on the needs of the individual patient at any one time,” he says.

That could include non-clinical staff and community groups as well as healthcare professionals, Soni says, adding: “The challenge from an NAPC perspective is helping people to understand what that means.”

In particular, it’s about fostering collaboration and “getting away from the historical tendency to see each other as competitors”.

As Soni’s anecdote illustrates, different care settings have sometimes viewed one another with suspicion. Do pharmacists today understand the pressures GPs face, and vice versa? “There has been some suspicion, but some of it is just that you don’t know what you don’t know and are making presumptions based on what you see or hear,” Soni says. “In many cases, that’s seen from a distance.”

As a contractor, he has occasionally had to fend off perceptions that he’s only interested in shifting units for cash, while many pharmacists are equally mistaken about the working lives of their counterparts. “We have perceptions about GPs sitting around with their feet up,” sometimes driven by the difficulties in getting in touch with practices to make an appointment, says Soni. “Actually, when you sit down with a GP, you realise the sheer amount of activity going on.

“Personally, I’ve worked with my local GPs for 30-plus years and historically, trainees have come in to spend a day with us,” he says – an exchange that has been “really useful”.

With referral-based services on the rise, has some of that gap been bridged? “Without any doubt,” he says immediately. “GPs are seeing they can better utilise some of their resources as a result of pharmacies managing these seven conditions”.

Pharmacy, he says, is much more needed in the health system than some primary care colleagues realise – but pharmacists share some of the blame for not pushing to have their voices heard and articulating a clear message. “It’s important to have a seat at the table, but if you feel overawed or less confident in those environments then you’re just ticking a box and it’s not productive,” Soni says.

“I hate the term ‘clinical pharmacist’,” he adds, acknowledging that a frequent challenge over the years has been perceptions of pharmacists’ professional status. “We don’t just pick something off the shelf,” he says. “We carry out a clinical assessment and decide what’s appropriate for that person.”

 Read-write access to patient records will only help to drive the medicines optimisation agenda. Pharmacy has much to contribute here. Soni says he has found that hospitals often don’t adopt the same robust approach to medicines optimisation. “The GPhC will hold us to account for the tiniest little thing, but if you look elsewhere it’s a bit looser.”

He goes on: “Community pharmacy has probably been the best example of medicines safety because of how the processes work, and the way we’ve had to adapt and change as systems became bigger and more complex.”

In the case of the aforementioned GPs, he argues that a pharmacist might turn around to them and say: “Well, how well do you manage antimicrobial stewardship? For us in community pharmacy, it’s a natural thing. We can often advise patients that they should just take paracetamol and don’t need antibiotics.

“After staff, the biggest NHS spend is on medicines, and yet we don’t give that enough value. We need to be better at understanding the value medicines bring and how to produce better quality outcomes for patients; optimisation isn’t always about eliminating or stopping medicines.”

No money in dispensing

Is Copes Pharmacy embracing Pharmacy First enthusiastically? “Absolutely,” says Soni. He describes the £645 million attached to this and other services as welcome, “but it’s putting money in that should have been there anyway,” he says. “It’s not the whole solution, but it’s part of it.

“It recognises what pharmacy can bring. What we still haven’t got is a recognition of the value pharmacy brings to the utilisation of medicines; it’s not just filling widgets – we bring a value that isn’t brought by anybody else.”

Is that recognition likely to come? Soni is on the record as saying that the best possible contract the sector could ever secure is only going to be enough for a contractor “to wash their face” with, meaning the days of profitable dispensing are gone.

He argues that the clinical services agenda has been blighted by NHS England’s myopia about what doing more actually costs. “It isn’t just a question of telling them we can do extra within our existing funding package – it’s just not possible. You’ve got to recognise the costs attached to service delivery, and for pharmacy, dentistry and optometry, those costs are not paid for within our funding.”

But some of the onus must be on providers building a case for funding. “I can’t affect what happens nationally, but I will try to have conversations with people about what should be commissioned at a national level so there is consistency in what we offer.

“That consistency is unlikely to just come overnight; the opportunity is to start things at ICS, place and neighbourhood levels so we can demonstrate the positive impact on care.”

And while pharmacists won’t have any control over factors like housing, these can be important determinants of health and should be borne in mind when having conversations at neighbourhood level, he says.

If an approach pays dividends for a given community, “it should work across a bigger footprint” – for example, by upscaling from PCN to ICB. “And if you can demonstrate the value you’ve brought at ICB level, then why not commission it nationally?” Soni asks.

Are there particular condition areas for which he has ambitions? “There’s a whole piece of work we can do around managing long-term conditions generally,” he replies. “Not the complex multimorbid conditions, but things like hypertension, diabetes and COPD – particularly in the early stages. We can show how we can change outcomes and deliver better value.”

He suggests that the hypertension checking service could provide a springboard for a more comprehensive approach involving lifestyle advice and medication management. “From a pharmacist perspective, we can probably do a lot of that if it becomes more complex,” he adds.

And why not have pharmacists referring to other pharmacists with specific expertise in a particular therapeutic area, he suggests. “If I’m using particular medicines for hypertension and the patient’s not responding in the way they would expect, rather than referring to a GP, can we refer to another pharmacist if the issue relates to medicines? If it’s not medicine related – for example, if there’s something going on in the diagnostics – that would go back to the GP.”

And peer-to-peer referrals could pay a skills dividend: “The next time I see a patient who is resistant, having had a conversation with a more skilled pharmacist, my base skill level is higher and I can therefore think about how I provide a slightly higher level of treatment.” This could stop patients ending up in acute care, he believes.

Enough work for everyone

What is the NAPC’s view on the workforce challenges blighting seemingly every healthcare sector? “It’s a very challenged workforce picture for every sector,” says Soni. “It doesn’t matter who you are; there is this constant cry for more GPs, nurses, pharmacists, etc.

“There’s an NHS Long Term Plan – fantastic. But that is at least a decade away. I can’t tell patients they’re going to have to wait 10 years until I have all the staff I need. It goes back to who we utilise; the people we have at the top of their licences. There is more than enough work for everybody. It’s not just about how I as a doctor or pharmacist manage a patient, it’s about how we work together to support the public.”

This involves drawing on more junior team members – for example, in the promotion of public health awareness campaigns on topics like weight management. “It’s not just about the health professional,” he says. “It’s the teams around us.”

Does he see pharmacies looking at new ways to deploy their staff? Soni describes this as an “internal challenge” the sector is grappling with. He says that while pharmacists have their own frustrations with GPs grumbling about work being given to pharmacies, “we do the same thing” when it comes to delegating to pharmacy technicians and other colleagues.

“We’re being asked to deliver Pharmacy First, but where will we find the capacity for that? How do I use my technicians and dispensing staff to manage the dispensing process and give me the capacity to take on new work?” He goes on: “There’s always been an argument for having more than one pharmacist, but that’s expensive and the resource to fund it isn’t growing on trees. We’re all operating in a cash-limited environment.

“Having two or three pharmacists on site is absolutely where we want to get to, but we also have to work out what they’re going to do. It’s not the same thing they do today – it’s not checking prescriptions.”

Soni talks about the pharmacist’s role as evolving from managing ‘transactional episodes’ to ‘outcome episodes’.

Many people feel the Additional Roles Reimbursement Scheme (ARRS) has done community pharmacies a disservice. With the bird’s eye vantage point his NAPC role gives him, does he agree? “To an extent,” he says. “ARRS was very fixed. It was about having to have this number of pharmacists, social prescribers and so on, when it should all come down to neighbourhood care and the question of what is right for the population you’re serving.

“If I’ve got a number of community pharmacists and utilise them in different ways, do I need the pharmacist in the GP practice? That’s the conversation we should be having.”

So pharmacies should have access to the employment budget? “Absolutely.” Some people will resist it, “but the whole point is to open up those discussions” and having clued-up pharmacy representatives at board level meetings will help focus attention on core purposes, believes Soni. “You need to think about the function and then worry about the form. In a lot of cases, it’s about what’s the form and how do we deliver the function? That’s the wrong way round.”

ICBs have the potential to change the pattern in England of having a “commissioning-led model, rather than outcomes-led”. ICBs may still be “responsible for the money”, but they’re also concerned with care integration and health inequalities. All this gives pharmacies an opportunity to engage: “You need to find out how to get to those people so you can influence them,” says Soni. “More and more areas are seeing their ICBs investing in community pharmacy leads. Are you prepared to step into that space and be one of those people?

“What does good quality care look like, and how do we make that work financially? My philosophy throughout my career has been to chase the care, not the money. If you deliver the right thing, the money will follow.”

Get out of the red

I tell Soni I’ve spoken to more than one contractor who is doing all that he advises – from local networking to delegation within the pharmacy team – and still finds themselves in the red for the first time in their careers. Is it just a brutal fact that the long-running funding pain will lead to many more pharmacies going to the wall?

“We are in a very challenging environment; I see it in my own pharmacies,” Soni acknowledges. “The dispensing contract is not economically viable, but some of the income we generate in fees helps to ameliorate some of the losses we make on purchasing drugs. I don’t look at the core contract as the mechanism that will make my pharmacies profitable.”

He talks about the need to “max out” services like NMS, Pharmacy First and hypertension checks. Can private services play an important role? Yes, he believes. “Pharmacy has almost let itself get sucked into this idea that everything is about the NHS.” Travel, weight management and ear wax removal all have potential, he says.

And there is scope to be a bit more imaginative too. Soni says he’s having conversations “about the potential to deliver, at scale, HPV vaccines through community pharmacies as a private service for those who are over 25,” as well as a potential MMR programme.

But he warns pharmacists that they must compile data on any services they provide so they can present a compelling case to commissioners. Especially important, he says, is to record patients who can’t afford the pharmacy’s private service. “Then they can tell the commissioner: ‘Here’s the evidence to show you which people aren’t accessing this as a consequence of costs.’ Then I’ve got an argument for getting something else commissioned.” He recommends working with local universities to get involved with research projects as an example.

These enterprises have borne fruit before, he says, explaining that flu vaccines began as a private pilot, leading to the highly successful national programme and then the Covid vaccination drive. “Now pharmacy does more Covid vaccines than the other providers put together,” he adds.

A final question for Soni: what is pharmacy not worrying about enough? “The big thing is probably not thinking about what, where and who is responsible for the change that is happening. Who’s doing the buying, and who’s who at place and neighbourhood levels?” He says that at a conference last year, he asked an audience of 200 how many knew what an ICB was, and only three or four put their hands up. “If you don’t know what’s going on, you can’t influence it,” he says.

It’s not just contractors who are affected: “We will soon have pharmacists graduating with prescribing qualifications – how are we going to use them? How do we make sure locums get trained up and have those skills?”

He also believes that pharmacy must be mindful of the changes that may be coming down the line with the Independent UK Pharmacy Professional Leadership Advisory Board – a body spearheaded by the UK’s four chief pharmacists, and which has at times clashed with Soni’s old organisation the RPS over attitudes to sector leadership.

Soni says of the Society’s performance over the years: “There were elements where we could have done better. I think at the moment there are a lot of things not being done from a leadership perspective. I’m sorry to say I don’t think we currently have an operating leadership that has the confidence of the profession… it’s reacting to things rather than proactively leading.”

We need a more forward-looking approach at the top of the profession, Soni says, citing genomic medicine and point of care testing as areas where guidance is needed. “Who is thinking about the opportunities out there? Doing what we do today is no longer going to be viable.”