Answers on an (online) postcard
While there’s general agreement that a vision and a strategy for community pharmacy in England would be a good thing to have, as our round-up of initial views suggest, while some individuals have clearly done some thinking, there are, as yet, few concrete ideas being pitched into the process by pharmacy organisations, other than “better funding”.
As an overall approach, this is understandable. Bottom-up thinking will be, after all, vital to the outcome of any such process if it is to gain real traction (or buy in). But it leaves pharmacy owners, pharmacists and others with the daunting task of answering five very broad questions in a first survey, with a deadline looming at the end of the first full week in December. Want some prompts to get you thinking?
What does ‘good’ look like?
Community pharmacy often looks like it’s playing on a different pitch to everyone else. While the sector has clear responsibilities related to medicines, the strategic vision must be contextualised with community pharmacy as a team player within primary care.
With regard to the national contractual framework, pharmacists have a unique set of skills and knowledge that should be applied to the NHS’s priorities for medicines optimisation and quality improvement in the delivery of services to patients. They’re the only game in town.
Community pharmacy, therefore, needs to play its part in tackling the long-standing challenges of hospital admissions caused by medicines misadventure, low uptake of guidelines, overprescribing and waste, and of poor adherence contributing to poor outcomes for patients. There should be clear workstreams that recognise each.
But what about non-NHS services? While this ‘vision’ has been commissioned by PSNC, there are many community pharmacy owners now who see the NHS contributing a diminishing percentage to gross revenues (and therefore the work being undertaken by their teams). Where do you want that to figure? Does the negotiator have a role, or is this where the views of your trade associations and other representative bodies need to play a role?
Community pharmacy needs to get to a place where it is clear what is expected of it and where patients and the public know what it does. This may mean working towards a universal offer (like in Wales) and an end to optional services. Reframing what community pharmacy does in terms of its impact on managing medicines-related risk might help in prioritising the evolution of the contract over the next decade. It might also open up new conversations about the need to tackle the health inequalities in access to medicines, a focus that might endear the sector to integrated care systems.
‘Good’ needs to be achievable, but not necessarily easy. Ambition implies stretch – not more of the same. Is pharmacy’s ambition too often defined by those tasked with delivering against it? With the Nuffield Trust and The King’s Fund doing this work, you can think as big as you like.
Contractors (and pharmacy teams) have demonstrated during the pandemic that they can move faster, more flexibly and with great purpose when they have to, or when the right incentives are in place (financial or professional).
Implementation always seems to be an afterthought. ‘Good’ should include a framework for delivery that recognises that change is difficult and may require different levels of support. The benefit of an incremental plan is that it breeds confidence in a successful outcome, and can also cope with delays along the way, which might be caused by a tight financial settlement one year, for example. It would be helpful for contractors to know the key metrics and the staging posts on the road to the desired state.
Key building blocks for achieving ‘good’
The ‘everybody must be able to’ mentality has been a huge drag on community pharmacy’s ambition. It stifles innovation. Everyone moves at the pace of the slowest. The rationale for change, including the development of new services, needs to be clear.
If the ambition, vision and strategy are agreed, then each development should be aligned within a workstream designed to deliver a particular outcome. When the end goal is clear, it is easier to see change as steps along the way to something better.
Service evolution must be built into the model. Services have been decommissioned in the past because they stood still. Capturing key data and measuring service impact has to be built into any development for the future. IT providers should be seen as partners, rather than suppliers. Feedback on progress is essential and will ensure that implementation and improvement support, where necessary, can be targeted at those who need it most.
There is nothing wrong with bottom-up development. Pharmacies with a mindset that welcomes innovation and change should be celebrated as outriders for pilots and detailed work ups of new elements of any future workplan. If they’re already wearing the t-shirt, they won’t thank you for offering them a straightjacket. Instead, you should be asking them how they did it.
As we move towards more integrated care pathways, it is inevitable that priorities will differ at system, place and neighbourhood levels. The vision and strategy needs to accept that a patchwork of service provision may be inevitable, but variation in the way a particular service is delivered should not be. Pharmacy should not be afraid of setting standards for service delivery. It’s why most trade bodies exist.
The reluctance of government to sanction open-ended service provision (and therefore open-ended cost) should be accepted. More thinking should be done about how defined cohorts of patients might be tackled in sequence.
Key barriers to achieving ‘good’
Community pharmacy cannot have a vision that is divorced from the reality of what those who commission it want – what the chief pharmacist in Wales, Andrew Evans, calls the ‘investible proposition’. Create an investible proposition and the next conversation is about the investment.
In England, the Pharmacy Integration Fund, which is supporting current developments in the sector, from independent prescriber training to regional pilots for cancer case finding etc, is all about working across boundaries, across health and social care. It is unlikely to fund things that will solely benefit pharmacy, but is interested in facilitating integration later, even if the benefits cannot be guaranteed upfront.
The aim has to be a vision (and strategy) that is agreed or at the very least accepted by the NHS and the Department of Health and Social Care, but also by other stakeholders, such as local government, with an interest in how community pharmacy might improve the lot of those they serve.
Dissonance across the sector will not help; the vision and strategy needs to be agreed by all those who claim to represent the sector (or parts of it). This means compromise will be necessary, so the rules of engagement need to be clear from the outset. No organisation or person (this is the lesson from the Community Pharmacy Forward View in 2016) should have a veto; absence or abstention from the process is no excuse.
Key enablers to achieving ‘good’
Communication, communication, communication. Vision and strategy development at scale needs to leave no stone unturned in engaging with the sector, building the case for change with people, contractors, pharmacists, pharmacy team members. The future has to be one they can shape, even if it is grounded in the realities of what that ‘investible proposition’ might need to contain.
Workforce is crucial. As the pandemic has demonstrated, the community pharmacy workforce is dedicated, hard-working and flexible. It’s also tired and facing the same cost of living challenge as the rest of the country, while working in an industry uniquely squeezed by a flat funding contract running until 2024.
A workforce capacity and capability plan is an essential element of any ambitious vision and plan. A new contractual framework might not be in place until 2024, but the skills gap can be filled in the meantime by a business case presentation to the Pharmacy Integration Fund for extra-contractual funding, if necessary.
Don’t discount the value of offering personal development as a means of retaining existing staff in the sector. More highly skilled people will also respond to change better, facilitating more rapid adoption of new services.
Innovative models of delivery to be explored
Community pharmacy is now used to a wide range of service models commissioned nationally or locally, across pharmacy, via networks or even, as with Covid vaccinations, from individual contractors in particular locations. Pharmacies are now used to delivering end to end services for all patients as well as for single patients, as sole providers or as a member of a multidisciplinary network, under a single specification.
While the item of service payment model has served pharmacy and government well over time, there may be risk/reward models better suited to specific service developments that meet the needs of patients and the NHS. In developing a strategy, and without being prescriptive, the sector should indicate a willingness to explore all of them, including ‘year of care’, partial and full risk sharing, outcome-based incentives, framework and basic service level payments. This list is not exclusive.
You might find that asking yourself “what’s in this for me?” and “what might that look like in may pharmacy?” a useful way to frame answers to the current consultation questions. It personalises the exercise, but at the outset, with such broad and open questions, this might not be a bad thing.
You might also like to consider how you want the possible futures to be presented back to you. There is often a stage in exercises like this where options are presented for appraisal – they might be worst case/best case scenarios, or ‘future day in the life’ narratives, for example. For people who are visual learners, picturing the outcome will be easier than reading about it.
The work PSNC has commissioned is vitally important. In other parts of the UK, community pharmacists have had a degree of agency, and a lot more certainty, in the direction of travel of their pharmacies and businesses for some time. Community pharmacy in England needs that too and it’s therefore vital that you have your say.
While it’s early in the process – too early maybe for those who like to react to something rather than respond to a blank space in an online consultation form – please offer whatever thoughts you can at this stage, since they will shape the way this work develops. You can find the details of how to get involved here.